Integrated mental health care

Camden CCG

The model involved the whole James Wigg Practice team working with community, social, third sector and hospital services, as well as patient participation in service provision.


Our inner city London practice has become a one stop shop for mental health care which is provided by a fully integrated multidisciplinary team encompassing: 

  • General practice 
  • Psychiatry and psychology 
  • Social services
  • Complimentary therapies
  • Voluntary services
  • Charity funded activities
  • Patient support groups (run by patients)

The practice list size is 24,000 with above average deprivation and high mental illness prevalence. The services are based together with shared IT, educational programmes and weekly multidisciplinary meetings.

Outcomes of the programme included improved patient care, staff training, patient satisfaction and morale.

Impetus, aims and objectives

We believe that a holistic multidisciplinary team approach, encompassing medical and social aspects, achieves better outcomes. We developed close links with community and secondary care organisations, the voluntary sector, patient groups, and  set up a charity to provide complementary therapies and activities.

Our Health Centre design enables many organisations to work together through a shared reception desk, shared IT services and an open-plan workspace.

Our objectives were to have:

  • Rapid access for patients
  • Integrated teams working together
  • Combined health and social care
  • Prevention of unnecessary hospital admissions
  • Relapse prevention
  • Decreased GP consultations
  • Improved patient satisfaction
  • Improved efficiency and effectiveness
  • Education/training for receptionists and clinicians 

Planning and putting procedures into place

We worked with our patients to design the health centre around our vision (achieving the RIBA Client of the Year Award).JWP image It includes an open-plan workspace with IT ‘hot-desks’ where all disciplines work closely together and communicate easily. Clinical sub-teams were developed to stimulate communication and team working.

Kentish Town Improvement Fund (KTIF) is a charity with trustees which is made up of practice partners, patients and the practice manager and there is a full time administrator based in the shared workspace.

Liaising with Camden Social Services led to a pilot scheme involving two full time social workers working in the shared workspace. From this there was a streamlined verbal referral system and regular reviews and feedback.

Liaising with Camden and Islington NHS Foundation Trust led to a pilot psychiatry project with a new primary care team based in the practice to assist with complex cases with monthly project review meetings.

Working with patient volunteers and Patient Participation Group (PPG) we were able to set up and run Cancer Support and Diabetes Support groups.

Standard procedures were developed within the practice, such as an induction programme, integrated IT training and support and ensuring attendance at weekly multidisciplinary meetings. We also hold educational meetings for all staff including tutorials for FY2 and GP trainees.


The project coordinator was the Managing Partner, who was accountable to all other partners; individual partners lead in different areas.  All services attend and present at a weekly clinical meeting. Separate planning and communication meetings are held on weekly, two weekly, monthly and quarterly basis’ for different groups of workers within the practice and other involved organisations.

An open-plan workspace is used by GP clinicians for all activities besides consultations which links clinicians with all other workers and reception staff.

A number of new integrated services have been introduced, such as:

  • Primary Mental Health Care Team (PMHCT) – consisting of a psychiatrist, psychologist and a CPN. They provide staff training and have one-to-one discussion of complex cases, are family based, and give an educational focus for GPs.
  • Two full time social workers – there are simplified referral pathways with social workers on site. There is also direct access to housing and financial support, carer services/support, and discharge and admission avoidance planning. 
  • Cancer support group - patient run with practice support and funding from Macmillan. The group is also open to patients of neighbouring practices.
  • ‘Silver Circle’ support group - for patients experiencing difficulties with ageing. 
  • Drug counsellor – there is a weekly clinic and ongoing liaison with GP lead for methadone prescribing.

A full list of services provided at the practice can be found here.

The KTIF charity, which is practice based, has a full-time administrator on site, hosts permanent rotating exhibitions orientated towards mental illness, workshops for patients with mental illness, different therapy sessions – such as art therapy, aromatherapy, a gardening project and a dance class for patients with Parkinson’s disease, and multilingual baby sing-along sessions which are helpful for isolated mothers.

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