A partnership between Nottinghamshire Healthcare NHS Trust a nd the University of Nottingham

1. Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and LincolnshireCLAHRC NDL Overcoming Difficulties Engaging Long-term Regular Attenders in Primary Careinto anIntervention Study A partnership between Nottinghamshire Healthcare NHS Trust and the University of Nottingham Chris Atha, Cognitive Behavioural Therapist Shireen Patel, Research Associate CLAHRC NDL

2. Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and LincolnshireCLAHRC NDL Background The top 3% of frequent attendance in primary care is associated with: • 15% of all appointments in primary care (Neal et al 1998) • Five times as many prescriptions and hospital contacts (Heywood et al 1998) • A range of chronic physical health problems and higher rates of mental disorder (Ferrari et al 2008, Luciano et al 2010)

3. Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and LincolnshireCLAHRC NDL Background • If frequent attending continues for more than two years it can mean that the health service may not have found a way of helping with some of their problems (Smits et al 2009) • There is an established link between chronic physical health problems and mental health (Katon 2003, Ford 2008) • Cognitive Behavioural Therapy (CBT) is recommended but lack of adherence to CBT remains a central issue (Alicia et al 2006)

4. Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and LincolnshireCLAHRC NDL Methods/aims Cognitive behavioural formulation only Regular attenders (30+ appts in 2yrs) baseline interviews and medical records analysis n = 100 Patients selected from 3 Nottinghamshire GP practices Cognitive behavioural formulation & therapy Normal attenders (6-22 appts in 2yrs) baseline interviews and medical records analysis n = 100 Qualitative interviews motivation for consultation n=15 Qualitative interviews for implementation analysis with staff n=33

5. Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and LincolnshireCLAHRC NDL Recruitment figures at 18 months

6. Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and LincolnshireCLAHRC NDL Engagement adaptation methods • The barriers to the recruitment of regular attenders were identified • Strategies were implemented at an organisational and service user level • Recruitment figures were re-assessed 6 months after the changes were implemented

7. Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and LincolnshireCLAHRC NDL Barriers to Recruitment The barriers to recruitment were identified at two levels: Organisational Service User

8. Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and LincolnshireCLAHRC NDL “I think there’s also a bit of, well who are these people? I don’t know ...There’s a bit of a trust issue as well I think.” GP “Feel safer with me than they might do with some new outsider.” GP • Strategies • Building relationships from the outset by adopting a more informed approach to working with practice staff i.e. Initial meeting with all staff • Regular feedback sessions with practice staff to provide an update of recruitment and treatment patients • Clear consideration of terminology used when explaining the study to participants at initial contact TRUST AND RELATIONSHIP "I've had this letter, I think they (researchers) think I'm barking mad.” PN “Obviously it makes it better for the patient to see the same doctor and obviously you build a relationship and a trust.” PT

9. Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and LincolnshireCLAHRC NDL “I went back and spoke to Dr L about it and she said, you have been let down by the system.” PT “First assessment appointment waiting time (for the local counselling service) of somewhere around six to eight weeks.” GP • Strategies • A researcher and therapist present at baseline interview • An addition of two therapists to allow greater flexibility and choice for patients • Flexibility about number of appointments, location of therapy and management of other client concerns “The previous counsellor, she left me feeling exposed and in a mess really ..” PT PREVIOUS NEGATIVE EXPERIENCES “….. like having the rug pulled out from you sort of thing because what was doing me really good, was just taken away like that and I ended up and I still think I wish that I hadn’t started in the first place.” PT

10. Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and LincolnshireCLAHRC NDL “I talk to patients right from the beginning about, you know, this might be psychological, but when it looks like it actually might be, it’s like, it’s very offensive. Either that or they just don’t hear it. It doesn’t go in.” GP “Me personally, I've probably on more than a few occasions rubbed patients up the wrong way by mentioning it too early in their view.”GP • Strategies • Collaborative approach involving patient, therapist and GP • Provision of a script for GPs to explain study to patients • Therapists able to explain rationale for treatment at baseline interview • Individualised treatment approach using a bio psychosocial approach READINESS “It took a while to accept I had a problem. I knew I had depression but I didn’t think it was anywhere near to what it was.”PT “But I needed to take the chance asI was at that turning point when I knew I needed to do something and anti depressants didn’t seem very appealing to me because of the side-effects.” PT

11. Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and LincolnshireCLAHRC NDL Recruitment rates after changes implemented

12. Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and LincolnshireCLAHRC NDL Comparison of average monthly recruitment rates

13. Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and LincolnshireCLAHRC NDL Recruitment rates over time (6 monthly intervals)

14. Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and LincolnshireCLAHRC NDL Conclusions • Working in collaboration with organisations and service users • Active monitoring of barriers to study progress and adapting strategies to meet needs • Highlighting benefits of the research to all those involved • The project enabled us to identify key issues on how to engage high service utilisers of primary care • May provide guidance to the government and CCGS prepared to invest in psychological treatments for people who have a complex mixture of physical, mental and social problems

15. Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire and LincolnshireCLAHRC NDL Acknowledgements Our sincere thanks to the practices and patients who participated in our study Thank you for listening, any questions? Chris.atha@nottingham.ac.uk or Shireen.patel@nottingham.ac.uk