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.