Small steps back to work

(pictured: Sally Greenfield, clinical lead for supervision in Reading)

A talking therapies scheme in Berkshire is exceeding expectations in supporting people with mental health issues into employment. Julie Griffiths finds out how

Project details:

● Project name: Berkshire West Talking Therapies.

● Locations: Generic community settings such as GPs’ surgeries.

● Aim: To improve support for adults with mild to moderate mental health problems and reduce numbers on sick pay or incapacity benefits.

● Outcomes: 151 are off sick pay or incapacity benefits and back to work or college.

● Waiting times: Maximum wait is six weeks for some forms of therapy.

● Annual funding: £1.2m from government plus £1m from NHS Berkshire West.

● Number of service users: 4,800 referred and 4,010 entered treatment between January 2009 and June 2010.

● Number of staff: 40 full-time equivalent therapy posts, 1.5 employment advisers, five administration and supervision staff.

Within weeks of taking office, health secretary Andrew Lansley and care services minister Paul Burstow championed the Improving Access to Psychological Therapies (IAPT) programme in a visit to the successful Berkshire West Talking Therapies scheme.

IAPT was introduced under Labour to address the poor access to support for people with common mental health problems, such as depression. It began with pilot sites in 2006 before being rolled out in 2008.

As well as improving care for patients, it aimed to reduce the economic cost of ­mental ill-health, by removing 25,000 people from sick pay and benefits between 2008 to 2011.

NHS Berkshire West’s local target – to take 106 people off benefits or sick pay by March 2011 – was smashed in months. From January 2009, when the service began, to the end of June 2010, IAPT helped 151 people back to work. Over the same period, 4,010 people received treatment.

NHS Berkshire West, which covers a population of 500,000, commissions the service from Berkshire Healthcare NHS Foundation Trust. Commissioning lead Nick Buchanan says the primary care trust realised service provision had been focused on severe mental health problems with little in place for the remaining 90% of users with mild to moderate depression or anxiety.

“We knew that some people escalated into specialist services because we were unable to support them early on,” he says.

The service delivers cognitive behavioural therapy (CBT), which National Institute for Health and Clinical Excellence guidance cites as the most effective way to treat anxiety and depression.

About 85% of referrals come from GPs, with the rest from social workers, health professionals such as health visitors, or users themselves.

A key element of the service is its patient focus. Patients are assessed to work out how best the service can meet their needs. Help is available in a range of formats, including interpersonal therapy, group courses, computerised programmes (see case study) and guided self-help. One-to-one therapy takes place in community settings, such as GPs’ surgeries, to minimise any stigma attached to seeking help.

Well-being practitioners

The team comprises psychological well-being practitioners, who help those with milder needs, and high-intensity therapists for people who need more support. Training for both types of post is provided by Reading University. The practitioners are trained in six to seven months, a year for high-intensity therapists.

Employment advisers have been part of the team since the start of 2010 so that, when clients are ready to think about work, there is help in areas such as CV writing and interview skills.

Sally Greenfield, the scheme’s clinical lead for supervision, says progress is at the individual’s pace. Patients with mild problems can recover in six to eight weeks while those with more long-term problems might take four to six months.

The recovery process may include voluntary work, then part-time hours before the individual takes a full-time job. “People often think it’s all or nothing,” says Greenfield. “Going back into full-time work straightaway might be overwhelming and, psychologically, people perceive themselves as a failure. Small steps have a cumulative effect and their self-belief grows.”

CBT can help individuals break the cycle of negativity that is a symptom of depression or anxiety by challenging damaging beliefs and encouraging clients to recall previous achievements. “Most people forget about those times,” says Greenfield.

So far the impact of IAPT on other health services in Berkshire West is unknown. But Dr Arek Hassy, associate IAPT lead and a GP who is involved in auditing the project, believes it will be significant. In general practice alone, IAPT is likely to have a massive effect, he says.

About 30% of consultations in general practice each year have a mental health component, he says. Without the right help, patients continue to return to the GP as their depression worsens.

“The GP armoury is weak,” says Hassy. “There are drugs or watchful waiting or, for those severe enough, there are psychiatrists, but most people are not at crisis. There has been a big gap.”

He says the need for the service is shown by the consistent levels of referral rates across all 54 general practices in the area.

Although CBT is not a miracle cure for all, the recovery rates are good, says Hassy, who analyses the statistics on a week-by-week basis. For this quarter, it is at 56%, which is very good, he says.

Nick Buchanan believes that IAPT’s success is such that even the government’s proposed abolition of PCTs is unlikely to threaten the service. Mental health problems will not disappear and IAPT is valued by GPs and the public – patient feedback shows 93% were satisfied with the Berkshire West service.

“We don’t know where mental health commissioning will be in a new structure,” Buchanan says. “But, as the service develops and there is confidence in it, then that’s a good protection for the future of IAPT.”

Case study: ‘It kept me focused on things I could do to help myself’

Isobel*, 62, developed depression and anxiety after a physical illness. She had been on sick pay for several months when her GP suggested talking therapy may help her to return to her teaching job.

The Berkshire West Talking Therapies service recommended an online cognitive behavioural therapy programme called Blues Be Gone, which enabled Isobel to work towards recovery in the privacy of her own home, supported by weekly calls from a psychologist.

“I found it much more user-friendly than if I had to keep an appointment because, at that time, driving and having to be places was a problem,” she says.

The programme measures depression levels and Isobel says she was horrified to see how high her score was at the start.

As recommended, she devoted 60-90 minutes a day for five days, then had two days off, before repeating the pattern until the 60-hour programme was completed. In March, Isobel felt able to start a phased return to work over six weeks.

“The support of the programme was essential when I was returning to work because I could go straight on to it when I got back from school,” she says. “It kept me focused on the positive things I could do to help myself, not the things that I couldn’t.”

Without the support of the Berkshire West service, Isobel believes she would have been forced to leave work altogether.

* Name has been changed

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