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New Ways of Working for

Primary Care in Mental Health

The primary care sub-group aims to guide commissioners and providers in the redesign of primary care mental health services and roles in the context of an NHS in transformation. This ongoing change provides significant challenges to primary care mental health (PCMH), but also opportunities for developing functions and roles critical to the success of the whole ‘primary care-led commissioning’ and ‘care closer to home’ agendas. The sub-group included practitioners and managers from primary and secondary care, and from diverse professional groups. It considered evidence from generalists and specialists across the age range to develop guidance complementing other initiatives – the introduction of Quality and Outcomes Framework indicators for mental health, the increasing access to the psychological therapies work stream and guidance from the primary care mental health programme of NIMHE/CSIP.

This summary first re-examines the clinical typologies of people presenting to the

primary care workforce and its practitioners, then looks at the critical values for

PCMH. It outlines three themes, and provides examples of how excellent primary

care mental health can be delivered through new roles in the workforce. It includes

practical guidance on how practitioners from primary and specialist care can

effectively and safely work together.

The scope of mental health problems in primary care

Primary care mental health is often characterised as the realm of common mental

health problems. It also lies at three critical interfaces: 1) between the lay and medical

worlds; 2) between primary care and specialists; and 3) between physical and mental

healthcare. Problems presenting as a challenge to the workforce in primary care range

in their severity, complexity and co-morbidity and chronicity; and across the lifespan.

With this in mind, we propose that the workforce needs the skills, knowledge,

attitudes and competences that reflect the following range of clinical typologies:

• Common mental health problems: Short-lived distress related to life situation,

low-grade ongoing mood and anxiety symptoms, through to diagnosable episodes

of depression, anxiety or other psychiatric problems.

• Mental health problems associated with physical health: Health anxiety;

distress related to recent physical investigation or diagnosis; medically unexplained

physical symptoms; mental health problems resulting from long-term physical

health problems.

• Long-standing complex non-psychotic mental health problems, such as

recurrent depression, often associated with psychiatric and physical co-morbidity,

recurrent self-harm, substance misuse, homelessness and unemployment.

• People with psychosis: new and recurrent episodes, ongoing disability, social

exclusion and physical illness.

• Those with cognitive impairment: dementia, learning difficulties or

developmental and organic disorders.

The essential characteristics of primary care

The following characteristics are important to understand when considering NWW,

as they provide the building blocks on which new systems of care, new roles and new

skills are developed:

• High-volume throughput and rapid point of access to healthcare:

– access that is timely, acceptable, and available 24 hours a day;

– engages, sorts, holds, treats and signposts large numbers.

• Undifferentiated symptoms and tolerance of diagnostic uncertainty:

– early stage of presentation when a diagnosis is uncertain;

– the problems of the mind and body are intertwined;

– levels of distress or symptoms that are an understandable response to life events.

• Continuing care over time:

– providing proactive health promotion over decades;

– chronic disease management for long-term conditions;

– care for whole families over time.

Values for primary care mental health

Primary care and mental health services each have sets of values underpinning care.

The following is an amalgam – a set of values embodied in the examples of good

practice from around the country:

• Recovery and social inclusion

While promotion of recovery and working towards inclusion in mainstream

society (having meaningful work and relationships, and participating in creative

activities) are now accepted values for mental health, they are relatively new as

explicit aims for primary care practitioners. However, they build on the related

values of holistic and patient-centred practice held by many GPs and other

primary care staff, and can complement more medically oriented functions of

diagnosis and treatment allocation. Generalists in primary care can help people

to understand that distress may be normal and does not imply pathology. They

can orient consultations around individuals’ strengths and social aspirations.

• Choice of treatment

The last ten years have seen an expansion in the range of psychological, social

and educational options advocated in primary care for people with mental health

problems. As these modalities become mainstream for people of all ages, then

working with individuals as partners to choose the most appropriate, accessible

and desirable management option will need to be embedded in new systems of

care for people with different problems.

• Care closest to home

GPs and community nurses have long had a philosophy of caring for people

at home. Practice-based commissioning provides incentives for an increased

involvement of primary care among those with complex mental health needs

within the community. Care closest to home also suggests the critical importance

of working with families and other partners in care, as well as with the resources

of the individual patient.

• Working and learning together

By working together, we will have something to learn from each other: patients

and practitioners; specialists and generalists. By welcoming specialists into

primary care, generalist practitioners will become more skilled, willing and able to

support people with mental health problems to become independent. Conversely,

primary care skills can be utilised within a specialist setting. This also includes the

critical new notion of working with patients as self-carers and as experts through

experience.

Three themes to underpin New Ways of Working for the primary care mental health workforce

By considering the clinical typologies and the key values set out above, and by

building on the essential characteristics of primary care, we developed three themes:

ensuring high-volume and rapid access to the most appropriate care; breaking down

the mind–body divide; and developing proactive care where it counts.

• 1. Ensuring high-volume and rapid access to the most appropriate level

of care

Timely access to a wide range of psychosocial interventions is possible via the

primary healthcare team for a range of conditions and at all ages. This requires

both excellent consultation skills and adaptable and resourced care pathways.

Generalists require skills to handle the emotional presentation – to help people

understand or accept distress, or to discuss possible onward referral. Although

a diagnosis of, for example, depression is valuable to some individuals, others may

be set on the path to recovery through acknowledgement of distress and prompt

access to non-stigmatising care.

Stepped care provides a framework for allocating the intensity of intervention

according to need. By promoting choice and open access, and trusting patients to

define their ongoing care needs, LIFT – Least Intervention First Time – embodies

a philosophy that builds on strengths and avoids dependence. As well as needing

investment in a range of services, stepped care requires new skills and systems of

supervision for both generalist and specialist practitioners in primary care. This

is particularly important if primary care generalists and specialists are to work

together to provide the range of psychosocial interventions required for those

with complex, recurrent non-psychotic conditions.

The Improving Access to Psychological Therapies programme incorporates

many of these concepts. See the documents Designing Primary Care Mental Health

Services and Skills For New Workers from the CSIP/NIMHE Improving Primary

Care Mental Health Services – A Practical Guide, available at

www.csip.org.uk/resources/publications/primary-care.html. These provide detailed

guidance on how to tailor systems and the skill mix to population needs.

Box 1

Walsall Primary Care Mental Health Trust is moving away from utilising a

secondary care model of mental health service delivery towards a robust

primary care mental health service, grounded in the strengths of primary care.

Walsall has placed its most senior clinicians within frontline primary care; they

have been trained in brief assessment techniques (risk and triage) to enable

20–30-minute initial consultations. Outcomes include:

• increased numbers of people that can be seen;

• reduction in waiting times and in the number of non-attenders;

• faster access for first appointment, in a less stigmatising setting;

• early diagnosis and treatment;

• links with specialist mental health services;

• education and training of the primary care team, e.g. GPs, midwives and

health visitors;

• a liaison role between primary and secondary care to discuss cases; and

• assistance for the primary care team with development and maintenance

of severe mental illness registers to meet the Quality and Outcomes

Framework (QOF).

• 2. Breaking down the mind–body divide

Increasing importance is being given to the mental health of people with longterm

physical problems, understanding the psychological needs of those with

medically unexplained symptoms, and ensuring that those with severe and

enduring mental health problems receive excellent physical healthcare. Given this

trend, primary care remains in an excellent position to promote the integration

of care for mind, body and emotion.

Practice-based commissioning provides incentives for improving psychosocial

care for people with long-term physical conditions. Such initiatives may

improve people’s ability to self-manage illnesses, such as diabetes, and may help

prevent unscheduled admissions. They will require practice and district nurses

to acquire new mental health roles and skills, and will provide opportunities for

occupational therapists, with their dual training, to become core members of

primary healthcare teams.

Improving physical care for those with psychosis and other mental health disabilities has been tackled head on by the Disability Rights Commission (DRC) and its Doing the Duty campaign. For more information, visit the DRC website: www.drc-gb.org PCTs have a duty to actively prevent ‘diagnostic overshadowing’ and to ensure that those disabled by mental health problems and learning disability have their physical health needs met. This will require closer co-operation and better communication between generalist and specialist teams, particularly around the QOF and CPA systems.

Box 2

Devon PCT: Wellness Recovery Action Planning (WRAP) is a preventative

approach for managing stress and maintaining well-being which can be used as

an advance directive. This approach is embedded throughout the mental health

voluntary and statutory sectors in Devon, and a version more suitable for use

in primary care has been developed. Training courses for primary care staff

have begun to address how WRAP can support self-management for people

with long-term physical health conditions, and promote mental health

recovery approaches in primary care.

Plymouth PCT: A Well-being Network to enhance opportunities for people

with long-term mental health problems has been established in North West

Plymouth. It aims to improve well-being with one-off events and increased

signposting to existing opportunities for increased exercise, healthy eating,

creative leisure and smoking cessation. Patients involved with three voluntary

organisations, two primary care liaison teams and local general practices are

involved. The main changes for service users include: experiencing new forms

of exercise, eating new foods, being invited to attend new groups, contributing

to mutual help, being involved in planning and evaluation, and having practice

nurses do physical checks in the community settings.

People with medically unexplained symptoms are over-represented in outpatient

clinics and on investigation waiting lists. Best practice requires GPs and

specialist physicians to:

• attend to people’s concerns, beliefs and expectations;

• act consistently; and

• engage with individuals’ psychosocial worlds.

Mental health specialists can help the most difficult cases.

• 3. Developing proactive care for long-term mental health conditions

in primary care

While general practice has a long tradition of providing ongoing care, the

inputs have often been reactive rather than proactive in nature. Practice-based

commissioning and payment by results will provide the incentives for bringing

care closer to home for people with dementia, long-term physical conditions,

psychosis, learning difficulties, and also the heterogeneous group of people with

severe and enduring mental health problems caused by recurrent depression,

ongoing anxiety and other co-morbidities. The QOF in general practice provides

a foundation of incentives for all but the last of these groups. However, there is

relatively little specificity within these mental health domains of the new contract;

the emphasis is primarily on medical care, and values such as recovery and

promoting social inclusion are not addressed.

Practice-based commissioning will encourage practices to extend systems of

chronic disease management. Systems of recall and review, specialist liaison and

information for patients will be developed. Initially, until proved cost effective,

models of care (such as WRAP) that build on strengths and promote recovery will

need to be promoted locally through service user influence, local contracting

strategies and professional pride in best practice.

It is this last area of proactive care where specialists and generalists will have

to start working together most effectively. The previous New Ways of Working

Report outlined a series of mechanisms for joint working, many of which

involved working and learning together through discussing cases and designing

the detail of local services alongside user experts.

Box 3

Northampton: Proactive interface working for perinatal mental health.

An integrated care pathway for perinatal mental health provides a proactive

structure and support for the early intervention required to predict and detect

mental disorder and/or mental distress. For perinatal mental health, the delivery

of a stepped-care approach in primary care involves the initial engagement of

new cases and mothers at high risk by well-established, skilled primary care

workers (health visitors, community nurses, GPs and midwives) with a generic

set of competences that allows them to deliver low-intensity psychological

treatments. The more severe cases are referred on to specialists, who share

care and offer support, training and advice to primary care workers.

To support new ways of working in primary care, some important practical issues

need to be considered, and the next section begins to explore these.

Practical guidance on roles and responsibilities at the interface

This section provides a summary of the guidance available to support those

professionals who are being asked to carry out new roles at the interface, and enable

them to complete these roles in a high-quality, safe and defensible way. The sub-group

responsible for this piece of work included representation from different professions,

unions, defence bodies, the Department of Health and Royal Colleges. As traditional

boundaries between professionals, and between primary and specialist care, are

broken down, the notion of medical responsibility is transformed into sharing

responsibilities between practitioners and patients or service users.

• Providing advice about a patient or service user you have not seen. This

occurs frequently when primary care clinicians ask for advice from specialists, and

occasionally it happens in reverse. The following principles should be adhered to.

– The person giving advice should ask for sufficient information about the

clinical case and record this. A record should be kept of the problem and the

advice given, including the date and a patient identifier as an absolute

minimum for defensible practice.

– Best practice would indicate that, for telephone advice, the information

should be provided in writing, so that it can be incorporated into primary

care or other records.

– Email advice provides a useful audit trail, but needs to be incorporated into

primary care records.

• Advice for clinicians working within another team. Increasingly, clinicians

are appropriately asked to work alongside other teams in order to provide coordinated

and multidisciplinary care. For example, community psychiatric nurses,

social workers and occupational therapists may be asked to take on the role of a

link worker and provide advice and shared care for people with long-term

problems. The following principles and guidance have been developed.

– It is good practice for clinicians working for other organisations to provide

care within a primary care setting.

– Responsibilities for the care being provided should be documented in an

agreement between the two teams.

– It is considered good practice for linked workers, doing assessments or

engaged in shared care, to make the principal recording of records into the

notes of the team they are working with, rather than their own team’s notes.

Some may wish to keep supplementary records or copies of records for their

own or for their organisation’s use. This was not considered essential practice.

– Agreement for retrieval of records made by practitioners outside the

organisation they are working in should not be a problem, as medical records

are NHS property rather than belonging to primary care or the specialist

Trust.

• Chronic disease management and shared care. The co-ordinating function for

chronic disease management may well be located within primary care and might

be the joint responsibility of administrators in primary care and clinicians either

from primary care or from linked organisations.

– It is essential to record the responsibilities for components of care in terms

of which team and which professional are responsible for carrying these out.

This is particularly critical for the various sub-components of care with

respect to lithium, depot injections and clozapine treatment.

– In shared care, both primary and secondary care records should include all

oral/parenteral medication (not just psychotropic) and significant diagnoses

in order to prevent interaction errors and prescribing against

contraindications.

Joint working within CPA and other care navigator functions (e.g. QOF) should

ensure proportionate engagement of all involved in the care of individuals with

complex needs. Invitations to attend lengthy CPA meetings or case conferences

may not be the most appropriate way of engaging others. Alternative

mechanisms, such as requesting key information to be sent to care co-ordinators

or having verbal discussions prior to CPA meetings, is considered best practice

when liaising with those unlikely to attend.

While the contents of this chapter are in many ways aspirational, and we

recognise the very real problems for commissioners, managers and practitioners,

the examples are from real services. Further explanation and examples will be

given in a more detailed report to be produced by the primary care sub-group,

which will be available in summer 2007. It is anticipated that NWW, the IAPT

and CSIP primary care programmes will work together in the future to support

implementation of this agenda.

Contacts: Richard Byng at richard.byng@pms.ac.uk and

Barry Foley at mbarryfoley@aol.com,

New Ways of Working in mental health for everyone...