Introducing Speciality Mental Health Practitioners within Primary Care

Dewi Richards, Service Director CCC

Jade Harrison, Clinical Lead Emotional Wellbeing service

Betsi Cadwaladr University Health Board


Community Care Collaborative CIC (CCC) is a community interest company reimagining primary care to meet not only the medical but the social and pastoral needs of our patients.

Since our start a little over a year ago, our Emotional Wellbeing Team (EWT) has been at the heart of our approach. Comprised of Mental Health Nurse Prescribers, senior social workers, social workers and specialist care navigators, our EWT provides an expert first-port-of-call, reducing onward referrals and delivering improved health and social outcomes for our patients.

CCC’s EWT are currently active at three surgeries (Hillcrest, Boras Park, Forge Road Southsea).

Image of team with Vaughan Gething MS, Minister for Health and Social Services
Image: A visit from Vaughan Gething MS, Minister for Health and Social Services

Project Aims

CCC aims to reimagine primary care by bringing together voluntary, public and private sectors to develop and deliver an innovative, person-centred, social model of care. Working for the benefit of the community and as an asset locked organisation, any surpluses we make are reinvested into the enterprise.

By introducing specialty mental health practitioners within primary care, our aim is to:

  1. Provide a trusted and effective EW first-point-of-contact within the primary care setting for patients.

2. Reduce onward referrals and prescription rates by providing a range of services including psychotherapy, support groups, medication reviews and memory assessments.

3. Improve the mental health, wellbeing and social outcomes of our patients.

With traditional routes to mental health care typically involving an appointment with a GP often resulting in prescription or onward referral to a SPOAA, our EWT aims to increase GP capacity by creating a service that is accessible by anyone regardless of age or presenting mental health concern.

Image of staff sat at their desks

By connecting people with community assets and providing “one-stop-shop” support, ultimately, the aim of this project is to improve patient mental health and wellbeing, prevent escalation into crisis and facilitate a happier, healthier Wrexham.


Forming a new service, the first of its kind required much governance and dedication from the individuals employed by the CCC. The team needed to form links with the local health board and ensure pathways were established to safeguard themselves and the individuals within their care. The first year we encountered the expansion of service from 5500 patients up to 18.000 as well as working through a pandemic which has increased demand on mental health services.

Key Outcomes

The Emotional Wellbeing Team have only been operational for a short time but have already achieved fantastic outcomes for patients.

Using figures from EMIS, in the 6 months prior to CCC’s takeover, the three surgeries were able to see a total of 454 people with 760 total contacts. Over the same period following the introduction of the EWT, the surgeries were able to see a total of 1,230 individuals across 3,640 contacts. This represents a 171% increase in patients seen and a 378% increase in overall capacity.

Image of team member looking proud

Comparing 8-months pre/post introduction of the EWT, routing GP referrals were reduced by 47% and urgent referrals fell by 61%.

Bar chart showing the number of regular and urgent referrals 8 months before and after the introduction of the Emotional and Wellbeing team

The report below, published November 2020, examines the social and economic impact of Community Care Collaborative CIC’s (CCC) emotional wellbeing team across three surgeries in Wrexham.

Patient Feedback

We asked patients, “what has changed for you as a result of accessing the EWT?”

“[I] accessed AA as a result and recovered from alcohol addiction.”

“Lewis and Jade are angels in my life, huge positive impact for me and [I’m] managing life much better”

“[My] confidence has improved, weight been lifted. [I’m] no longer contemplating suicide.”

Using wellbeing questions from the national census, happiness before/after intervention improved from an average of 3/10 to 7/10, life-satisfaction improved from 4/10 to 7/10, and sense of meaning increased from 3/10 to 8/10.

Team Feedback

“The ewt has most definitely had an impact on individuals, I find it very refreshing following up patients and seeing them improve week on week”

Lewis Hales

“…highlighting the difference you’ve seen in patents as a result. What’s nice is hearing patients calling specifically asking to talk to a member of the EWT”

Jade Harrison

“For me, working in a surgery for over 25 years I have noticed a huge benefit of having the team here. G.P don’t have time to talk to patients no more which is what is needed.”

Dr Paul

Next Steps

The EWT will continue to serve the Wrexham community, expanding our range of services and expertise. By doing so, we hope to further reduce onward referrals, particularly to local primary mental health support services.

Voluntary and community services are key partners in our approach and our care navigators are expanding our network of relationships. We also hope to introduce consultant psychiatrists to our regular MDT meetings, allowing us to better serve patients with multiple and complex needs within the primary care setting.

Finally, given the success of the project, we hope to replicate our approach on a wider basis.

Our Exemplar Experience

“…the Bevan exemplar programme has guided our project and they have been on hand every step of the journey”

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Bevan Exemplar Innovation Showcase – December 2020