Mind the gap!

What happens to people with moderately severe psychological problems, too complex for primary care to help with, but not so severe that a community mental health team (CMHT) would be appropriate? In most mental health trusts in the UK, this group of service users all too frequently falls through a precarious gap in care provision.

However, here at Redbridge Psychological Services in North East London, we are addressing this issue head on. Our former Heads of Adult Mental Health, Liz Deeble and Lesley Wyner, came up with the idea for our Intermediate Psychological Service (IPS), which is now in its sixth year of operation. IPS provides a stand-alone option for precisely the type of people at risk of falling through the gap between primary and secondary care.  
The gap is partly the product of shifts in mental health care over the past 25 years. In the late 1980s and early 1990s, government policy brought about a revolution in the way people with mental health issues were cared for. Inpatient care in psychiatric hospitals was replaced by care in the community; closure of many of the large old hospitals from 1986 onwards saw their former residents coming under the care of CMHTs.

Today's gap in psychological services can be seen as a legacy of this shift. Many people who would have been inpatients are now living in the community, being seen by CMHTs, and the domino effect is that CMHTs are overstretched and so inevitably resources are focused on the most needy. This means that the stipulations for who is seen by a team have become extremely stringent, and therefore many people with complex issues, who would formerly have been seen by a CMHT, no longer meet the entry criteria.

So what happens to this type of service user? Typically, the only resource available to them is primary care. Assuming they have a sympathetic GP, they may be referred for counselling, usually six, 50-minute-long, solution-focused sessions. However, this is often just not sufficient to address what may be years of trauma and complex problems.

A typical example of the type of person at risk is someone like Anna (an alias). Anna was sexually and physically abused as a child by a family member. She suppressed memories of this throughout her teens, but had various problems, such as anxiety, low self-esteem and difficulties in forming relationships. Despite these issues, Anna managed to go to university, get a good job and is now in a long-term relationship. However, she frequently feels depressed and anxious and worries about her weight. She often makes herself sick after she's eaten, and she has recently started self-harming by cutting her arms.

Anna's problems would generally not be viewed as sufficiently severe to warrant the intervention of a CMHT. Despite all that she's been through, she hasn't developed a serious mental illness or psychosis and, to those around her, she seems to be coping reasonably well on a day-to-day basis. However, the service which a primary care trust would be able to offer her, typically six sessions of counselling, is unlikely to address all the issues that Anna is dealing with, and in fact may have a negative effect: brief counselling could open up a flood of issues for Anna, but then leave her with no outlet for her feelings or resources for dealing with them when the sessions come to an end. Anna's mental and physical well-being are clearly put at risk by this gap between primary and secondary care provision.

'This is where Redbridge's Intermediate Psychological Service comes in,' explains Gill Brooks, Head of IPS. 'IPS provides a net for precisely the type of service users who don't meet CMHT entry criteria but who are too complex for primary care.'

Prior to 2002 Redbridge followed the model that is typical of the majority of UK mental health trusts. We offered two possible resources for people who were referred to them, either secondary-level CMHT psychotherapy of 20 sessions or primary care of six sessions. This meant some people with moderate difficulties received too few sessions to meet their needs, and fell through the gap since the CMHT would not accept them. Others were inappropriately taken on by the CMHT service for people with severe and enduring mental health problems.

Under the new intermediate system, service users with moderately complex problems are offered around 12 sessions of individual therapy by counsellors or psychologists. Therapies offered include CBT, psychodynamic, systemic, humanistic and integrative.

Seeing more referrals than expected

It turned out that that there was a clear demand for the new service. In its first five years there has been an average of 375 referrals a year to IPS, which is 50 per cent higher than the 250 a year we expected at the outset. And the trend is upwards.

What's more, IPS sees all these people with low levels of resources – no more than four whole-time-equivalent clinicians at any one time. As Brooks adds: 'In the financial year ended March 2007, we received 450 referrals – giving an average 110 referrals per whole-time clinician per year. These figures alone speak volumes about how hard and efficiently our staff work.'

Since IPS started, it has reduced pressure on the CMHT psychological services, with referrals having decreased from a yearly average of 200 in 1999–2002 to 178 in 2002–2006. IPS means intermediate service users are no longer referred to a CMHT, keeping them out of the mental health service for severe and enduring difficulties.  IPS also offers longer treatment than primary care, perhaps leading to better treatment outcomes for intermediate service users, helping prevent deterioration to CMHT level.  

Redbridge Psychological Services continue to offer a fairly substantial therapy group programme for IPS and CMHT psychological service users, alongside the individual therapies. These include short-term (around 12 weeks) problem-focused groups, such as managing OCD or coping with anxiety and depression, as well as long-term (18 months to three years) psychodynamic groups run by group analysts.

Cutting waiting times and giving satisfaction

Redbridge IPS has maintained low waiting times while increasing therapy sessions from their primary care days. In 2006 most of those referred were seen within six weeks for an initial assessment, with 88 per cent seen within 13 weeks, and all within 21 weeks. 82 per cent of those then placed on the therapy waiting list began therapy within 13 weeks of their assessment.

And service users seem to benefit from what IPS offers. Analysis of outcome measures from October 2005 to July 2006 shows that IPS service users rated themselves as coping significantly better and their problems having become significantly less severe by the end of therapy. All respondents also reported finding therapy helpful (though people who chose to respond to the research are likely to be self-selecting).

A service model for the future?

To the best of our knowledge, Redbridge IPS was the first service of its kind in the UK. Research from NHS websites and mental health commissioners produced no information of similar services at the time or before Redbridge began. After placing an information request in The Psychologist, we discovered that a similar service, the Adult Psychological Therapies Service (APTS), was officially launched in December 2006 in Tayside, Scotland. Like Redbridge IPS, the Tayside APTS is a stand-alone service at Tier 2 level, separate from the CMHTs, which offers therapy to adults with moderate psychological problems. Dr Maurice Winton, Consultant Clinical Psychologist and head of APTS, informed us that APTS is currently being formally evaluated for the first time. He was confident this would show positive treatment outcomes for service users and that the service would remain for the foreseeable future. He commented that heads of other adult psychological services in Scotland have also shown interest in APTS as a template for future service models.  

As Redbridge IPS is now well established, it seems likely that further Tier 2 adult mental health services will develop across the UK. This should help adults with moderate emotional and psychological problems receive prompt and appropriate psychological therapy, and prevent them falling through a previous gap in services.

-    Emily Pryce-Jenkins has now finished her placement at Redbridge as a trainee clinical psychologist, and Tanya Woolf is Head of Community Psychological Services there