One thing that causes considerable dissatisfaction among patients and service users, GPs and mental health workers is how the interface works between primary and specialist care.
Service-users tell me about the tremendous variation between services across the country, and how, if they have been discharged to the care of their GP, it can be very difficult to get accepted back into services.
GPs can feel there is no point in referring to services who set the threshold very high, such that only those deemed to be at ‘high risk’ get accepted into care.
Mental health teams feel overwhelmed by referrals and try to ‘stem the flow’ by finding ways to triage and divert, which then just leads back to greater irritation in primary care.
Getting this right can bring real benefits for everyone. But there are also many different competing models. What principles do we need to think about?
- Think ‘population’ not ‘services’: What are the needs of our population? Where are needs unmet? Service models designed for an inner city may not work in a rural area.
- Think ‘people’ not ‘referrals’: A ‘referral’ is a person in distress. In the last blog I discussed how access to care and navigating your way around a system can be complex. You shouldn’t have to be an expert to do it.
- Think ‘primary care’ not just ‘mental health teams': Primary care is the service that people are never discharged from – it’s the bedrock of the NHS. GPs and mental health professionals need to be able to talk to each other. GPs want advice from specialists. Specialists need to understand the competing demands of primary care. Make time and space for them to meet up – not only to be involved in co-planning changes with service-users, but also to liaise, learn, meet and share information in every day work.
- Think ‘continuity’ not ‘boundaries’: It should not be so difficult for people to move in and out of services – especially if they are already well known. Rather than having a hard cut-off when a person is discharged back to their GP, it might even be possible to work more flexibly, with different levels of intensity of care and contact.
- Think ‘helping’ not ‘assessing’: Service-users complain about constant assessment by services to see if they ‘fit’ with the criteria. People get constantly reassessed as each service does not accept the assessment carried out by another. Much more time can be spent deciding who is not suitable than actually providing care – and this may be on limited evidence without even seeing the person. The PRISM service in Cambridgeshire and Peterborough has the mantra ‘don’t screen- intervene’.
- Think ‘evidence’ not ‘word of mouth’: What is the evidence for and against a particular model? What evaluation has been carried out? There is more evidence out there than many realise (see below), but also a lack for some models, such as ‘Single Point of Access’ which have been widely implemented.
- Think ‘leadership’ not just ‘development’: Support and value your local clinical leaders –including patients and service-users. Real change at the interface usually begins when GPs, psychiatrists, psychologists, nurses, OTs, managers, patients, service-users and everyone else come together with commissioners. But committed clinical leadership drives change forwards and ensures it is sustained.
Further links to the evidence:
Gask L Kendrick T Peveler R & Chew-Graham C A. (Eds.) (2018) Primary Care Mental Health. Cambridge University Press.
Newbigging K, Durcan G, Ince R, Bell A (2018) Filling the Chasm- Reimagining Primary Mental Health Care. Centre for Mental Health and University of Birmingham.
NHS Clinical Commissioners (2017) A review of the scientific literature informing the development of models in primary care mental health in England
This is the second in a blog series to coincide with the release of Relias' new mental health training courses for primary care. Read part 1 here. In part 3 of our blog series, Linda Gask discusses collaborative care. Subscribe above to ensure you don't miss future posts.
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