Managing patients with complex needs: Evaluation of the City and Hackney Primary Care Psychotherapy Consultation Service
This report sets out the findings of an evaluation of the City and Hackney Primary Care Psychotherapy Consultation Service (PCPCS), an innovative outreach service provided by the Tavistock & Portman NHS Foundation Trust which supports GPs throughout the London boroughs of City and Hackney to manage patients with complex mental health and other needs that result in frequent health service use. The main conclusion is that the service improves health outcomes and leads to a reduction in health service use in both primary and secondary care settings. The resulting financial savings are equivalent to about a third of PCPCS treatment costs. The service also achieves very high satisfaction ratings among local GPs.
The PCPCS is designed to meet the needs of specific groups of patients who fall through gaps in existing service provision and may be difficult to manage in primary care because of the complexity of their conditions. Also, these patients are often frequent users of health services, not only in the primary care setting but also in secondary care, including regular attendances at A&E and outpatient departments. This is a point of obvious concern to GPs in their commissioning role. The purpose of this study was to ascertain what benefits may flow from the work of the PCPCS. These include improved mental health, wellbeing and functioning among patients; cost savings from reduced use of NHS services; and benefits to GPs including improved capacity to manage patients with complex needs and reduced workload.
In evaluating the impact of the PCPCS on mental health and wellbeing, use was made of outcomes data routinely collected by the service at the start and end of every course of treatment. A number of different instruments are used, including: the Patient Health Questionnaire (PHQ9), which provides a measure of the severity of depression; the Generalised Anxiety Disorder Assessment (GAD7), measuring the severity of anxiety; and the Work and Social Adjustment Scale (WSAS), measuring the ability of individuals to do day-today tasks including paid work.
Concerning the impact of the PCPCS on NHS costs, detailed information on health service use was collected for a sample of 282 patients treated by the PCPCS, covering three time periods: 12 months before the start of treatment; the period during treatment, which on average lasted 10 months; and 12 months after the end of treatment.
Concerning the benefits of the PCPCS for GPs, estimated changes in workload as measured by numbers of patient consultations are given in the data just described on service use. In addition, a short survey of local GPs was carried out in late 2013, asking a range of questions about their satisfaction with the service.
Outcomes for patients and services: Averaged across all three measures, 75% of all patients show improvements in their mental health, wellbeing and functioning as a result of treatment. About 55% are shown as having “recovered”, meaning an improvement in mental health which moves a patient to below the threshold after treatment.
It is estimated that treatment by the PCPCS reduced the costs of NHS service use by £463 per patient in the 22 months following the start of treatment. Savings in primary care accounted for 34% of this (mainly fewer GP consultations) and savings in secondary care for 66% (fewer A&E and outpatient attendances and inpatient stays). Just over a third of the overall fall in service use occurred while treatment was in progress and the remaining two-thirds in the following year.Compared with the year before referral, the average number of GP attendances per patient seen by the PCPCS fell by 25% in the year after treatment. A typical course of treatment by the PCPCS lasts for 12 or 13 sessions, at an estimated average cost of £1,348 per patient. The subsequent savings from reduced health service use are equivalent to about a third of this cost.
Cost effectiveness: Based on the cost-effectiveness framework used by NICE, it is estimated that treatment by the PCPCS has a cost per QALY (quality-adjusted life-year) of around £10,900. This is well below the NICE threshold range of £20,000 - £30,000, indicating that the service is good value for money.
GP satisfaction: A survey of local GPs using the PCPCS found very high levels of satisfaction with the service, covering such aspects as the referral process and the accessibility and responsiveness of the service. On a 1-10 rating scale, average scores were typically in the range 8.5 – 9.0 for each question in the survey.
Parsonage, M., Hard, E. & Rock, B. (2014) Managing patients with complex needs: Evaluation of the City and Hackney Primary Care Psychotherapy Consultation Service. Centre for Mental Health.