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Bevan Exemplar Cohort 5 Projects

Establishing a Family Wellbeing Service in Primary Care

Sue Wynne, Sara Owen and Sallie France

Betsi Cadwaladr University Health Board in partnership with North Denbighshire Primary Care Cluster and participating North Wales Primary Care Clusters


The importance of mental health and wellbeing cannot be understated. It affects and influences the lives of individuals, families, communities, and societies. Mental health affects all aspects of a child’s development including their cognitive and social development. With good mental health, children and young people do better in every way.

Recent years have seen a rise in the prevalence of emotional distress in children and young people. The Mental Health Foundation suggests, “Mental health problems affect about 1 in 10 children and young people”. The challenges faced by children and young people seeking support for their mental health have been highlighted by a number of national enquiries and consultations, leading to calls for system wide reform to improve early detection, facilitate timely access to evidence based treatments, and increase the provision of universal and targeted preventative approaches.

Children, young people and families’ access wellbeing support from a range of settings. It is widely acknowledged that we must improve capacity across the system if we are to support children, young people, and those who care for them to achieve emotional wellbeing. Primary care, alongside other health, social care, and education settings, is ideally placed to play a key role in the early detection of mental health concerns, and to facilitate access to appropriate needs based advice and intervention.

Project Aims:

To establish a pathway in primary care to support early identification of children and young people who are experiencing or at risk of developing a mental health disorder.

Utilise familiar primary care information systems (EMIS/Vision) to support needs led decision-making, and enhance access to high quality advice and service information to support early intervention.

To embed a Family Wellbeing Practitioner (FWP) in each primary care cluster. The FWP is a clinician with expertise in child and adolescent mental health and early intervention, and maintains strong links with universal and targeted children’s services and specialist mental health services (S-CAMHS).

They provide:

  • Training and consultation for primary care colleagues to enhance early detection and promote awareness of early help resources and services.
  • Direct consultations to children, young people and families who need more than self-help or signposting information, but do not require a specialist mental health service S-CAMHS. Practice clinicians can refer directly through EMIS.
  • Consultation for families who have received advice and signposting but require further support within six months of the GP consultation. Families are able to self-refer, reducing the need for repeat GP consultations.
  • Bridge the gap between universal and targeted support services and S-CAMHS, ensuring that each family referred has a plan to address their concerns.


Phase 1: Single Cluster (North Denbighshire Primary Care Cluster)

Design and delivery happened simultaneously. “Leap of faith” and ongoing commitment needed across CAMHS and the cluster to work in partnership to overcome barriers and improve design processes.

Extracting data for pre and post referral comparison took time due to accessibility of data sources. Clinical effectiveness tools (CGAS and GBOS), patient satisfaction questionnaires (ESQ), and training satisfaction questionnaires were collected from the onset.

Phase 2: Scale up phase (3 additional clusters)

Securing funding to maintain and scale up. Positive evaluation of initial pilot underpinned a successful bid for mental health improvement funding to recruit specialist nurses for each cluster.

Stakeholder engagement, communication flow, and implementation more challenging due to scale (number of surgeries involved), and disruption brought about by the pandemic. Implementation timescale has modestly increased, however support from cluster coordinators, GP leads, and practice mangers has enabled the project to progress.

Recruitment, induction and service planning coincided with lockdown requiring new and novel approaches to standard processes.

Key Outcomes:

Data collected from the initial pilot site showed positive outcomes across all measures including clinical effectiveness, patient satisfaction, and stakeholder satisfaction.

ESQ Patient Satisfaction Ratings

Review of 138 satisfaction questionnaires over a six-month period, with satisfaction rated 1 to 3 (3 being positive), returned mostly 3’s for care and overall satisfaction across all age categories.

Impact of Referrals to S-CAMHS

Analysis of referral data pre and post introduction of the family wellbeing model over a six month period showed a 39% reduction in referrals to S-CAMHS from the pilot site, compared to a modest increase over the same period from non-participating clusters.

CAMHS SPoA reported receipt of high quality referrals from pilot site, enabling timely allocation to appropriate urgent or routine care pathways.

Phase 2 (Ongoing) Implementation Outcomes

Specialist nurses recruited and implementing across three additional primary care clusters. First pilot site maintains an operational service.

Awareness training is in progress across 16 of 25 new practices, and has been delivered face to face or remotely via video or audio presentation to suit practice preference.

F12 EMIS template/protocol updated for new clusters. Development of Vision template is in progress.

Service User Quotes:

“Understanding our difficulties and knowing how to help is really appreciated. Also being seen before things get worse is going to prevent more difficulties in the long run.”

“I was given a lot of support and advice in regards to my concerns. She (FWP) listened and was objective in what I was concerned about”

“from start to finish excellent service and support”

Next Steps:

Complete awareness training and implement the model across remaining practices in Conwy and Denbighshire. Deliver high-risk mental health training in participating practices as soon as Covid-19 priorities allow

Evaluate satisfaction and clinical effectiveness across new primary care practices. Review phase one evaluation strategy to measure impact on referrals whilst controlling for Covid-19 variance.

Extend evaluation plan to measure impact on repeat GP consultations.

My Exemplar Experience:

Working with the Bevan Commission has been both inspiring and informative. I am grateful for the opportunity and would recommend the exemplar programme to anybody interested in innovation.