Resetting the rules for primary care and mental health
By Dr Paul Turner
Professor Michael Sharpe noted in his blog in March 2018:
"The reality is that our healthcare system is predicated on a false assumption. That is, the belief that there are two populations of patients: the mentally ill and the physically ill."
Despite the frequent iteration of the truism that 90% of mental health care is carried out in primary care, this falsehood, I suspect, underpins the historic organisation of care which dictates that ‘real mental illness’ is managed in specialist care whilst primary care manage people’s physical health alongside common (mild to moderate) and often self-limiting mental health problems. In reality the situation is much more complex. (Isn’t it always?)
In a world of increasingly precise referral thresholds, mental distress and illness are hard to manage well in primary care without the skills which often reside on the other side of the gateway. Diagnostic thresholds consistently prevent early identification and support for people’s needs whilst physical health care for those with mental illness is often reduced to ticking boxes because integrated collaborative working is not the norm.
Mental distress and illness are hard to manage well in primary care without the skills which often reside on the other side of the gateway
Research tells us that:
- Half of the people referred by their GP for a new outpatient appointment with persistent physical symptoms will have a non-organic cause for their problem.
- Two thirds of people who present in mental distress do not find their needs being met.
- 70% of people who take their own lives will have seen their GP in the previous year but only 8% were deemed suitable for specialist mental health services.
The list goes on and includes people who suffer with chronic pain, those who attend A&E with mental health problems and the large numbers of people whose distress has emanated from early adversity in childhood.
All of these gaps in effective care have a cost. In the West Midlands alone we spend an estimated £1billion on mental health services, and in addition we spend another £1billion on managing the people whose mental ill health adversely affects their physical health.
Filling the Chasm makes compelling reading. It articulates clearly how we must challenge prevailing assumptions in mental health care. It sets the scene for a sea change in thinking, commissioning and providing by encouraging a refocus on really understanding how human beings behave and seek help when in distress, and therefore how we should respond. It unequivocally sheds light on, as Linda Gask suggests, the tendency for “the service user [to be] assessed for their suitability for a service rather than…to meet their needs”.
[The report] sets the scene for a sea change in thinking, commissioning and providing by encouraging a refocus on really understanding how human beings behave and seek help when in distress
We must shake ourselves from the belief that the historic separations between specialist and generalist, between health and social care, between statutory and voluntary/charitable sectors are inviolable. Collaboration is the oil which enables interventions to work. It is evidence-based, but it is also a tricky source of ambivalence in a dualistic system. ‘Perfect Depression Care’ in Detroit, the origin of the now ubiquitous phrase Zero Suicide, is based on collaboration between professionals as well as with their patients. The collaboration bit so often is lost in translation to a target- and intervention-obsessed health economy.
The descriptions in Filling the Chasm of various projects and services from around the country illustrate vital aspects of what effective collaboration can achieve. They aptly remind us that mental health development, especially for unmet or unrecognized needs, fits ‘an image of heroic pirates resourcefully bending the rules’.
The collaboration bit so often is lost in translation to a target- and intervention-obsessed health economy.
But the variation we see around the country is unacceptably huge in terms of historic and current investment and ability to create sustainable change. Let’s be honest. This variation exists because, hitherto, primary mental health care has been neither understood nor prioritised. The Five Year Forward View for Mental Health (FYFV) is not the last word, and neither is Improving Access to Psychological Therapies (IAPT) in its current iteration. We have an opportunity to re-imagine primary care mental health care, fuelled by an upsurge of unanimity amongst ‘pirates’, innovators, service users and academics.
The rules need resetting in favour of a newly skilled multi-professional front line for mental health care which is designed around people’s needs rather than tweaking an outdated primary/secondary care system that is based on faulty assumptions. Lots of good has been done, barriers broken down and progress made, but as clinicians and academics challenging our modern NHS we should not feel it necessary to prelude every observation of unmet need with congratulatory words about how much good is being done as a way of appeasing political will.
The rules need resetting in favour of a multi-professional front line for mental health care which is designed around people’s needs rather than tweaking an outdated primary/secondary care system based on faulty assumptions.
As Nye Bevan said at the inception of the NHS in 1948:
"We shall never have all we need. Expectations will always exceed capacity. The service must always be changing growing and improving. It must always appear inadequate."
Paul Turner is a General Practitioner at Karis Medical Centre, Edgbaston, Birmingham and Joint Clinical Director for Mental Health West Midlands Clinical Network, NHS England
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