Author Simon Sawyer, RMN , MA , is senior mental health triage nurse, Gloucestershire PCT and Gloucestershire Partnership NHS Foundation Trust.
Abstract Sawyer, S. (2007) Developing a mental health triage service in primary care. This is an extended version of the article published in Nursing Times; 103: 49, 28–29.
This article describes the development of a mental health triage service that eventually ran across Gloucestershire between June 2004 and January 2007. The service was provided directly to clients with common mental health problems. It particularly focuses on the first cluster of GP surgeries to be covered in Cheltenham . It outlines the success in improving access for service users to appropriate and timely assessment as well as reducing referrals from GPs to specialist mental health services.
In the decade before this project, significant changes took place in the provision of community mental health care in the UK . Community mental health teams (CMHTs) previously had a remit to assess and treat clients with a broad spectrum of illnesses and problems, ranging from relatively minor depression and anxiety to severe and disabling psychotic illnesses. However, as the 1990s came to an end there was increasing pressure and emphasis for specialist mental health services to address the needs of clients with severe and enduring illness. This meant that those people in the mild to moderate part of the spectrum should be receiving help from primary care services and non-statutory agencies.
In many parts of the country, there was a discernible gap (of both time and planning) between the withdrawal of specialist care input into the mild to moderate client group and the provision of improved and appropriate cover in the primary care setting. In many areas, GPs in particular became increasingly frustrated with the ever-growing numbers of referrals returned as inappropriate for the new CMHTs. The CMHTs were likewise feeling swamped by too many referrals, which took time away from their identified client group and their complex needs.
This article outlines the establishment in Gloucestershire of a primary mental health team (PMHT), later known as the primary mental health service (PMHS), in 2000. This led to a county-wide service of experienced mental health triage nurses running assessment and signposting clinics in GP practices. It increased the numbers of clients receiving assessment and appropriate signposting or referral to other services. Referrals to CMHTs and other specialist teams were greatly reduced, allowing them more time and space for complex cases.
This article focuses on the first cluster of surgeries in the then Cheltenham and Tewkesbury PCT area, and its particular success in meeting its targets.
The primary mental health team was formed in 2000 under the leadership of Jackie Prosser. It had its origins in a project from the previous year called Making it Happen. The publication of the National Service Framework for Mental Health (Department of Health, 1999) was the main driver in the team’s establishment, and was soon followed by the NHS Plan (DH, 2000), the NSF for Older People (DH, 2001), NICE guidance on anxiety and depression ( NICE , 2004a; 2004b) and work produced by the Social Exclusion Unit (2004), as well as other national guidance on this field of healthcare.
Due to the change in emphasis for CMHTs, there was a large group of clients with mild to moderate mental health problems – predominantly related to anxiety and depression – who were finding it difficult to receive an assessment of their needs or an indication of where they could receive help.
In addition, there were fewer counselling services available in primary care compared with the mid 1990s. The range of non-statutory and independent provision of psychological help was increasing, but GPs and specialist teams generally had limited awareness of many of them, or how they could refer patients to them.
In 2001 the PMHT developed a county-wide delivery strategy for mental health in primary care and established the first psycho-educational courses for stress management, which are still running around the county. By 2003 there had been agreement from the three PCT local implementation groups (LIGs), to varying extents, to role out a mental health triage service in primary care. In addition, in line with the document Fast Forwarding Primary Care: Graduate Primary Care Mental Health Workers - Best Practice Guidance (DH, 2003), there was an agreement to fund graduate mental health workers (GMHWs), with one for each cluster of surgeries. Interviews for these two groundbreaking roles – triage nurses and GMHWs – took place early in 2004 and the first intake started work at the beginning of March.
Funding for what was now the PMHS came from two main sources: the PCTs and the Gloucestershire Partnership Trust ( GPT ). Most of the triage nurses and GMHWs were funded by the PCTs. The remaining clinical posts and the management roles were funded by the GPT . This working relationship between PCTs and GPT , though somewhat unusual, worked effectively and, I believe, helped to produce the positive results that we achieved.
There were several major goals and targets which the triage service was set to achieve, including:
Increase capacity and access to expert assessment, appropriate treatment and onward referral if necessary. It was hoped that each full-time triage nurse would have 500 face-to-face assessment and follow-up sessions per year;
Produce a detailed directory of local resources, relevant to the support of individuals with mental health problems;
Produce a model of service that could reduce stigma and social exclusion;
Reduce inappropriate referrals to secondary care services – hopefully by 50%;
Establish a good working interface between primary and secondary care staff and services;
Build sustainable partnerships with agencies and community resources outside healthcare services.
Another very important principle for the PMHT was to work within a stepped care model. This was in line with NICE guidance, and was also felt to be the right and appropriate philosophy by which to work. We would endeavour to offer and deliver the least intrusive or complex treatment/input that could help clients to tackle their problems. We would start where possible with a leaflet or advice if that were needed, and would try to offer a book on prescription or a guided self-help programme based on CBT principles before considering options such as referral to the specialist psychological therapies service or CMHT. In a four-step system, the vast majority of clients I saw (at least 90%) were helped within steps 1 and 2. A step 2 intervention could be follow-up by me or a referral to the GMHW for guided self-help.
Setting up the triage nurse service
Before the first clinical activity there was a three-month period of preparation work, from March to early June 2004. This included the first group of three triage nurses joining in some of the training programme for the graduate mental health workers. This was important in forging a bond between each nurse and their identified GMHW. This working relationship was to be among the most positive and effective of my career to date.
I joined my GMHW in carrying out a thorough audit of the cluster area in which we were to work. This was to establish a profile of existing services – both statutory and non-statutory – that were available. These included counselling organisations, housing associations, benefits and advice centres and many others. We also made use of available public health data for the locality, to give us a better idea of the demographic make-up of the area of Cheltenham we were covering.
We also made frequent visits to the five surgeries that I was to cover, setting up slots on their computer systems, explaining the service to as many staff as possible, training reception staff regarding the correct forms to give out and booking available rooms.
I set up my own ‘assessment pack’ in a suitable sized case. This contained all possible forms, leaflets, resource lists, relaxation CDs and guided self-help material that I might need in an average clinic. We had designed concise and useable screening forms as well as a basic onward referral form with room for more detailed information. We already had PMHS patient leaflets for depression and anxiety. I designed and wrote a further one for anger problems.
The ability to refer direct to a GMHW for a client to receive guided self-help was a useful one. The PMHS had its own CBT -based guided self-help programme for anxiety called Gaining Control of Your Life (PMHS, 2004). In 2005 this was followed by an equivalent programme for depression. Clients would usually take 6-8 weeks to complete these programmes, with a weekly phone call from the GMHW.
An area of preparation that was vital was forming relationships with staff from the specialist services in the area, including the CMHTs, the psychological therapies service and the crisis service. Unlike my two triage colleagues covering the other initial clusters in the county (and indeed every subsequent triage nurse appointed), I had not worked in Gloucestershire before, having moved to the job from Surrey . I therefore did not have existing contacts, relationships and support networks. Initially I had to work harder to gain the trust of the CMHTs but, as my work began to reduce the number of referrals to them, so their confidence and trust in me grew.
It was decided that initially we would use the Hospital Anxiety and Depression Scale (HADS) screening tool; the clients would be given these to fill in as they arrived for their appointment (Snaith and Zigmond, 1984). In 2005 the PMHS decided to use the nationally available outcome measure Clinical Outcomes in Routine Evaluation ( CORE ), which is particularly useful in measuring effectiveness and outcomes of psychological therapy input. I agreed to pilot this system in my clinics from August 2005, and found it extremely easy to use and effective. As a result of my successful piloting of CORE , it was rolled out to the other triage nurses and GMHWs in December 2005. The graduate workers would use the CORE questionnaire at important points during and after clients’ involvement with guided self-help.
As each new cluster of surgeries was identified and rolled out, I was closely involved in training the new triage nurses, as I was able to offer my experience in setting up the first cluster from scratch.
The triage clinics in operation
By mid-June 2004 my first four clinics were up and running – the fifth started in November 2004.
Each surgery had a similarly sized population of between 9,000 and 11,000 patients. The total population of the five surgeries was around 48,000. Because of these comparable sizes, I was able to offer one clinic in each surgery every week. Clinics would cover a morning or an afternoon and comprise four 45- minute slots, with preparation and winding-up time before and after. It was hoped to spend 30-35 minutes with each client, with the remaining 10 minutes for documentation. GPs and other health workers would be able to book clients directly into the slots. All clinics took place at the GP surgery sites. Triage nurses were also available for consultation by any of the primary care staff.
I would try to form a provisional hypothesis of each client before they came in, through a quick look at their computerised notes. The interview itself would start with me quickly perusing the completed HADS or CORE questionnaire and then leading into the mental state screening.
After assessment any of the following actions could be offered, using the stepped-care approach:
No further input - problems resolved between referral and assessment;
Giving information, leaflets and phone numbers for advice centres;
Books on prescription;
Giving contact details for independent counselling organisations;
Referral to the GMHW for guided self-help or Beating the Blues (Ultrasis, 2000-2007) – Beating the Blues is a computerised CBT programme recommended by NICE;
Referral to the psychological therapies service;
Referral to the CMHT or early Intervention service;
Referral to the crisis team for consideration of admission or intense support.
My philosophy with any client I assessed was not to let them leave the room empty-handed, as much as I could. Even if they only had a phone number or a leaflet, it could be all they needed to begin to overcome their problems.
Initially it was very difficult to adapt from a lengthy CPN -type assessment to half-hour triage screening. After a few months, this had become much easier.
Occasionally I would offer one or two follow-up sessions. I might do this if:
The client had just been prescribed medication which had not yet had time to take effect;
A wish to see how the client had been getting on with a book on prescription;
If I had been unable to complete the assessment in the first half-hour available.
Results and outcomes
The vast majority of clients were:
Only seen once;
Experiencing mild to moderate problems with anxiety or low mood.
Had not seen a mental health professional before;
Were female (57.8% to 42.2% male)
Were aged 21-50.
During the period covered by the triage service I made many referrals to other agencies and workers, which included:
Some 56 direct referrals to CMHTs;
Some 41 direct referrals to the psychological therapies service;
Some 117 referrals to the GMHW.
Referrals to non-statutory counselling agencies increased noticeably and, for a while, their waiting-list times increased.
One area of particular interest to me that was quite shocking was the number of clients who claimed to have been sexually abused, either in childhood or as an adult. I have no formal figures for those who disclosed such issues, but I would estimate that I saw at least one per week – or more than 100 throughout my time with the PMHS – who related a history of childhood abuse.
The following statistics reveal the extent of my assessment activity. Throughout the two-and-a-half years, I ran 547 clinics. My colleagues in the other initial clusters in the county reported similar activity figures.
The sheer numbers involved can be seen here. Although assessment duration was shorter than that for a typical CPN assessment, I probably saw as many new clients in two and a half years as a triage nurse as I would have done in 25 years working in a CMHT.
Total for all clinics
Figures as a percentage
Percentage variation between five main clinics
Referrals to triage for assessment
Arranged follow-up sessions
Total booked sessions
Total sessions attended
64.6 – 87.2
11.0 – 30.0
1.3 – 5.4
Statistics from the GPT suggest that there was a marked reduction across the county in inappropriate referrals to CMHTs. In the PMHS’s initial progress report of March 2005, there is a comparison of referrals to CMHTs covered by the GP surgeries in the triage nurse scheme before and during the scheme (Andrews, 2005). Between June and December 2003, six months before the scheme began, there were 369 referrals to these CMHTs. Between June and December 2004 (the first six months of the scheme) there were 219. This was a reduction of nearly 41%.
By halfway through the year 2006-2007, it was estimated by the PMHS that reductions of 50-80% had been made in referrals to CMHTs covered by our service. These figures are based on statistics from the GPT that are yet to be finalised. These initial results suggest that referrals from the individual surgeries covered in my cluster were reduced by 50-75% from the time I began in June 2004.
My 1,590 total attended sessions greatly improved on the hoped-for 500 contacts per year. I actually averaged 615 contacts per year.
Review and audit
The clinical effectiveness of the CBT -based treatment packages provided by the PMHS was measured using the CORE system. There are good figures relating to the efficacy of these programmes in the various internal progress reports for the PMHS produced under the lead of Caroline Andrews.
In the first year of the triage nurse system two satisfaction questionnaires were circulated.
In October 2004, a survey of health professionals such as GPs, practice nurses and CMHT staff was undertaken. There was strong awareness of the various PMHS services available - between 67% for the website and 97% for the triage service.
Other results from the staff survey include:
The majority (27 out of 30, 90%) found the new service helpful or very helpful;
Some 28 out of 30 (93%) found it useful or very useful;
The vast majority (29 out of 30, 97%) found it accessible or very accessible;
Nearly two-thirds (19 out of 30, 63%) found it had reduced their workloads .
Some of the comments regarding the triage service included:
‘I am sure it has significantly reduced our referral rate to secondary mental health services.’
‘XXXXX XXXXXX is a great asset to the practice and patients, but we need more of his time.’
‘You are a victim of your own success – now more hours are needed.’
In February 2005 a survey of service users was carried out. Results included:
Some 87% found the service appropriate to their difficulties;
Nearly all (96%) felt that things were explained in a way they could understand;
The majority (89%) felt the triage nurse listened to what they had to say;
Some 90% rated the care received as good or excellent.
A total of 141 questionnaires were sent out and 55 were returned, giving a response rate of 39%.
This article has to be limited to describing the triage nurse scheme in detail, and not the other significant activities and projects also run by the primary mental health service in the same time line.
The PMHS was a ground-breaking service that gained good reviews and responses from its key partners and its clients.
The triage nurses achieved all the main targets originally set out, and often outperformed them. I can say that, in all of my 21 years as a qualified mental health nurse, the 31 months in this role have been the most enjoyable. More importantly, however, I believe that in my time with the PMHS I did the most important, clinically effective and statistically significant work of my career to date.
It is perhaps unfortunate that the difficult financial climate of the past two years led to a more rapid and extreme restructuring of community mental health care in Gloucestershire than had been originally anticipated, which led to some root and branch changes in January 2007. Although the PMHS was disbanded and subsumed into a new, larger team - which also had to take on some of the work previously done by CMHTs - very similar triage work is going on in GP practices around the county, and now every surgery is covered. There have been some difficulties, but I think it is right to say that both the new Gloucestershire PCT and the new Gloucestershire Partnership NHS Foundation Trust are keen to ensure that the lessons learnt and achievements made by the PMHS are not lost.
This project was a mental health finalist in the NT Awards 2007.
Andrews, C. (2005) Developing Primary Mental Health Services in Gloucestershire: Initial Progress Report. Gloucestershire: GPT (available in GPT archives).
Clinical Outcomes in Routine Evaluation ( CORE ) www.coreims.co.uk
Department of Health (2003) Fast-forwarding Primary Care Mental Health: Graduate Primary Care Mental Health Workers - Best Practice Guidance. London: DH.
Department of Health (2001) National Service Framework for Older People. London: DH.
Department of Health (2000) The NHS Plan: A Plan for Investment. A Plan for Reform. London: DH.
Department of Health (1999) National Service Framework for Mental Health: Modern Standards and Service Models. London: DH.
Snaith, R.P., Zigmond, A.S . (1984) Hospital Anxiety and Depression Scale. London: nferNelson.
NICE (2004a, amended 2007) Anxiety: Management of Anxiety (Panic Disorder, with or without Agoraphobia, and Generalised Anxiety Disorder) in Adults in Primary, Secondary and Community Care. London: NICE .
NICE (2004b, amended 2007) Depression: Management of Depression in Primary and Secondary Care. London: NICE .
Primary Mental Health Service (2004) Gaining Control of Your Life: A Self-help Workshop for Anxiety. Gloucestershire: PMHS.
Social Exclusion Unit (2004) Tackling Social Exclusion: Taking Stock and Looking to the Future. London: Office of the Deputy Prime Minister.