Prevention and Personalisation Service, Stockport UK.
Planning mental health care through user defined well being goals.
A collaborative approach to commissioning and a strong consortium of providers underpin the Prevention and Personalisation Service run by Stockport Mind alongside All Together Positive, a user-led social enterprise.
The service supports users of mental health services to co-create care pathways, supported by a Wellbeing Pathway Planner and access to a wide range of services from a variety of networked providers including peer groups, volunteering, debt and housing advice and clinical support.
The service aims to help two categories of people: those who are at risk of worsening in their condition and going into secondary care (the Prevention Pathway), and those who are in secondary care and could be supported by primary care and community services instead (the Recovery Pathway).
The design of the service rests on three key principles: focusing on service users’ aspirations; measuring what matters to users; and building for scale by embedding Pathway Planners in GP practice across the city. There are three steps to the pathway planning process, which happen on a timeframe that works best for each individual:
Initial emotional support, talking through why the service user is there and how they feel about themselves and their life in general, including but beyond their mental health.
Identifying aspirations for how the individual would like their lives to look in a week, a month or a year’s time.
Identifying barriers that are keeping the individual in secondary care (e.g. medications, social isolation) and preventing the individual from moving towards those goals, then working to remove or overcome them.
Progress is measured against an individual’s own goals, supported by outcome frameworks that look at headway made towards goals in categories such as volunteering, employment, finances and wellbeing. Individuals’ mental and emotional health is also measured through WEMWBS, the Warwick-Edinburgh Mental Well-Being Scale. Service users are asked to complete this as early as possible in the process to have an accurate baseline and again around 3 months later.
Since the launch of the service in 2012 there has been a significant decrease in the number of people referred to the mental health secondary care Single Point of Access. GPs have also reported a decrease in repeat appointments with service users who had previously accessed the GP on a regular basis but for whom there was no clear place to refer. The new pathways are ultimately expected to reduce referrals and re-presentation to secondary care by at least 60%, and increase discharge rates into primary care by 25%.