DacCom PbC Ltd

PBC Business Case Approval sought 

from the Governance Sub Committee - January 2008 

Provision of Primary Care 
Counselling Services in Dacorum 

Introduction

Since the introduction of Primary Care Organisations in 1999, primary care counselling has been the focus of change in structure, management and funding. Many GP practices have used individual self employed counsellors on a variety of contracts to provide this primary care service. 

In the Dacorum area, GP practices have felt this approach provided patients with the best and most appropriate pathway to counselling services and remain of that opinion.
However, there is a need to provide a more standardised approach across Dacorum to ensure equal opportunity to surgeries and their patients to access the counselling service, more regularised treatment of the counsellors employed to provide the service and improved rigour.

In order to achieve these aims, it is proposed that a Locally Enhanced Service (LES) is created which GP surgeries across Dacorum are invited to sign up to in order to continue providing a Primary Care Counselling service for their patients. 

The LES will provide:

•	cost savings by addressing the current inequalities where patients do not attend session appointments
•	introduce counsellor “levels” and pay bands according to the counsellor’s qualifications and accreditation
•	require regular meetings between counsellors to enable on-going training, potential cross referrals of patients (e.g. to a more experienced counsellor etc.),and significant event reviews
•	rigour by way of standardised referral and feedback forms

It is considered that this approach will provide a cost effective, non discriminatory counselling service to the patients of Dacorum. Full details of the proposed LES can be found in the enclosed documentation.
The benefits of implementing this LES

There have been various papers published which support the clinical effectiveness of counselling in primary care namely:

•	“National Survey of Counsellors working in Primary Care: evidence for growing professionalism?” (Royal College of General Practitioners) concluded “that the majority of counsellors met national criteria for good practice”
•	“Treatment Choice in Psychological Therapies and Counselling (DoH) confirms recognition of the distinct practice of primary care counselling and its place within the range of therapies offered within the NHS”
•	“Depression: management of depression in primary and secondary care (NICE Guidelines) stated “..in mild and moderate depression, short term psychological treatment of 6 – 8 sessions over 10 – 12 weeks should be considered”

We also believe the proposed LES fits strategically with recent proposals issued under the Mental Health review e.g.:

“Commissioning a brighter future: improving access to psychological therapies – a positive practice guide” (CSIP Choice and Access Team May 2007) - this document describes services that provide everyone with depression and anxiety disorders with access to the right treatment. It also sets out the learning so far from the demonstration sites. We believe the counselling service to be provided by this LES will help achieve one of the main aims within the guide i.e. successful psychological therapies ensure that the right number of people are offered a choice of the right services at the right time with the right results.

There has been increasing demand on the counselling service within Dacorum over the last few years but issues in meeting this increase. Most of this has been caused by budget restraints as most counsellors have confirmed they have additional capacity available. In order to ensure more of the right number of people are receiving the right services with the right results, the LES includes:

•	A 10% increase in counselling budget approved by the DacCom PBC Ltd Executive (see financials page 3) to increase capacity of the current service
•	A standardised referral form for GP use which contains suggestions on other alternatives to counselling before the referral is completed
•	Cross referral of patients to a more appropriate counsellor if needed as part of the proposed regular counsellor meetings

In addition, The Improving Access to Psychological Therapies (IAPT) programme is at the heart of the Government’s drive to give greater access to, and choice of, talking therapies to those who would benefit from them. One of its key policies is to ensure there is no discrimination over access to such therapies. The counselling LES does not discriminate over age, sex, gender or race and so fits in with this policy. We also believe that the counselling service LES provides for the first steps in the “Stepped Care Model” illustrated by this programme as the intended patient pathway.

Finally, the Mental Health Act 2007 Guiding Principles state 5 guiding principles at the heart of its review and this counselling LES will meet all 3 of the 5 appropriate principles for counselling i.e. the Respect principle (discrimination), the Participation principle (patients involved in making their own decisions about their own care and treatment) and the Resources principle (a good and fair service to everyone without wasting money or time).
Another key improvement to counselling services this LES will deliver is in the financial area which in itself leads on to increased service availability to all Dacorum patients requiring access to counselling services. This will be achieved as follows:

•	Currently there are a majority of counsellors who are being paid for a session even if the patient did not keep his/her appointment. The LES seeks to provide uniformity across Dacorum on such matters and therefore it proposes that a flat rate payment of £5.00 is made if the patient fails to turn up and has not cancelled their appointment within 2 working days (see LES for full details). 

As counsellors are currently paid between £20 - £50 per session (average £35.39) this represents potentially large costs savings.

Indicative figures produced from Dacorum practices for the period 1st Jan – 30th Jun 2007 show the “Did Not Attend” (DNA) rate averaging at 7% of total appointments available. Therefore potential savings of this proposal are:

Average Cost per Session	Annual Dacorum Budget	No of sessions p.a. at average cost	Average No of Sessions DNA’d	Cost of all DNA’s	
£35.39	£169,319.00	4785	335	£11,852.00	
After adjustment for payments made to some counsellors and not others	201	£7,111.40	
Add back flat rate £5.00	335	£1,675.00	
Net potential saving	3.2%	£5,436.40	

This change could therefore deliver around 155 more counselling sessions available for patients

•	An increase in the annual budget by 10% will also lead to additional sessions being available as the DES is expected to deliver minimal/zero increase in payments made to the counsellors within the new Levels :

Average Cost per Session	Annual Dacorum Budget after 10% uplift	No of sessions p.a. at average cost	Extra No of Sessions (Gross)	
£35.39	£186,250	5,263	478	

•	A sample exercise comparing current session rates paid to counsellors and the pay bands applied to the new levels indicate that there will be virtually no change to the average rate of pay per session and therefore all savings made will be directly available for additional sessions for patients

•	By purely enhancing the current counselling services the continued savings in Administrative costs will continue to be seen i.e. there will be no separate administrative team handling all referrals which will need to be funded from the counselling budget. All funding will therefore go towards patient care which was a main objective of this proposed LES and which would therefore deliver full value for money

The impact of this LES on the current service providers will be minimal:

•	They will continue to receive referrals for the GP surgeries they are ‘attached to’ (although others may be received following ‘cross referral’)
•	They will be able to continue using the GP premises (albeit some will now have to pay room rental) 
•	The number of sessions available to each patient will remain a maximum of 6
•	Feedback shows that current payment rates to the counsellors will effectively remain the same

Patient benefits will continue as before and in some cases improve:

•	The counselling service will continue to be provided by fully accredited counsellors holding BACP, BABCP, UKCP or BPS accreditation. Such accreditation being renewed every year
•	Patients will still be able to have the convenience of using their surgery for any sessions with the counsellor
•	A more appropriately experienced counsellor may be assigned to their case as a result of the LES introducing the cross referral process at the regular counsellor meetings
•	The current service is something which works for patients and the LES seeks to maintain this

Improved rigour will be achieved by:

•	Standardisation of referral form when referring a patient to a counsellor. All GP’s will provide the same information and in the same format and will have considered alternative routes for the patient before completing the referral
•	Standardisation of feedback to the GP’s following completion of the counselling sessions. Currently the level of feedback is rather hit and miss with some surgeries not actually receiving any 
•	Provision of feedback will ensure that the appropriateness and the effects of counselling can be ascertained by the GP enabling a decision on need for any further treatment which may be required
•	Regular counsellor meetings will enable a high level of clinical governance as detailed in the LES
•	Accreditation of the counsellors will be established and evidence provided to the GP surgeries
•	Monitoring of ‘did not attend’ appointments through the new feedback and activity forms will inform surgeries of the level of counselling service they are receiving and prompt any investigation into this if felt necessary. Such monitoring has previously been inconsistent and sporadic

It is intended that, should approval be granted, the full documentation for the LES will be distributed to all 19 GP surgeries within Dacorum during February 2008.

GP surgeries will be given 4 weeks from the date of distribution to obtain their counsellor’s signature to the Surgery/Counsellor Agreement form and sign and return the LES Agreement form.

The LES will be effective form 1st April 2008 until 31st March 2009.

Recommendation

We seek and recommend approval from the Governance Sub Committee to this proposed Counselling LES for Dacorum practices because:

•	The proposal maintains a successful and cost effective counselling service to the patients of Dacorum
•	The proposed refinements to the provision of this service will enhance GP, patient and counsellor experience and at the same time improve rigour
•	The continuation of the existing service has been shown to be clinically effective and maintains strategic fit with national priorities
•	An increase in the budget sought will enable increased capacity through this service as the treatment of ‘did not attend’ patients is regularised and existing payment levels to the counsellors are broadly maintained
•	By ensuring existing administrative tasks continue to be handled between the GP surgeries and the counsellors and by paying a flat minimal rate for ‘did not attend’ patients then the value for money the in house counselling service provides is maintained

Geoff Smith
Manager
DacCom PBC Ltd
January 2008