Many stakeholders discussed the process of the initial referral into IAPT, and the PWP assessment that sought to identify whether their needs could be met by the internal pathways or whether they would benefit from external support. Service deliverers and community partners expressed mixed feelings regarding how well this worked in practice due to the occasional occurrence of inappropriate referrals. Ascertaining suitable and available support in the community was key to the Wellbeing Navigator’s role, and service-users generally reported their interactions to make the process of finding suitable support easier. The quality of collaboration between staff members, internally and externally, and between service deliverers and users, acted as important barriers or facilitators to the success of this suitability identification process.
Intra- and inter-service collaboration
PWPs’ understanding of the role of the Health and Wellbeing pathway was necessary to ensuring appropriate referrals. Efforts were made to raise PWPs’ awareness and integrate them into the new model, by participating in a HLHM ‘pilot’ programme to experience it from the service-users’ perspective, service managers explaining the pathway during team meetings, and PWPs asking service-users for feedback early on. This helped PWPs to view the new service more positively, and overcome a sense of change fatigue that accompanied organisational changes.
“[Service managers] came to our clinical skills groups that we have every week … talked through what the pathway was, who was suitable and how to refer … there just seems to be always a lot of change, and some feedback from clinicians was: ‘It's hard to keep up.’ But I think, generally speaking, it's been really good” (Service deliverer 8, PWP).
There were barriers affecting the ability of Wellbeing Navigators to discern appropriate wider services to connect service-users with. These included a lack of named contacts when seeking further information about available support services, and plans to co-locate with other services (practitioners with varied expertise being based in the same location) not coming to fruition, partly attributed to COVID-19-related restrictions.
“The gold standard would be for some of us to be much more co-located ... a team of people in there that might include a psychologist, some doctors, some social prescribers, a mental health nurse, someone from IAPT ... you can just discuss the person's needs and get them to the right place” (Service developer 2).
In addition, community organisations having limited capacity and complicated eligibility criteria reduced the Wellbeing Navigators’ inclination to connect service-users with them. For example, Service deliverer 7 (Wellbeing Navigation) described services only being accessible to ”certain postcodes ... dependent on where their GP is based”, but this was not clearly laid out on their websites, and other participants mentioned a need for more timely updating of service changes to avoid redundant referrals.
“One patient the other day that had been referred by Wellbeing Navigation ... but the service has since closed ... keeping our intranet up to date ... maybe link up with other people's databases” (Service deliverer 1, HLHM).
Communication with service-users
Even when the PWPs understood the value of the Health and Wellbeing pathway, there were still concerns regarding whether the initial assessment enabled them to identify wider needs to then pinpoint appropriate routes of support. The primary purpose of the assessment was to evaluate psychological wellbeing and determine the need for therapy, and depending on the severity of the service-user’s situation and the PWP’s caseload that day, the lifestyle questions could be missed all together. This was an ongoing challenge, as extending longer than an hour would not be effective as “people get tired and then they might not take that information in” (Service deliverer 9, PWP). Giving service-users more information and allowing online self-referrals directly into the Health and Wellbeing pathway was proposed to streamline the process. However, this relied on digital access and the service-user having the confidence to ask for help.
“I really like the HLHM video, so if there was a platform where you could find out about all these services, like ‘yep, I’m interested’ and that’s the referral. So that’s less work for the PWP, probably a more informed decision from the patient” (Service deliverer 9, PWP).
Once a service-user was referred to them, staff within the Health and Wellbeing pathway made a further assessment and gathered information on their circumstances, knowledge and readiness to change. This step was integral in delineating how they could actually support the service-user, and led to Wellbeing Navigators then compiling a list of relevant resources including charity helplines and websites to suit their needs.
“They will have an assessment with a PWP, and from there they could be referred to us. There’s different types of criteria that they, not necessarily have to meet, because when we do speak to them, sometimes the criteria changes ... they may say one thing but actually it’s something else” (Service deliverer 5, Wellbeing Navigation).
Service-users’ responses to being offered the Health and Wellbeing pathway were influenced by their expectations about the support they would receive, and how the new support was communicated to them at the point of referral and assessment. Those without clear expectations were generally more accepting of the non-clinical support, whereas those who expected therapy expressed more resistance. For example, Service-user 11 (Wellbeing Navigation) came into IAPT expecting a less costly version of counselling, but after being offered Wellbeing Navigation while on the waitlist for therapy, they lost faith in the whole service and refused therapy when made available.
“You can see on the GP notes, they said to the GP I just want to talk to someone about this, I really need some counselling ... that’s not really what we do ... we do try and say [we’re not a counselling service] in assessment, but after an hour of talking about all the most horrible bits of your life they might not be in a great place to really receive that” (Service deliverer 12, clinical lead).
“I was hoping for some real support ... in the first instance it was, well it seems to be it functions like a signposting agency really and I didn’t get a lot from it” (Service-user 11, Wellbeing Navigation).
Both service-users and deliverers emphasised the importance of receiving the right support at the right time, with some service-users likely benefiting from having therapy first to address the symptoms of their mental health issue, while others needed to address practical issues beforehand otherwise “that sense of helplessness might continue if they’re thinking there is no solution” (Service provider 7, Wellbeing Navigation). This was alluded to by Service-user 18 who disengaged from IAPT therapy due to their therapist not tackling wider issues occurring in their life.
“I slipped through the net … if you're slipping through the net because your mental health is getting worse because new things have happened, but they're still desperately wanting help – I didn't feel there was any option to say, ‘actually, life has just got a bit worse’” (Service-user 18, IAPT-only).