Primary care mental health service procedure

Contents

1 Aim

The aim of this standard operating procedure (SOP) is to ensure that all colleagues working in the primary care mental health service (PCMHS) have a full understanding of the processes and procedures to follow to ensure a quality service that provides safe and effective care to our patients.

2 Scope

This document will apply to all Rotherham, Doncaster, and South Humber NHS Foundation Trust (RDaSH) colleagues including substantive, temporary, those on honorary contracts and locum, of all grades and disciplines, working on behalf of the primary care mental health service (PCMHS), which includes those recruited through the additional reimbursement roles scheme (ARRS) in general practice, and should be read in conjunction with the primary care mental health service (including additional reimbursement roles scheme) policy.

3 Link to overarching policy

This standard operating procedure is overarched by the following policy, which can be found on the RDaSH trust policy website.

Primary care mental health service (including Additional Reimbursement Roles Scheme) policy.

4 Procedures

4.1 Definitions

Below are some brief definitions of Dialog and Dialog+, which will be discussed throughout this SOP. For a more detailed explanation on these as well as Recovering Quality of Life (ReQoL-10) and Goals Based Outcomes (GBO) please see section 4.10.

Dialog is a person centred patient rated scale of 11 questions that a patient answers. These questions measure quality of life and ensure there is a focus on meeting a persons wider needs.

Dialog+ builds on the Dialog scale to provide a full therapeutic intervention and forms the care plan.

4.2 Pathway flow

To view the clinical pathway from general practice (GP) to mental health practitioners (MHP) please refer to the GP and MHP pathway (staff access only) (opens in new window). For the Primary Care Mental Health Hub (PCMHH) pathway please follow this link PCMHH team pathway (staff access only) (opens in new window).

Transformed primary care mental health teams may differ in name or title, for example Rotherham is PCIMHT. Within this document these teams are referred to as the Primary Care Mental Health Hub team (PCMHH).

4.3 Referrals

There are two main referral routes into the PCMHS and these reflect the development of “step-up” and “step-out” pathways.

For patients with mental health related concerns GPs can directly step them across to the mental health practitioners (MHPs), or mental health and wellbeing triage coaches (MHWBTC) where they are in place and as appropriate. GPs can also discuss the best pathway with a clinical member of the PCMHS.

When patients first make contact they will be booked into appointment slots via the Care Navigator within GP surgeries, these appointments are booked with the MHWBTC, where they are in place, otherwise they are booked in with the MHP. Patients who have a degree of complexity or comorbidity that require a more detailed assessment of their mental health needs, can be booked to see the MHP via any of the following, the care navigator, the MHWBTC or the GP. The MHP will manage any follow-up appointments for themselves.

Should a patient require stepping up from the GP or MHP to the PCMHH, all routine referrals (step-ups) can be sent directly to the team, ideally by e-referral or alternatively by email via the email referral route already in use by the team (email addresses will differ between care groups, please liaise with your team leader if you are not aware of the details to use).

Traditional referral routes will remain for GP’s and others to refer complex cases including requests for urgent or crisis interventions where a degree of risk to self or others is present.

Referrals from other services including but not limited to the local authority, MAPPA, police etc can continue to be made either through a SPA function (where one is in place), or directly into the PCMHH or Specialist Mental Health Service as appropriate.

4.4. Step up and step out or down

Where deemed appropriate a regular multidisciplinary team meeting (MDT) will be held within the PCMHS to discuss:

4.4.1 Step down

Near the end of a specific intervention and period of care, a patient led review will be completed and will inform the next step when a less intensive level of care is required.

4.4.2 Step up

When a patients risk has increased, their needs intensified and, or effective engagement has reduced, which may require multiple agencies to be involved.

• for example, MHP worker to PCMHH or PCMHH to specialist mental health services.

Please note this only applies to routine patients, not for those requiring a crisis response.

4.4.3 Step across

This would reflect when a patient is signposted to another service:

• for example, NHS Talking Therapies to PCMHH

4.4.4 Step out

Once a period of brief intervention has been offered the expectation is that a patient can step out of the PCMHS. Some things for consideration are:

• in order to support early intervention, prevention and facilitate recovery the patient must be able to easily access the PCMHS again if required. This can be facilitated via the GP and MHPs in general practice. As the PCMHS incorporates the MHPs as well as the PCMHH, both can offer support as appropriate
• an MDT discussion to review care and next steps or interventions may be required at the point a patient requires re-access to the PCMHH if accessing for the same reason as their previous contact
• the PCMHH is not an open access service and therefore people are required to go back through their GP and MHP if they need support (once stepped out and down), people can access support via GP and MHPs as often as they need

For patients who avoid contact with the PCMHH team, please refer to the disengagement policy.

4.5 Inclusion and exclusion for primary care mental health service

4.5.1 Inclusion

• People over the age of 17 years and 6 months with a low or moderate mental health need that can be met in a primary care setting.
• People wanting to engage with support for their mental health.
• People who are living within the place geographical boundary and registered with a GP within the appropriate Primary Care Network (PCN).
• People who require a routine assessment of their mental health and an intervention for a low or moderate mental health need within a primary care setting.
• People who, following intervention in the PCMHH, may require onward referral to specialist mental health services.

4.5.2 Exclusion

• People who do not present with a mental health issue.
• People under the age of 17 years 6 months.
• People in need of a crisis response.
• People whose needs can be met by the NHS Talking Therapies (previously IAPT) and any other similar commissioned provision such as IESO.
• People who require an assessment for attention deficit hyperactivity disorder (ADHD) or autism spectrum disorder (ASD) to be undertaken, the PCMHH do not conduct these assessments.
• People whose needs are already being met by specialist mental health services.
• People who have a level of complexity or need for multi-agency working that require specialist mental health services.

4.6 Mental health appointments in general practice

Appointments with MHPs and MHWBTC are available five days a week and include telephone reviews in addition to face-to-face appointments. For PCNs with MHWBTC in place, only telephone appointments are offered. Any variation from this would need to be for a specific clinical reason and as by local agreement.

Care Navigators and reception colleagues within the GP surgeries have direct access to automatically book a patient into a daily triage slot.

Appointment time slots are 20 or 30 minutes, at times these slots may need to be longer for the MHPs to allow them to undertake follow-up appointments, therefore they can double book slots or alternatively split their 30 minutes into 15-minute slots. Administration time also needs to be accounted for within the working day. Section 4.6.1 below shows the break-down per MHP and MHWBTC role and the maximum capacity of appointments that could potentially be undertaken for each MHP.

MHP’s can offer 1 to 4 sessions with patients. If a patient requires more than 4 sessions a review of their needs should be completed and consideration taken to step them up to the PCMHH.

MHP and MHWBTC will work via the clinical system in place, be that SystmOne or EMIS.

• Appointments are recorded on the shared PCN appointment ledger wherever possible.
• In the absence of a shared ledger, appointments are recorded on the individual practice’s appointment ledgers.

The MHPs should spend 70% of their time (27 to 30 hours based on whole time equivalent) delivering clinical contacts and the remaining 30% of their time offering advice, support, consultation, and the facilitation of onward access to mental and physical health, well-being, and biopsychosocial interventions. The addition of a MHWBTC to PCN’s releases clinical time from the MHP to support this.

4.6.1 The below highlights the mental health practitioner and mental health wellbeing triage coach appointment capacity

4.7 Appointments within the primary care mental health hub

Referrals (step-ups) received by the primary care mental health hub (PCMHH) will be screened within 7 working days and allocated to the most appropriate intervention and key worker. A patient may also be referred to the Voluntary Community and Social Enterprise (VCSE) sector and to Individual Placement Service (IPS). It is imperative that primary care mental health teams work closely with VCSE partners, IPS and Talking Therapies, who should be a part of the MDT for integrated working. Allocation of the referral will need to be input onto SystmOne. Patients can be allocated to more than one profession in the PCMHH.

MDTs should include a breadth of disciplines that can include but not be limited to psychological professions, talking therapies, occupational therapists, mental health pharmacists, mental health social workers, substance use expertise, advanced MH clinical practitioners, the local authority, IPS and the paid employment of peer support workers, senior lived experience practitioner and expert by experience roles (VCSE). Expertise from all members (clinical and non-clinical) of the MDT should be available and easily accessible to ensure timely care and support offered to patients. Consideration should be given across the MDT as to the most appropriate level staff should operate at (for example, MHPs will be working at PCN-level whereas an OPMH clinician may operate across multiple PCNs).

Referrals (step-ups) that require further discussion after being screened will go to the MDT for a decision to be made on whether there is a need for any further assessment to establish a treatment plan, or whether advice and guidance or signposting can be offered before transferring their care. This should also occur within the first 7 working days of the referral (step-up) being received by the PCMHH. For those referrals who are deemed appropriate for the PCMHH to support, they will be allocated to the most appropriate intervention, as above.

For referrals (step-ups) not accepted for intervention from the PCMHH the no wrong door approach should be taken, this means guiding people, who present at any point in the system, to the right support without delay and without the patient feeling the impact of this movement. Referrals can be stepped out of the PCMHH via a transfer of care to the most appropriate support and service, ideally via e-referral or alternatively email, documented accordingly on SystmOne and PCMHH referral closed down.

Appointment invites will ideally be sent out via text with a link for people to book their appointments (where available). Alternatively appointments can be confirmed by text message or letter.

As the PCMHH is a primary care service offering short term and brief interventions that enables quick accessibility and works towards meeting the 4 waiting time standard, patients should not be held on a caseload for more than 12 weeks. If someone has been on the caseload for longer than 12 weeks, there should be a review of the care plan (Dialog+) and goals and an understanding gained on whether the patient requires stepping up to specialist mental health services, this may require further discussion at MDT with representatives from specialist mental health service or other appropriate services and teams as required. Once agreed a transfer to the most appropriate service should be undertaken by e-referral or email and detail of the referral recorded on SystmOne and then closed down.

For patients who have been on the PCMHH caseload for 12 weeks or fewer (whose interventions have come to an end and stopped) a review of the patient reported outcome measure (PROM) and patient reported experience measure (PREM) and care plan (Dialog+) and goals should be undertaken to determine whether there has been an improvement in the quality of their life. An increase in the Dialog+ score by 0.25 is evidence of an improvement. The outcome of this review will determine next steps, whether to step up to specialist mental health services or whether to step them out of the PCMHS. An MDT that includes representatives from specialist mental health service may be required.

Following stepping someone out of the PCMHH, a keeping well telephone call from a key worker within the PCMHH should be considered, ideally to occur 3 months after patient has been stepped out of the service.

In order to facilitate recovery the patient must be able to easily access the PCMHS via the GP and MHP, as per pathway, this would be as a new referral (step up). Should the PCMHH see repeated returns for the same presenting reason this will need a discussion and plan at MDT.

4.8 Assessment within general practice

All patients requiring a step up from a general practice surgery to the PCMHH are required to be seen by an MHP. Appropriate triage and documentation should be completed before a patient is stepped up to the PCMHH and sent via agreed referral route (see section 4.3, referral).

For patients booked into a triage and first appointment slot within general practice a PHQ and GAD may be completed where appropriate to enable a clear understanding of their needs and the most suitable intervention required (for example, talking therapies or signposting to link workers and VCSE partners). Whilst it may not be necessary for every patient triaged, some will require a Dialog and ReQoL-10 (Recovering Quality of Life), a patient reported outcome measure (PROM), to be completed, ideally prior to their first appointment.

Should a patient be stepped up to the MHP either from the MHWBTC or as a follow-up appointment a Dialog should have been completed. The MHP should then complete a Dialog+ (care plan) with the patient, based off the Dialog already undertaken at triage.

For patients who require stepping up from general practice to the PCMHH, a Dialog+ (care plan), should be completed, a ReQol-10 and mental health self-harm ARDENs template (risk) can also be completed if clinician feels this is required. This information will be completed on the clinical system within general practice. For those practices using SystmOne, if the patient has consented to share their information, this information can be viewed by the PCMHH in the shared record. Alternatively, if they have not consented and it is not viewable in the shared record the above documentation will need to be attached to the referral via email. For EMIS practices, the PCMHH can use the “Third Party Patient Record” node to view the last 3 consultations only.

Further detail on Dialog and Dialog+ can be found under section 4.10 of this document.

4.9 Assessment and care planning within the primary care mental health hub

Once a referral is received by the PCMHH, the waiting time standard “clock starts” and only stops once each step below (1 to 4) is undertaken and recorded accurately or if the referral is not accepted and their care transferred.

For accepted referrals, patients will be allocated to the most appropriate person, people, intervention based off the information provided within the Dialog+ (and ReQoL-10 if used), if the referrer is an MHP. If the referral did not come from the MHP then a Dialog+ and potentially a ReQoL-10 will need to be undertaken by the PCMHH and an appointment will need to be scheduled for this. A Dialog+ should be completed if a patient is going to be seen more than once (if one has not been received with the step-up or referral).

If the referral is accepted then the following needs to take place within 4 weeks after a referral is received.

1. Patient receives a meaningful assessment. A meaningful assessment is the capture of any comprehensive assessment that is capable of leading to the start of an intervention or agreeing a co-produced personalised care plan. Ensuring effective assessments is critical to ensuring that individuals are directed to the right support and avoiding delays to waiting times. The meaningful assessment should then lead to the appropriate intervention being identified.

Please note that if the referral has come from an MHP then a Dialog+ should have been undertaken (a ReQoL-10 may also be completed) and therefore a meaningful assessment has been undertaken and appropriate intervention identified.

2. Dialog+ and ReQoL-10 should be saved as an “Assessment” on SystmOne to be accurately recorded and contribute to stopping the clock.
3. A baseline outcome measure should be completed and recorded, such as Goals Based Outcomes (GBO) or Dialog or ReQoL.
4. Either the first clinical or social treatment or intervention has taken place or a personalised co-produced care plan is completed. This needs to be saved as “assessment and treatment” on SystmOne to be accurately recorded and to stop the clock to achieve the 4-week waiting time standard compliance.

The assessment and intervention or care plan can take place in the same appointment.

The care plan agreement table (MHS009) must be completed, alongside the care plan table (MHS008) in order for the care plan to be counted.

For further details around the waiting time standard, the clock start and stop and what is required to be completed please refer to the 4-week wait guidance (staff access only) (opens in new window), where you will find supporting documentation such as the technical guide and a definitions document, oversight can also be sought by reviewing the PCMHH pathway (staff access only) (opens in new window) which highlights where the clock starts and stops within the pathway.

During a clinical or social intervention and treatment there may be times when it is necessary to further discuss the patient and their treatment options at an MDT, where this is the case key workers should bring the case for discussion.

Patients should not be kept on the PCMHH caseload longer than 12 weeks. For further details please see section 4.7 Appointments within PCMHH.

After 12 weeks or at the end of the treatment and intervention, whichever is first, the care plan, PROM or PREM and goals should be reviewed with the patient (Dialog+, ReQoL-10, GBO) to understand where the patient is on their recovery journey, whether there has been an improvement in their quality of life and what the next steps need to be. Next steps following this are detailed in section 4.7 Appointments within PCMHH.

4.10 Dialog and Dialog+, ReQoL-10 and goal based outcomes (GBO)

4.10.1 Dialog

Dialog questionnaire is a person centred patient rated scale that the patient completes, where able, and will help inform what support is required and who is best placed to offer this. Where patients are unable to complete colleagues within the PCMHS can support them to complete. Patients do not necessarily need to feel like this is a questionnaire, if not completing themselves, colleagues can coach the patient through these questions to aid this being completed.

The questionnaire is a scale of 11 questions which allows a patient to rate their overall quality of life and experience of the care they receive. It identifies a PROM on the initial 8 questions on life domains, and a PREM from the final 3 questions on the treatment they are receiving. It helps structure a person’s care by considering what is important to the person themselves, enabling a holistic and patient-centred approach.

Dialog may not be meaningful for those with dementia or neurodegenerative disorders, as it was not devised for these diagnoses. Considerations need to be made on diagnosis and services for patients based on a patient’s ability or mental capacity to understand the questions being asked.

4.10.2 Dialog+

Doalog+ is a care plan that builds on the Dialog scale to provide a full therapeutic intervention using a 4-step approach. This is based on solution focused therapy and has been specifically developed to make routine patient-clinician meetings therapeutically effective. Dialog+ focuses on the patients’ desired future, not their past problems or current conflicts and is personalised and outcome driven.

The 4-step approach includes:

1. understanding, reasons for dissatisfaction and what works
2. looking forward, directing the discussion from the problem to thinking about alternatives and best-case scenarios
3. exploring options, what can the patient, the clinician and other people do?
4. agreeing on actions, decision-making and documenting

PCMHS colleagues can coach the patient through the Dialog+ questions or approach to aid this being completed without it necessarily feeling like a questionnaire.

4.10.3 ReQoL-10

This assesses the quality of life for people with different mental health conditions, specifically quality of life, it is an enabling tool for users. It provides a better understanding of and measures the factors contributing to personal recovery. It assesses the CHIME (connectedness, hope, identity, meaning and empowerment) factors for people with different mental health conditions.

4.10.4 Goal based outcomes (GBO)

This focuses on the patient’s goals and tracks what is the most important thing to measure in any intervention. It is a way of evaluating progress towards goals across all aspects of clinical work. There are no pre-defined questions and up to 3 goals can be recorded.

These measures are intended to be used as a suite of complimentary measures across a transformed Community Mental Health Service, they are not intended to be used all at the same time or in every part of a service. Although there is an opportunity for services to use all these measures with individuals as appropriate to their needs.

More information is available in the Dialog and Dialog+ guide (staff access only) (opens in new window) for colleagues.

4.11 Clinical documentation: recording Interventions

All MHP and MHWBTC clinical records will be recorded in the PCN electronic patient records. The PCN will provide full access to the relevant primary care systems in line with local data sharing agreements.

Colleagues in the PCMHH will record all contacts using the appropriate SystmOne templates, as mentioned below.

The documentation listed below can be completed within the PCMHS, including MHP and MHWBTC, some can be completed as required and as per clinicians decision. Those on the list are intended to be used as a suite of complimentary tools and are not intended to be used all at the same time or in every part of a service. Although there is an opportunity for services to use all these measures with individuals as appropriate to their needs. As a minimum 2 out of the 3 PROM and PREMs should be completed, that is Dialog, Dialog+, ReQoL-10 and GBO.

• Dialog on first contact within primary care.
• PHQ and GAD where appropriate.
• DIALOG+ to be completed by MHP in primary care system (if patient requires further input following their initial and first contact appointment) and if stepping up to PCMHH DIALOG+ to be either available via the shared record or attached to email referral.
• For initial contact within general practice (triage and assessment) the read code XaL0u requires adding to template.
• For follow-up contact (including treatment) read code “XaZrH” needs adding to the template. This code can be added by the MHP based in general practice or the PCMHH team, whoever has the second contact with that patient.
• Care plan: Dialog+ and ReQoL-10
• Risk management: included in Dialog+. Colleagues may wish to consider completing a Mental Health Self Harm ARDENs template (if in general practice) or Safety Plan in the PCMHH as required
• Patient reported outcome measures: Dialog, ReQol-10 and GBO, as required (at least two).
• Additional tools: CORE-10, PHQ9 and GAD7 as required.

The clinical documentation process is listed below:

4.11.1 Mental health and wellbeing triage coaches and mental health practitioners

4.11.1.1 Triage

• Undertake PHQ and GAD (as appropriate).
• Complete Dialog as appropriate, required if follow-up by MHP is required.

4.11.1.2 Assessment

• Complete Dialog+ if seeing patient more than once.
• Complete ReQoL (as required).
• Complete ARDENs Mental Health Self Harm template (general practice) as required.

4.11.1.3 Interventions and Step up to primary care mental health hub

• Review and complete Dialog+.
• Review ReQoL (as required).
• Complete GBO.
• Review and update ARDENs mental health self harm template (general practice), as required.

4.11.1.4 Step down and out

• Complete Dialog questionnaire.

4.11.2 Primary Care Mental Health team

4.11.2.1 Screen and triage

• Review Dialog+ questionnaire and allocate.
• Complete Dialog if not already received.

4.11.2.2 Assessment

• Complete Dialog+ if seeing patient more than once (if it has not already been completed or received).
• Review or complete ReQoL 10 (as required).
• Complete safety plan (if required).

4.11.2.3 Interventions

• Review Dialog+ questionnaire (care plan).
• Complete GBO.
• Review Safety Plan (as required).

4.11.2.4 Step up, down or out

• Complete Dialog questionnaire.
• Review ReQoL (as required).
• Review GBO.
• Review safety plan (as required).

4.11.2.5 Additional tools

Additional tools that can also be used:

• Core-10
• PHQ9
• GAD7

4.12 Step up, step down and step out

MHP can offer 1 to 4 intervention sessions with patients, if more than 4 are required consideration should be taken to refer to the PCMHH.

Patients should not remain on the PCMHH caseload longer than 12 weeks. For further details around this, please refer to section 4.6, appointments in PCMHH.

Should a patient require stepping up to the specialist mental health services, the Dialog+, ReQoL, GBO documentation or tools should be completed, as discussed above in Section 4.9. These tools should identify the patient need and then be sent with the referral and step up to the specialist team and recorded on SystmOne accordingly. A safety plan can also be completed if required.

Stepping a patient down from the PCMHH or from MHP intervention should be based on the outcome of reviewing the Dialog, ReQoL-10 and GBO and should no further intervention be required they can then be stepped out of the mental health service. However in order to facilitate recovery the patient must be able to easily re-access the PCMHS. A keeping well telephone call from a key worker within the PCMHH can also be considered, ideally occurring 3 months after patient has been stepped out of the service.

5 Associated documents

• Corporate and local service induction policy
• Mandatory and statutory training policy
• Annual leave and general public holidays policy
• Sickness absence policy
• Supervision policy
• Lone working policy
• Waiting time standard supporting documentation (staff access only) (opens in new window)
• Dialog and Dialog+ guide (staff access only) (opens in new window)

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Document control

• Version: 1.
• Unique reference number: 1087.
• Ratified by: Clinical policy review and approval group.
• Date ratified: 6 August 2024.
• Name of originator or author: Service managers, Community Mental Health directorate (Rotherham, Doncaster and North Lincolnshire).
• Name of responsible individual: Chief operating officer.
• Date issued: 28 August 2024.
• Review date: 31 August 2026.
• Target audience: All colleagues working within the primary and community mental health service.
• Description of change: New SOP to support those working within the service to understand processes and procedures.

Page last reviewed: January 17, 2025
Next review due: January 17, 2026

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