Mental Health In Primary Care - Mind
Mental healthin primary careA briefing for ClinicalCommissioning GroupsJune 2016
When we’re worried about our physical health, weusually seek help as soon as possible so that we’reless likely to become ill. Similarly, if we have a mentalhealth problem, we want to receive help promptlyfrom somewhere close to home so that we canrecover and stay well.Those working in primary care – GPs,practice nurses, pharmacists and others– are our first port of call for health care.They are seen as the experts in providingholistic care for both our physical andmental health. Primary care settingssuch as GP practices and communitypharmacists are close to people’s homeand are easily accessible.Clinical Commissioning Groups (CCGs)are playing an increasing role in thecommissioning of primary care services– whether they have been delegatedcommissioning, are joint commissioningor have a greater involvement in2commissioning, with NHS England. This ishappening at a time when primary careand mental health services are both understrain and in the spotlight.Right now, we have an immenseopportunity to improve mental healthsupport within primary care.We believe that if we get mental healthsupport in primary care right, we canhelp people stay well. This is good forindividuals, families, communities and thewider health and social care system. It canalso lead to cost savings as the likelihoodof people needing crisis care decreases.Mental health in primary care A briefing for Clinical Commissioning GroupsIn this briefing for CCGs in England we: present the current issues around providingmental health support in primary care identify what mental health support inprimary care should provide make recommendations for commissionerson how to achieve better mental healthsupport in primary care.Over the next few years we will be campaigningfor improved mental health support in primarycare and we want to help you to achieve this.
Contents1. Mental health support in primary care right nowCase study 1: City and Hackney Primary Care Psychotherapy Consultation Service2. What is primary care mental health?478Case study 2: Robin Lane Health and Wellbeing Centre3. How should primary care mental health work with other services?Case Study 3: Mind Active Monitoring1011124. How can Clinical Commissioning Groups help?Case Study 4: Primary Care Plus13155. How Mind can help15Mental health in primary care A briefing for Clinical Commissioning Groups3
1. Mental health support in primary care right nowOn average,Only 24 per centof people inEngland witha commonmental healthproblem receivetreatment.1GPs spendnearly a fifthAroundOne in threeof their appointment timeon social issues.3GP appointmentsinvolves a mental healthcomponent.2People with physicallong-term conditions aretwo to threetimes more likelyto experience mental healthproblems than the generalpopulation.457 million prescriptionsfor antidepressants were administered in 2014,an increase of 46 per cent since 2012.5?4Medically Unexplained Symptoms (MUS) account forup to a fifth ofGP consultations.Mental health in primary care A briefing for Clinical Commissioning Groups6Half of GPshave been found to beat high risk of burnout,7and 16 per cent reportexperiencing a significantand unmanageable amountof work-related stress.8Only67 per cent ofrough sleepersare registered with aGP compared with 98per cent of the generalpopulation.9
One in four of us will experience a mentalhealth problem in any given year, but most ofus don’t get professional help. Of those of uswho do get treatment, the majority are treatedwithin primary care.10 This is why good mentalhealth support in primary care is so important.Often people don’t discusstheir mental health directly.In fact, they may discussother concerns that areimpacting on or are relatedto their mental health.Local GPs and other primary care staff, suchas practice nurses, pharmacists and others,are the first place we go for healthcare adviceand support, and just like our physical health,they are there to look after our mental health.GPs recognise how important mental health isto their daily work, and are aware that oftenpeople don’t discuss their mental health directly.In fact, they may discuss other concerns thatare impacting on or are related to their mentalhealth. It may be a physical health issue or asocial matter such as relationship problems,unemployment or work related issues, welfarebenefits, financial worries and social isolation.This may lead to people attending their GPpractice frequently before their underlyingmental health needs are addressed.Furthermore, GPs and other primary carestaff also have a clear understanding of justhow much our mental and physical health arerelated. For example, those of us with physicallong-term conditions, such as diabetes, orchronic pain, will often struggle with ourmental health, and will have better outcomesif both our physical and mental health isaddressed. Primary care can provide thisholistic ‘whole-person’ care.I went to see one GP and hewas filling out a prescriptionbefore I had even sat down.Mental health in primary care A briefing for Clinical Commissioning Groups5
When I was waiting to be referredfor help it took months and I felt Iwas sinking lower and lower.For those of us who have accessed supportfor our mental health from our GP, it cansometimes feel like there is an overrelianceon prescribing anti-depressants.From the GP’s perspective, they feel likethey have little alternative but to prescribeanti-depressants as the waiting timesfor talking therapies are too long andthey want to keep their patients safe.When accessing talking therapies, therecan also be a lack of choice about whattype of talking therapy we receive. This is afrustrating situation for both those seekinghelp and primary care professionals alike.6For certain communities accessing anyprimary care services can be moredifficult, with wide variation in GPregistration amongst vulnerable groupsincluding vulnerable migrants, gypsiesand travellers, homeless people and sexworkers. Unfortunately these communitiesare also known to have particularlyhigh need for mental health support.All of this is happening during a time whenprimary care services are under a lot ofstrain. We know this is having an impacton many primary care professionals’ ownmental health and wellbeing. We cannotwork to improve the mental health supportMental health in primary care A briefing for Clinical Commissioning Groupsprovided by primary care services, unlesswe support the healthcare staff providingthose services and ensure the environmentsthey work in are mentally healthy.We cannot work to improvethe mental health supportprovided by primary careservices, unless we supportthe healthcare staff providingthose services.
Case study 1: City and Hackney Primary CarePsychotherapy Consultation ServiceThe Primary Care PsychotherapyConsultation Service (PCPCS) wasset up in 2009 in City and Hackney bya group of GPs who recognised thatsome people were falling through thegaps: their mental health needs wereunable to be fully addressed by theirGP practice, but their needs also didn’tmatch the remit of specialist care. Thisincludes people with chronic mentalhealth problems, personality disordersand those with ‘Medically UnexplainedSymptoms’. Often people had a range ofsocial and physical health problems too.The service is run by the Tavistock andPortman NHS Foundation Trust and islargely based in GP practices.It has two key functions:1. Providing support to GPs andother practice staff through casediscussions, joint consultations andbespoke training2. Providing a clinical service to thosereferred by their GP, including a rangeof psychological interventions forindividuals, groups, couples or families.Approximately three quarters of all patientshave shown improvements in their mentalhealth, wellbeing and functioning as aresult of treatment from the service.Compared with the year before referral,the average number of GP attendancesper patient seen by the service fell by aquarter in the year after treatment.The service has now been expandedand Team Around the Practice (TAP)has been running a similar service inCamden since 2015. This service is run inpartnership with Camden Mind.My friends can see thechange in me it’s so lovelybecause I have a voice now.Understanding myself hasbeen so important.Mental health in primary care A briefing for Clinical Commissioning Groups7
2. What is primary care mental health?Out of 21 mandatoryclinical modules,only one moduleis dedicated to mental healthin the GP training curriculum.11Primary care mental health refers to mentalhealth services and support which are embeddedinto primary care such as within GP practices,the work of community pharmacists, healthvisitors and others, as well as Improving Accessto Psychological Therapy (IAPT) services.Primary care mental health servicesincludes two elements:131. Ensuring the primary care workforce have theknowledge, confidence and capacity to providemental health supportThis element is about integrating mental healthinto core primary care services. For instance,GPs being able to look after and address ourmental health, as well as our physical health.A survey of practicenurses found that82 per centhave responsibilities for aspects ofmental health and wellbeing wherethey have not had training, and42 per centhave had no training in mentalhealth and wellbeing at all.128For this to be achieved primary careprofessionals need to have the necessary trainingand time to provide an adequate level of supportfor people’s mental health (and for the physicalhealth of people with mental health problems).2. Mental healthcare which is providedby primary care professionals whoare additionally skilled in mental healthand who are able and supported toprovide mental health servicesThis element is about providing more specialisedmental health support within primary care. Forinstance, a primary care mental health workerbased in a GP practice or a GP with extendedMental health in primary care A briefing for Clinical Commissioning GroupsScope of Practice (GPwER) in Mental Health,who can support their other GP colleagues inproviding mental health care.These services can provide more specialistmental health support for those who requiremore support but who don’t need or are unableto access secondary care, or who have beendischarged from secondary care because theirmental health problem is stable.Some places are beginning to develop enhancedprimary care mental health services to meet theparticular needs of their local population. Manyof these services involve having mental healthworkers attached to GP practices in some way,or a secondary care consultant working in thecommunity alongside practices providing supportand advice. By being attached to or workingalongside GP practices, mental health workerscan ensure there is joined up physical andmental health support. Mental health support canbe provided closer to home in a less restrictivesetting and there is less likelihood of peoplefalling through the gaps.Having a mental health worker attached to orworking alongside GP practices improves theknowledge, confidence and capacity of the otherprimary care professionals in the practice. Themental health worker can also provide mentalhealth support including advice on consultationsand formal training sessions.
When you go into a GP surgery yousee hearing aid signs that show they’rethinking of deaf people; wheelchair accesssigns. What about for people with mentalhealth? When I go in there, sometimes mybrain’s going so fast people might as wellbe talking Russian.This is supported by NHS England in the‘General Practice: Forward View’ whichsaid that the primary care workforce wouldbe expanded, including through investmentin an extra 3,000 mental health therapiststo work in primary care by 2020, whichis an average of a full time therapist forevery 2-3 typical sized GP practices.14Some enhanced primary care mental healthservices also incorporate models of socialprescribing. Social prescribing or ‘communityreferral’ enables primary care to referpeople to non-medical support within theircommunity. Social prescribing recognisesthat our physical and mental health areinfluenced by social factors, and that oftenpeople need greater support within thecommunity for things such as housing orbenefits, or to address social isolation.It’s hugely important toaddress inequality of accessand experience of primarycare services through fundingoutreach schemes and otherinnovative practices.These two aspects of primary care mentalhealth are vital if people’s experiencesof accessing mental health support areto improve. However, if people struggleto access primary care in the first place,certain communities will not benefit.For these reasons, it’s hugely importantto address inequality of access andexperience of primary care servicesthrough funding outreach schemesand other innovative practices.Mental health in primary care A briefing for Clinical Commissioning Groups9
Case study 2: Robin Lane Health and Wellbeing CentreA Health Champions volunteer schemethat was set up at Robin Lane Health andWellbeing Centre in West Yorkshire hashelped to address people’s isolation andmental wellbeing.The scheme was set up with supportfrom Altogether Better (a national NHShosted organisation) in 2012. Usingan asset-based approach, the centreinvited patients to become HealthChampions. The centre was surprisedby the level of interest, and now over50 volunteer Practice Health Championswork alongside the practice team, and19 groups and activities have beenestablished by the Champions, alongsidethe establishment of a community café.During this time the patient list hasincreased by 57 per cent without anyincrease in primary or secondary careconsultations and there has been a 10per cent reduction in use of A&E.10Mental health in primary care A briefing for Clinical Commissioning GroupsPractice
Mental health in primary care A briefing for Clinical Commissioning Groups 5 One in four of us will experience a mental health problem in any given year, but most of us don’t get professional help. Of those of us who do get treatment, the majority are treated within primary care.10 This is why good mental health support in primary care is so important. Local GPs and other primary care staff .
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