practice aligned

mental health

Our Practice Aligned Mental Health Service was devised in 2016 to address an unmet need. Thousands of patients have benefited so far.

Such has been its success, the service expanded rapidly in 2020 into neighbouring areas of Chester-le-Street, City of Durham, Darlington and Derwentside.

What does it mean?

The service is a specialist mental health team – based from a nursing model and comprising specialist non-medical prescribers and social workers – embedded within General Practice.

Launched in April 2016, the service was the product of collaborative problem solving between DDHF, The Tees, Esk and Wear (TEWV) Valley Foundation Trust, Durham Dales, Easington and Sedgefield Clinical Commissioning Group (DDES CCG

Reducing inappropriate referrals to secondary mental health services was a central aim, along with creating a system of easily accessible support for patients with mild to moderate conditions.

Being in local practices means that people can see a mental health expert in the familiar surroundings.

How it helps patients, practices and staff

GPs can refer to us anyone aged 18 or over who needs mental health help or support, except in cases of dementia or memory-related issues.

We’re then able to invest some time in each person, getting to know them and talking through their issues over the course of 6 hour-long meetings. These can be over 6 weeks, 6 months or however the patient prefers. 

We also make great effort to fit the sessions around what else is going on in people’s lives.

Longer, informal conversations in familiar surroundings put patients at ease, encouraging them to open up, and helping us to identify any root causes, and develop specific treatment plans.

For some patients, it may be enough to spend the 6 sessions working with us on positive problem solving, dealing with distress or behavioural issues.

For others, there might be more specialist help available, for example to tackle anger management or substance abuse. If the patient agrees, we can refer them onto these services.

As well as stepping people up to specialist or secondary services, we also help patients being discharged from those areas, offering them a period of support before they return to the care of their GP.

How it succeeds

Since its launch in 2016, the service has been a success on several levels, with both direct and indirectly positive outcomes. 

Firstly and most importantly, the service has worked with over 2,000 patients, providing them with time and expert support – two hugely valuable commodities. We’ve tracked patient progress through Gad-7 and PHQ-9 scores as just one measure of our positive outcomes.

By taking on the responsibility for longer appointments and further referrals, we have both reduced both inappropriate referrals and the workload on GPs.

In a specific example case, the sessions we offered over the course of 6 months created positive outcomes for the patient, and freed up 15 hours of GP time.

The hard work, compassion and dedication of the team has also been a huge driver of success. Equally, a positive staff retention rate with many gaining professional development and promotion shows the team also worked hard for the staff.


Day Wait to Assessment
Patients Seen*
Hour-long Sessions*

* April ’17 to December ’19


“I have been seeing [my mental health worker] for about 6 months he listens guides and provides help in this fight against depression not sure where I would be without him”

  • One of our patients