By Lucy Marks
The recent Centre for Mental Health report Filling the Chasm spells out clearly why primary care mental health is so important and what successful models could look like. Its message needs to be heard right now, serving as a reminder of what has been overlooked in the Long Term Plan. Mental health care needs to be delivered alongside physical health care in every community, in order to achieve the highest quality outcomes and at the same time reduce pressure on hospital services.
Mental health care needs to be delivered alongside physical health care in every community, to achieve the highest quality outcomes and at the same time reduce pressure on hospital services
After decades as a Consultant Clinical Psychologist in Primary Care, and as CEO of a social enterprise, Compass Wellbeing, for the last 5 years, providing primary psychology and counselling services in Tower Hamlets, I have learned that good practice in primary care mental health is a team sport. This involves working in partnership: a partnership between the patient, the therapist, the GP, and other key members of the primary care team (for example health visitors, practice nurses, school nurses). Discussions with patients and team members where there is some level of complexity or confusion takes time - but not discussing them usually takes more time. Some communication can be done in a straightforward way through updating the medical notes, but sometimes what is needed is a dialogue to align everyone’s thinking. Developing a shared understanding can really make a difference and lead to better decisions being made with the patient. This is particularly the case with patients with persistent physical complaints; patients who feel a deep sense of grievance - where nothing ever feels good enough; patients who are suicidal, or where there are safeguarding concerns; or with those who cannot face going to yet another service outside of primary care even if it might ultimately better meet their needs.
In my experience, GPs and other members of the Primary Care Team have always highly valued the opportunity to have some specialist advice about a patient they are concerned about and recognise how important this is for their own resilience. This can be about someone who might not be needing a referral for therapy, or a patient who might need an extended assessment in order to work out what the problem is in order to develop an ongoing management plan. Working with a GP who provides continuity of care makes this much easier and is ultimately more containing for the patient who has a sense that someone at the practice is holding them in mind.
Good practice in primary care mental health is a team sport. This involves working in partnership
Patients often find it far less stigmatising to be seen in their own practice for psychological therapy. Access to a range of therapies is needed, delivered by highly trained and well supervised clinicians in order to match the levels of complexity of problems faced by primary care patients. In Tower Hamlets our primary care psychology and counselling service incorporated Improving Access to Psychological Therapies (IAPT) with IAPT clinicians working alongside psychologists and counsellors, complementing what they offered by providing specialist therapies outside of the scope of IAPT.
Indeed, the IAPT services in East London that performed the best last year were Tower Hamlets and Hackney - both providing a multi-layered service that bridged the gap between IAPT and secondary care, as well as support and advice to GPs. There is growing evidence that IAPT services perform more effectively when they are working alongside other specialists.
Working with a GP who provides continuity of care is ultimately more containing for the patient who has a sense that someone at the practice is holding them in mind.
From my experience I know that there are many GPs who are really skilled in managing the mental health of their patients. When a consultation goes well the patient will have felt heard and understood, that their GP is on their side and that a collaborative and safe relationship is in place from which difficult and painful things can be discussed (Buszewicz et al. 2006). Successful consultations that address mental health are about having conversations that lead to being more in touch with emotional pain, resulting in being better able to tolerate that pain and uncertainty.
I welcome the recognition in Filling the chasm of the need to upskill primary care staff in mental health: it needs to be everyone’s business, not just those with an interest in mental health. I also welcome the report’s recognition of the importance of providing specialist supervision and advice to support GPs. Patients need a containing space and so do clinicians, in order to provide this for their patients. The pull towards the ‘don’t open a can of worms’ mentality is often strong given the pressures that community and primary care staff are under. The problem is that the worms remain there, but release of pressure and relief comes from looking them at a manageable pace.
Upskilling primary care staff in mental health needs to be everyone’s business, not just those with an interest in mental health
In his recent blog, Dr. Paul Turner emphasises that it is a collaborative relationship that enables effective change. This is also true in health behaviour change. If we are serious about maximising outcomes in health, we need to attend to psychological needs, mental health and physical health together, because mind and body are totally interrelated. Change takes place through relationships - so it’s relationships that need to be attended to and this is often not straightforward.
I believe that GPs and primary care staff are motivated to do the work they do because they want to have the greatest impact on the health and wellbeing of their patients. However, the enormous pressures they are under can make this particularly difficult to do right now. Maybe some of the answers, both to maximising outcomes and to the overly pressurised working environment, can be found in having support from experienced psychologists who can provide some help and relief to both fellow clinicians and patients.
Lucy Marks is an independent Consultant Clinical Psychologist