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Primary care mental health team
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About the service
The primary care mental health team provide advice and support to people experiencing a mental health problem that does not require secondary care mental health input. The team work proactively with service users who experience barriers which may impact engagement, or that may require outreach to their home due to physical/mental health reasons.
The team consists of:
Advanced clinical practitioners (ACPs) (**currently in training period and not accepting external referrals, will be working operationally from summer 2025)
ACPs will ensure that those with complex needs receive the best care possible. They offer support and advise primary care and wider partners.
Mental health community pharmacists
The pharmacy team provide expertise to ensure that people accessing community mental health care receive a treatment offer that is tailored to their individual needs.
Lead primary care mental health practitioners
The lead practitioners offer clinical leadership, as well as offering expert consultation and clinical opinion on appropriate care pathways.
Peer support workers (PSWs)
PSWs work alongside mental health practitioners, pharmacists, and advanced clinical practitioner to enhance the offer from a lived experience perspective. They also work with the Recovery College to support with co-production.
Primary care mental health practitioners (PCMHPs)
The PCMHPs offer comprehensive mental health and risk assessments for adults and older adults as well as expert consultation and clinical opinion on appropriate care pathway and intervention.
ARRS mental health practitioners
Mental health practitioners employed by the Trust but working directly within GP surgeries.
Individual placement and support (IPS) employment specialists
The IPS team helps individuals find and keep paid employment, aligning with their preferences and goals, while providing ongoing support for both employees and employers.
Why would someone choose the service?
The primary care mental health team provide an initial assessment for service users presenting with common mental health needs. We can signpost them to the most appropriate care or provide brief interventions when this is appropriate.
The majority of assessments take place in the service user’s home, but they may also be in a clinic setting, such as Drury Lane/Baghill House, or a GP surgery. When requested, we can complete assessments by telephone.
Where possible family members or carers will be encouraged to participate if we have the service user’s consent.
Staff you may meet
- Administrative staff provide essential support to doctors, nurses and other healthcare professionals. This can be in a variety of different settings, with administrators working as a receptionist in a clinic or a clerk on a ward. They may also be working closely with a consultant as a medical secretary.
- There are many different allied health professions including art, drama and music therapists, dieticians, speech and language therapists and occupational therapists. AHPs often work on their own and may work directly with a patient to develop interactive therapies to aid recovery.
- CPNs are registered mental health nurses who work in the community providing practical advice and ongoing support for people with mental health problems. This is most often in the person’s own home but it can also be in clinics, for example, in a GP’s surgery.
- Nurses who choose to specialise in the mental health branch of nursing work with GPs, psychiatrists, psychologists, and others, to help care for patients. Increasingly, care is given in the community, with mental health nurses visiting patients and their families at home, in residential centres, in prisons or in specialist clinics or units.
- There are many people who work behind the scenes to keep services running and you may meet them in hospital or community settings. They include porters, cleaners, plumbers, electricians, decorators receptionists and secretaries who all work to make sure healthcare settings are kept clean, tidy and safe.
- A pharmacist is an expert in medicines and their use. They work to ensure that patients get the maximum benefit from their medicines and can practice in hospital pharmacy, community pharmacy or in primary care pharmacy.
- Social workers help, support and protect people who are facing difficulties in their lives. They help people to take positive steps to overcome problems and improve their lives. This could involve assessing and reviewing a service user’s situation, building relationships with service users and their families and agreeing what practical support someone needs.
Why a professional should choose the service
The primary care mental health team have been developed in line with community mental health transformation.
The team can provide efficient entry into the Trust’s core team pathway if needed and can triage service users to the most appropriate service making the process as smooth as possible.
We have a team of experienced clinicians providing advice and information to the professionals who contact us, providing reassurance and support throughout the entire referral process. We work closely with IAPT, as well as third sector and Connecting Care partner agencies. We promote promotion of self-management and understanding around mental and physical health conditions.
In some cases, a direct referral to IAPT may be more suitable – please contact the team if needing advice on referral pathways.
We respond in a timely and compassionate manner to every referral to our service. Our highly qualified staff provide clinical assessments that give service users and carers maximum choice involve them in decisions made about their care or treatment.
Support offered
• Advice, guidance, and support on making appropriate referrals (excluding crisis)
• Home visits, use of GP surgeries, Drury Lane in Wakefield and Baghill House in Pontefract
• Short term interventions
• External referrals
• Support/check in if on external waiting list
• Update GP practices and liaise with other involved services/support networks
• Ensure services meet physical and mental health needs
• Identify and develop educational sessions for those within the hub and wider organisations
• Complete holistic mental health assessment and risk summary
Peer support workers
• Work as experts by experience
• Support people directly alongside mental health practitioners and mental health community pharmacists
• Work 1:1 with people accessing the service, helping identify goals, support to attend relevant appointments, navigate referrals, check-ins and advocacy where required
• Co-produce and promote courses to support the Wakefield Recovery college
• Co-facilitate individual learning plan appointments for new students accessing the Recovery College
Mental health pharmacy
• Patient consultations and medication counselling
• Home visits and telephone consultations
• Medication reviews for complex mental health regimens
• Working with practitioners for a patient centred approach
• Optimising mental health medication
• Medication advice – herbal, over the counter and illicit drugs
• Prescribing medication where suitable to aid mental health
• Providing mental health support for those with long term physical conditions
• Deprescribing
• Switching medications
• Assessing overuse and suitability of PRN medications
• Advice to primary care on complex care plans
• Answering queries from other practitioners
• Short term but not time limited interventions
• Discharge follow up
• Education sessions for other healthcare professionals
Referrals accepted from:
AHPs, CMHTs, Consultants, Drug/alcohol agencies, GP staff, GPs, Health visitors, Hospital staff, Housing associations, Local authority staff, Midwives, Other NHS services, Other Trust services, Single Point of Access team, Voluntary services
Referrals also accepted from:
WDH have mental health provision hosted by the Trust. The wellbeing service is open to WDH tenants over the age of 18 who have an unmet support need and are registered with a Wakefield GP. Referrals for WDH tenants can be sent to https://www.wdh.co.uk/health-and-wellbeing/mental-health-and-wellbeing-support/
Referral criteria:
• Registered with a Wakefield district GP
• Adults 18+. Can provide advice, guidance and consultation to young people approaching 18 if open to CAMHS or children’s services.
• Experiencing a mental health problem such as low mood, anxiety, stress, adjustment to significant life event changes – ** not acutely physically/mentally unwell, requiring crisis intervention or care coordination.
Mental health pharmacy criteria
• Registered with a Wakefield district GP
• Identified to have a current mental health need
• Adults 18+
** Person has consented to receive input from the primary care mental health team.
Exclusion criteria
• High risk to self or others
• Significant impairment of cognitive function – dementia, autistic spectrum or learning disability
• Those at significant risk of self-neglect
• Those who need to be primarily referred or have an active referral for forensic or neuropsychological assessment
• If the primary problem is drug/alcohol misuse case is best referred to substance misuse services – cases will be considered on an individual basis
• If not suitable the primary care mental health practitioners will work proactively with other providers/ services to ensure right care is secured.
• Those already working with a mental health service and engaging in treatment
Mental health pharmacy exclusion criteria
• Person is experiencing a mental health crisis and / or is actively suicidal.
• Acute intoxication
• Acute psychosis
• Alcohol withdrawal
• Injury which requires treatment
• Overdose/treatment or observations required.
• Personal care
• Routine medication reviews which could be carried out by primary care team
• Routine reviews (e.g. a routine annual antidepressant review)
• Care home patients