Beth Fisher, quality improvement project lead, and Sue Pike, service manager at Devon Partnership NHS Trust, share their quality improvement journey to make Devon’s TALKWORKS service more inclusive and effective for LGBTQI+ people.
TALKWORKS is an ‘Improving Access to Psychological Therapy (IAPT) service, delivered by Devon Partnership NHS Trust, offering evidence-based psychological therapy for people experiencing common mental health problems (depression and anxiety). The service is accessible to all people regardless of sexual orientation, gender identity, ethnicity, disability, marital status, religion or age.
Prior to this quality improvement initiative there had been no specific focus on improving access for treatment, nor specific interventions, for people who identify as LGBTQI+. There was also no training designed to raise awareness of LGBTQI+ issues, or on how to improve treatment outcomes.
As an IAPT service, TALKWORKS is required to collect patient demographic information at the point of referral/initial assessment. All patients are sent a patient demographic form prior to their assessment, but unfortunately not all this data is completed or recorded on the patient electronic clinical recording system, IAPTus. Sexual orientation has not been a compulsory field, meaning that it can be overlooked.
What the organisation did
TALKWORKS aimed to increase the number of LGBTQI+ people accessing treatment, and improve the quality of their care and clinical outcomes.
A cross-functional team was established to lead the improvement, and a self-selected equality champion was identified in each team across the region.
A stakeholder analysis was completed, identifying those groups likely to be affected by the change. Key stakeholders were consulted with, and remain engaged through on-going communication and consultation where appropriate. TALKWORKS attended a range of pride and diversity events across Devon, and asked people at the event if they would like to complete an anonymous survey.
Key findings from the overall survey were:
- 59 per cent of respondents were at least moderately concerned about witnessing negative remarks within the service.
- 98 per cent of respondents thought it was important that staff training include specific guidance in how to meet the needs of LGBTQI+ patients.
- 100 per cent of respondents believed that it is important to have LGBTQI+ specific material available.
- There were more concerns about self-referral to TALKWORKS among LGBTQI+ people, whereas 100 per cent of heterosexual participants stated they had no concerns about self-referral.
TALKWORKS then held a focus group with people who have used the service who either identified as LGBTQI+ or had a particular interest in improving services for LGBTQI+ people.
The following key themes were identified:
- not feeling understood by therapist
- developing LGBTQI+ specific training
- impact of sexuality and gender identity on mental health
- including sexual orientation and gender identity within therapy
- creating LGBTQI+ specific material
A driver diagram was developed outlining possible areas for change, based on the themes identified in the survey and focus group.
Improved compliance with sexual orientation monitoring information - The first change was to make recording sexual orientation a compulsory field on IAPTus which resulted in an instant improvement in reporting this information for the majority of teams. The next change was for the equality champions to give a clear rationale to staff regarding the importance of asking patients about their gender identity and sexual orientation, and why it is important to have demographic information recorded on the clinical record.
The teams that are showing a clear trajectory of improvement in compliance and are still improving month on month. This is a sign that there is a willingness amongst staff to continue to improve data recording, the change is more than simply making the sexual orientation field compulsory.
Increased staff confidence - Following initial training, a survey showed significant increases of staff confidence in working with LGBTQI+ colleagues and patients, an increase in knowledge of LGBTQI+ issues, and an increase in understanding of terminology specific to LGBTQI+ people.
It is hoped that continued staff training will lead to an improvement in the quality of treatment offered to LGBTQI+ people. The focus group gave valuable feedback about what would be helpful to include on staff training from the perspective of an LGBTQI+ person who has used TALKWORKS.
Positive staff feedback - A TALKWORKS leaflet was developed in the Pride colours, including quotes from Stonewall research. Feedback from the focus group and pride events was positive. The Trust is also part of the NHS Rainbow Badge initiative, currently progressing to its second phase, and staff are encouraged to make a pledge to LGBT inclusion, wear rainbow badges and display the posters.
Further changes have been identified that may help increase access to the service, and improve the quality of treatment for people who identify as LGBTQI+. These changes include:
- liaising with specialist services, including the South West’s Gender Identity Clinic and Intercom Trust, to improve treatment delivery and develop further LGBTQI+ specific material
- reflective discussion in clinical skills/high intensity meetings, case presentations – to help consolidate learning in recent training, and increase staff confidence and knowledge in working with people who identify as LGBTQI+
- equality champions in each team to continue to ensure EDI is on the agenda
- TALKWORKS representation at Pride marches and diversity events.
- Improve marketing within the LGBTQI+ community and organisations to raise awareness of the service