WINNER☆ - Cwmtawe Cluster Mental Health and Emotional Wellbeing (MH&WB) Model
This project also took home the Outstanding Contribution to Healthcare Improvement Award.
Debra Morgan, Business Development Manager, Swansea Bay University Health Board
Introduction
GP and cluster feedback indicates an overwhelming influx of patients with low to moderate mental health and wellbeing issues, leading to unmet demand. Services, such as social prescribing, struggled to cope, especially during 2020. Data-driven insights revealed significant service gaps, with high referral rates to local mental health services, alarming drug death rates in Swansea (40% more than any other local authority) and rising domestic abuse cases.
The West Glamorgan Population Needs Assessment 2022 -2027 highlighted increasing mental health challenges including rising mental health issues among young people, increasing dementia cases and high suicide rates, exacerbated by social factors such as loneliness.
The aim is to develop a cluster model of primary care mental health services to reduce GP-related appointments by 60% within three years.
Methods
A community-level primary care model was established focusing on early intervention and prevention of mental and emotional health issues using a PDSA approach. Key actions included:
- Community engagement
- Collaborated with partners across sectors for a holistic approach to care, ensuring the right person, right place, right time.
- Sequential testing of services like all-age counselling, social prescribing, and a Cluster Wellbeing Practitioners gateway.
- Established a Mental Health Virtual Ward pilot, safeguarding peer support group, and participated in A&E Frequent Attenders Meetings to address underlying issues.
- Expanded services included therapeutic drumming sessions and a Dementia Café.
Outcomes
- Cluster-based, preventative, multi-agency approach to low-level mental health services.
- Streamlined access to care with effective triage and referral, ensuring the right person is seen first time.
- Enhanced quality of life for patients and prevention of mental health crises.
- Increased identification of safeguarding issues and unmet needs of carers/family members.
- Hub model shared with other clusters and regional boards to support wider service development.
- Fortified partnerships and reduced impact on primary care, with less escalation to secondary services.
- Positive feedback from service users.
Learnings
- Multi agency ‘doorstep’ approach has resulted in improved access to the right support in a timely manner.
- Cross organisational referrals and data sharing need to be streamlined/fast tracked to prevent delays in accessing services.
- System is crucial for enhancing safeguarding practices.
- Working seamlessly across organisational boundaries ensures patients do not fall through gaps.
What next?
- Refine map of services and share learning to influence internal planning and delivery.
- Explore how key posts/functions become ‘mainstreamed’.
- Establish how the Cluster Psychologist will link with Hub services / community.
- Promote the Cluster led model of MH provision across other clusters.
