Integrated care programme in mental health

New Invention Health Centre – Staffordshire

The problem

The current model for patients with severe mental health problems doesn't always work seamlessly. The patient is seen by the Psychiatrist in a CPA (Care Programme Approach) review at the hospital and the Psychiatrist writes to the GP regarding the suggested care plan. The Psychiatrist depends upon the patient volunteering information, for example hospital admissions or out of hours service attendance, which may not always be given or correct. 

Often after receiving the Psychiatrist's letter, which can be 1 – 2 weeks after the actual consultation, the GP may realise that the suggested care plan may not be suitable due to the patient's co-morbidities or drug interactions. The GP would then need to contact the Psychiatrist to discuss an alternative plan, then contact the patient to discuss the alternative plan.

The psychiatrist for our practice, discussed a new model of CPA review in a primary care setting, involving a much bigger multidisciplinary team to include primary care professionals. We thought the inclusion of the GP and the patient’s GP record in the CPA review would help with early decision making, continuity of care and be more resource efficient. We drafted proposals for a project piloting this method for the practice and the Mental Health Trust and both were accepted.

The Bright Idea

We implemented an Integrated Care Programme Approach review for patients with severe mental health problems. The integrated CPA review is held at the GP surgery instead of at the hospital and is attended by the Consultant Psychiatrist, CPN (Community Psychiatric Nurse), Social Worker, Psychiatry Specialist, Practice Nurse and GP Mental Health Lead for the practice. So far, six integrated CPA review sessions have been held at the practice, which averages at one every other month. One morning session is booked for the integrated CPA review and six patients are booked into each session. The list is provided by secondary care and the practice secretary contacts the patients to book appointments.

The session included two parallel running clinics:

  • The Practice Nurse runs a physical health check clinic with 15 minute appointments. Using a template created on the EMIS system, the practice nurse does a physical health examination, checks if any blood tests or ECG are due and advises on health promotion if needed. An appointment is booked for bloods and/or ECG by the practice nurse or these tests are done while patient is waiting for their CPA review.
  • After the physical health check is done, the GP briefs the integrated CPA team about the patient’s physical health, attendance in the surgery or at any other health care services since last CPA review, any safety concerns recorded in the GP record and suggests a plan to address any physical health issues.
  • The CPA team reviews the patient’s overall circumstances and then, along with the patient and their carer, formulises a plan of care, discusses allocation of responsibilities to different team members, book any follow up GP appointments needed, issue any prescriptions needed and a provisional date for the next CPA review is agreed upon.

The pilot project is being managed so far without any additional external resources. A session of the GP's and Practice Nurse's time was required to be freed up on average every other month and time is needed for the Practice Secretary to liaise with the psychiatry secretary and to contact the patients to book appointments. Two rooms were needed in the practice to carry out the CPA reviews, one for the Practice Nurse to carry out the physical health check and a larger room, preferably a meeting room, for the integrated team.

From the pilot project, we have found that the team are able to look at more comprehensive patient records, including medication, out of hours attendance, A&E attendance and if any intervention has been needed for physical or mental health issues. Any changes to medication or the patient's care plan can be directly discussed within the care team to prevent issues further down the line. As the physical health check has taken place prior to the meeting the Psychiatrist doesn't have to withhold any treatment or medications awaiting any investigation results.

Patients who fail to attend the review meeting are also discussed during the time allocated. The reason for the DNA may be obvious in the GP record, for example the patient has been admitted to hospital, they have received a travel vaccination or the patient is housebound. The patient's attendance at the GP surgery since their last review meeting is discussed and any relevant consultations are discussed specifically.

90% of the patients involved in the pilot agreed that they were involved in the decision making and the team involved listened to them. All of the patients agreed that the management plan was explained to them well and that they would recommend this new system to their family and friends.

The impact


Patient experience better care and management of their mental health care. There is better continuity of care, improved patient satisfaction and less visits to GP for the same problem.


There is a much clearer process in place. Less practice appointments are needed as most of the issues addressed on one day and less follow-up appointments are needed. GPs have improved awareness and communication with members of team involved in patient's care.


The multidisciplinary team who are involved in the patient's care have established and direct communication with the patient's GP, resulting in better inter-disciplinary communication and quicker decision making.

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