The City and Hackney primary care psychotherapy consultation service (PCPCS) was established in 2009 to help manage the complex needs of people who often fall between gaps in mental health provision. The service focuses on assisting people with difficulties that are hard for GPs and other medical professionals to diagnose, explain or treat effectively, particularly persistent frequent attenders. It provides practical interventions to its patients to improve their relationships and quality of life.
The PCPCS aims to treat the whole person, taking into account biological, social, psychological and environmental or historical factors. There is a particular interest in the less obvious and often unconscious aspects of thinking and behaviours which can influence the relationship to being helped.
Founders of the service included: Phil Stokoe (the head of the Adult Service at that time), Louise Lyon, Rob Senior, Brian Rock and Rhiannon England. The PCPCS grew out of the Adult and Forensic Services at the Tavistock and Portman, and came into being because GPs in Hackney said that they needed support around patients with complex needs and high intensity users.
GPs were concerned that patients in a diverse community like Hackney can easily fall into the gaps between traditional NHS services, especially those that present with medically unexplained symptoms. It was because of this perceived need that the PCPCS was commissioned.
210 Kingsland Road
The PCPCS was initially located in the ground floor annexe of Shoreditch Health Centre at 210 Kingsland Road (which was formerly the Shoreditch Maternity and Child Welfare Centre – established in 1922 as the first health centre for mothers and babies in London and one of the first ante-natal and infant care out-patient centres in Britain).
The PCPCS was based on a hub and spoke model and all the clinical work took place at GP surgeries in the community. Around 85% of Hackney GPs are now hosting this service.
Michael Balint and David Malan
The theoretical basis of the work carried out by the PCPCS is rooted in the research and work of Michael Balint and David Malan, particularly around brief therapies. Michael Balint had always been interested in the work of GPs (his father was a GP) and the eponymously named ‘Balint Groups’ were a way of supporting GPs in dealing with the difficulties and stresses that they experienced working with patients.
As well as this in 1956 Michael Balint initiated a Brief Psychotherapy research group to explore whether his form of brief therapy – focal therapy – was effective. He invited David Malan to conduct the evaluation and this became the basis of a thesis.
The results were surprisingly good, but were treated with suspicion by many. Malan however, continued to research brief therapy, how to achieve effective therapeutic results in the fewest number of sessions and the factors that made this possible. His research methodology has been impeccable and has demonstrated that the results of brief therapy can be as good as, or better than, those found in long-term therapy.
At the PCPCS from the outset there has been a focus on brief therapy models. The close relationship with GPs has been particularly important to ensuring their effectiveness. Joint consultations are held with the GP and the patient at the GP’s surgery. This is helpful as it is a more familiar and neutral setting for both the GP and the patient. The resulting practice is then orientated to talking therapies to help resolve issues rather than medication.
Spitalfields City Farm
In 2011 the PCPCS established the Horticultural Therapy Service at the City Farm in Spitalfields, providing a friendly, supportive space to work on an allotment with the assistance of a gardener and a Link worker. Social therapies such as this have a long history going back to pre-Victorian ideas of fresh air and exercise and the roots of occupational therapy. Hugh Crichton-Miller, the founder of the Taavistock Clinic, was a particular exponent of such therapies.
The horticultural group is now held at St.Mary’s Secret Garden, a community garden which provides sanctuary and green space amidst the busy streets of Hackney. This is the only longer-term treatment offered by the PCPCS.
Exhibition at Dalston Lane Public Library
In 2013 the PCPCS established a photography group after input from a visiting psychoanalyst from south London. The group runs on a weekly basis for a period of 12 consecutive weeks and is facilitated by two clinicians to harness the process of creativity and promote personal wellbeing. In 2018 the group held two successful exhibitions – one at Dalston Lane Public Library and the other at the Tavistock Centre Art Space.
In 2013 the PCPCS moved to St Leonard’s Hospital
The success of the PCPCS and the expansion of its projects has led to the growth of public and patient involvement and has acted as a catalyst for the development of a Service User Advisory Group. These initiatives resulted in the Hackney group making an influential film for GPs about how to treat patients with depression.
In the years 2014 to 2017, the PCPCS ran a sister service called the Care Planning Service. This service provided personalised care for people with complex health, medical, and social difficulties, bringing together a network of care and support. It aimed to reach a broader range of patients who may not be able to access or attend psychological services. It achieved this by meeting with patients in their homes, and having an effective strategy of multi-agency collaboration. The Care Planning Service was led by Carolyn Walker (Psychotherapist), and was made up of an experienced team of doctors, social workers, psychologists and therapists. Similarly to PCPCS, there was a strong emphasis on working alongside the GP and other health agencies, to provide a more integrated approach to care.
In 2014 the PCPCS published Managing Patients with Complex Needs in partnership with the Centre for Mental Health. Authored by Michael Parsonage, Emily Hard and Brian Rock this report explains how people with medically unexplained symptoms, personality disorders and those with complex mental health problems frequently get ‘bounced’ around the NHS, passed from one service to another, with none able or willing to offer them the flexible, personalised and sometimes time consuming support they require. It shows how this issue was tackled by a group of GPs in the City of London and Hackney commissioned the PCPCS to help those with mental health problems who fell outside the scope of other local mental health services. It also demonstrates how a service such as PCPCS can improve health outcomes while reducing costs and strain to primary care services overall.
Because of the success of the PCPCS in 2015 a sister service was created in Camden, known as the TAP (Team around the practice), in partnership with Camden and Islington Foundation Trust and Hillside Clubhouse. The TAP also works with adults in the familiar environment of their GP practice to manage their mental health needs. It provides psychological therapy and social prescribing to people who feel stuck, socially isolated, very low, anxious or who experience persistent emotional and physical pain or a sense of being overwhelmed. Social prescribing is when health professionals assign a range of local, non-clinical services as such as photography or gardening. Like PCPCS they also aim to support GPs in their role when working with people with these types of difficulties and other mental health problems.
Since 2016 the PCPCS has also been developing links with the Psychological Therapies Alliance (PTA) in an effort to help primary care practitioners to work more co-operatively and cohesively.
In 2017 The Horticultural Therapy Service moved to St Mary’s Secret Garden in Hackney
More recently, in April 2019, the PCPCS has been a stakeholder in one year pilot of the High Intensity User Service at Homerton Hospital. This pilot is delivered jointly alongside East London NHS Foundation Trust, Homerton University Hospital NHS Foundation Trust, Family Action and the Volunteer Centre Hackney. It aims to provide support to patients who regularly attend A&E, by offering a person centred approach which focuses on the individuals’ issues. The service offers case management, psychological interventions, and social and practical support, delivered from a de-medicalised and humanising perspective.
From the inception of the service in 2009, PCPCS has had created a tradition of thinking and acting in creative ways to meet the needs of the local population. They have achieved this by holding the patient at the heart of all they do, and thinking about services from a systems as well as individual level.
In recognition of the unique service model and contributions to the field in mental health, the service received awards in:
- 2013, Psychiatric team of the Year, Royal College of Psychiatry
- 2013, Innovative Excellence, British Psychoanalytic Council
- 2015, finalist in the mental health category, British Medical Journal Awards
The service has attracted skilled, experienced, and enthusiastic staff from a number of professions, such as social work, nursing, psychotherapy, psychology and psychiatry. This diverse mix of professions has created a culture of curiosity, and openness, which has generated the essential conditions that have allowed this service to flourish. PCPCS are particularly proud of the on-going achievements of staff in their careers beyond PCPCS, with many of the managers moving into director positions at the Tavistock and Portman NHS Trust, and many of the clinicians gaining places on the sought after Interdisciplinary training in adult psychotherapy.
Most of all, this service recognises and values the contributions and relationships that have been established in collaboration with services, both statutory and voluntary, within the Hackney and City Community.
Author: Glenn Gossling 2019