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Friday 19 July 2019
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Mental health practitioners in primary care: ‘There’s more of a conversation happening’

As part of Management in Practice’s series on the wider primary care team, Rachel Carter explores how practices are working with specialist mental health staff

As part of Management in Practice’s series on the wider primary care team, Rachel Carter explores how practices are working with specialist mental health staff
 
Last year, NHS England announced that mental health therapists could become ‘the norm’ in general practice, as it launched guidance for GPs on how to co-locate this group of professionals into their surgeries. 
 
The guidance, developed in partnership with the BMA and the RCGP, followed a commitment in the 2016 General Practice Forward View to place an extra 3,000 mental health therapists - predominately provided through Improving Access to Psychological Therapies (IAPT) services - into primary care settings by 2021. 
 
Lat year, NHS England said 800 surgeries had taken the plunge by August 2018 - but how are practices approaching this type of integration and what benefits does it offer?
 
‘Less of a postcode lottery’ 
 
The Birley Health Centre in Sheffield is noted in the NHS guidance as an example of good practice and was seemingly way ahead of the game - it’s had IAPT therapists working out of its consultation rooms since the programme launched in 2008. 
 
Today, Sheffield is split into four localities and within these are ‘neighbourhoods’ of GP practices. A team of seven therapists, directly employed by the IAPT service, are based out of Birley and see patients in the practice every day. However, they also support other practices in the neighbourhood; depending on where demand is greatest. 
 
‘The IAPT manager is always looking at the data and if we’ve got a waiting list [for mental health treatment] elsewhere in the neighbourhood then they let me know one of our workers is going to be based there for a few months,’ says practice manager Kiz Haigh. 
 
‘As a result it [treatment] becomes less of a postcode lottery for patients, because we are managing the demand and putting people where they are most needed.’ 
 
‘The therapists are part of our care system’
 
GPs at Birley have previously reported that being co-located with the IAPT therapists provides more opportunity for informal learning, sharing information and face-to-face discussions about patients, helping to create an efficient way to address referral or risk issues. These benefits also extended to the wider practice team, Ms Haigh says. 
 
‘It means our reception staff, who are often dealing with patients first, have someone to ask too if they have query, rather than waiting to get through to someone on the phone.’
 
Ms Haigh works in partnership with the IAPT manager to organise the therapists’ schedules and has also been responsible for supporting them and helping them integrate into the practice team. This includes giving them an induction, inviting them to staff meetings and collecting feedback. 
 
‘We obviously have a duty of care to anyone coming into work here, even if they are not employed by Birley, so I will always make sure they feel part of the practice,’ she says. ‘They are not just someone coming in once a week, they are part of our care system.’
 
‘It’s about engaging the patient’
 
At Birley, the IAPT services include counselling clinics, cognitive behavioural therapy and guided sessions with psychological wellbeing practitioners. If a GP thinks IAPT will be appropriate, the patient is asked to go to reception and make a referral. 
 
‘That’s about engaging the patient. If they are involved with it and want to do it then we take it forward from there and the IAPT worker will contact them directly,’ says Ms Haigh. 
 
The IAPT worker and the patient then decide together what course of treatment might be appropriate, and Ms Haigh says a key benefit for patients is that they are able to access a full range of services within the practice – rather than having to travel elsewhere.
 
‘For people with anxiety and low mood, actually travelling somewhere else and going to a place they don’t know can make things worse. This removes that barrier,’ she says. 
 
‘Patients can come here and they know the building, they know the staff and it’s familiar.’ 
 
‘Enhanced primary care’
 
Being seen in their own GP practice, rather than going to separate premises specifically dedicated to mental health services, has also been popular with patients in Cambridgeshire and Peterborough. Here, a considerably larger ‘enhanced primary care for mental health’ service has been rolled out.
 
The service, known locally as Prism, includes 12 specialist place-based mental health teams, made up of consultant psychiatrists and community psychiatric nurses and aligned to groups of GP practices.
 
It also comprises a recovery coach team to support people moving back from secondary care to their GP practice, and soon-to-be recruited physical health workers, who will support people with severe mental health problems to manage any physical health conditions.
 
‘On the whole the patient experience is very good,’ says local GP Emma Tiffin. ‘They feel they get a better deal from the Prism team because they have more time and expertise.'
 
The teams provide early assessment and treatment, as well as referrals to other services in the community. A patient still sees their GP first and if Prism is considered appropriate a ‘request for service’ (the Prism word for referral) is made. 
 
‘We’ve worked really hard to get away from that secondary care language - because this is not a secondary care service plonked in primary care – it’s different,’ says Dr Tiffin. 
 
What it’s largely about, she adds, is supporting primary care to manage those patients with more complex problems, and ‘give that integration we’ve never had before’ in terms of knowing what’s available in the wider community to support a person’s recovery. 
 
‘Developing relationships’
 
Dr Tiffin, who is also the mental health lead for Cambridgeshire and Peterborough CCG, says Prism was partly set up to tackle the ‘crazy’ referral rates to secondary care.
 
Back in 2015-16, the area had the second highest rate in the country but nine of out 10 referrals were sent back to primary care, with patients either ‘not getting or needing’ specialist care. 
 
‘That wasn’t an efficient way of doing things - bearing in mind that each referral takes about three hours to process - and we needed to create capacity to actually treat patients,’ Dr Tiffin explains.
 
Another reason, she adds, was to address the gap for patients who ‘need a little bit more’ than what’s on offer in general practice but don’t meet the threshold for secondary care. 
 
An evaluation of the service by York Consulting found it has successfully cut referrals to secondary care mental health services – with 1,065 fewer assessments undertaken between May 2017 and March 2018.
 
This is compared to the number carried out under the single point of contact – known as the Advice and Referral Centre  – through with practices previously interacted with secondary care. Average waiting time for an appointment is now 14 days, a significant drop from the previous 37-day average. 
 
‘Having the Prism teams and consultants co-located also means GPs can contact them easily, we know who is accountable for our patients and we can discuss cases,’ Dr Tiffin says.
 
‘It’s been important in terms of developing relationships and is very similar to what the Government is trying to do with primary care networks - this is our mental health solution.’ 
 
‘Up-skilling staff’
 
The long-term plan confirmed that neighbouring GP practices will have to join together in primary care networks and reiterated the focus on a ‘wider primary care team’ – with networks sharing resources designed to enable them to employ extra staff from different disciplines and introduce new services. 
 
While the national direction of travel in terms of mental health in primary care has so far broadly focused on integrating IAPT therapists, some areas have opted to work with other professionals.
 
In Gloucestershire, for example, the CCG and the 2gether NHS Foundation Trust in 2017 launched a pilot that places specialist mental health nurses in surgeries. 
 
‘The idea behind it is that, with mental health patients, the nurse acts as we would act as GPs,’ says Dr Tara Hunt, a GP at Hadwen Medical Practice, which is taking part in the scheme.
 
At Hadwen, the mental health nurse works three days a week (although there are nurses working full-time in other practices, Dr Hunt says), offering a mixture of routine face-to-face appointments, telephone and urgent appointments to mental health patients.
 
‘She’s able to see the same range of patients, in terms of severity of problems, as GPs would, because she’s had a lot of experience in both acute and chronic mental health,’ Dr Hunt says of the mental health nurse at Hawden. 
 
‘By the nature of her being in the surgery those skills also get disseminated, so she’s up-skilling us - and there’s much more of a conversation about mental health happening.’
 
‘Fantastically improved’ patient experience 
 
Dr Hunt, who is also mental health lead for the practice, says one of the key challenges the pilot has helped to tackle so far is how to support people with acute mental health problems who come through to the on-call GP’s triage list for urgent or on-the-day issues.
 
This list often includes concerns such as earache, dizziness and abdominal pain, but among these there will always be quite a few mental health problems too. And due to their nature, for example someone feeling suicidal, they can be difficult to triage quickly. 
 
‘My feeling has always been that the appropriate place for those problems is not with the on-call GP: it would be great to develop a specialist service devoted to that,’ Dr Hunt says.
 
‘That’s effectively what this pilot has done - we have telephone triage slots in our nurse’s timetable so now those calls that come through to the on-call can be put directly to her.’ 
 
Data collected so far shows this is helping relieve pressure on appointments generally and decrease referrals to secondary care, Dr Hunt says.
 
She adds that it’s ‘fantastically improved’ the patients’ experience because they are appropriately triaged by someone with specialist mental health experience - and, if needed, seen by that same specialist on the same day. 
 
‘Consider whether it’s sustainable’ 
 
The pilot was recently extended until March 2020 to give participants more time to ‘really figure out’ the specific outcomes, Dr Hunt says, and one area that will be closely monitored going forward is how sustainable the role of the mental health nurse is.
 
‘We have much shorter appointments than secondary care and so, relative to their role in secondary care, the nurses are seeing a high number of patients in a day,’ Dr Hunt explains.
 
‘It’s a well-known phenomenon that you can get fatigued by that as a clinician. So, we have to look after people who are seeing a lot of mental health patients and consider whether its sustainable from their point of view, and how we can support it to be.’
 
Dr Hunt concludes that it’s essential to bring more mental health skills into general practice and that doing so is ‘ideally placed with the future vision of primary care networks.’
 
‘We’re trying to remove the stigma [around mental illness] and giving a patient who may be feeling desperate, anxious or suicidal the opportunity to come and see someone in the surgery with a [profound] understanding of their problem is hugely beneficial.’
 
For Management in Practice's previous feature in the wider primary care team series  – examining how working with in-practice pharmacists can relieve pressures within general practice  – click here