Mental health and general practice: intertwined futures

Many in the mental health sector had been eagerly awaiting NHS England’s implementation plan proposing how the Mental Health Taskforce report, The five year forward view for mental health, will be put into practice. If successful, the significance of the plan could extend well beyond the mental health sector: some of the most important opportunities relate to the way in which people with mental health problems could be supported in general acute hospitals and in general practice.

One of the main proposals in the Taskforce report is that mental health care should be integrated more closely with the rest of the health system, so that mental and physical health are considered together. The King’s Fund strongly endorses this principle, and we are working to support it through our ongoing research projects and learning network.

The implementation plan includes some welcome detail on how integrating mental and physical health care can be achieved in secondary care, for example, through expanding liaison mental health services in general acute hospitals, and by improving mental health support during the perinatal period. For the first few years, these approaches will be partially paid for from the Sustainability and Transformation Fund.

However, the vision for integration in primary care is less well-articulated. Our report, Bringing together physical and mental health, argued that some of the biggest opportunities for integration lie in developing new approaches towards mental health care in general practice settings, as part of wider moves to redesign models for primary and out-of-hospital care – a recommendation also made by our research on pressures in general practice. Improving this aspect of care is particularly important given that 90 per cent of adults with mental health problems are supported in general practice.

The implementation plan does include some important measures in general practice. The headline goal is for 3,000 new mental health therapists located in GP practices, as previously announced in the General practice forward view. The plan states that part of the rationale for this is to help relieve the pressure on general practice resulting from unmet mental health needs – something that is certainly required. And while this extra capacity may help, I have two concerns.

The first is that co-location does not necessarily equal integration – an observation that is often made but still worth repeating. Our research on specialists working in out-of-hospital settings shows that ‘drag and drop’ approaches are not the most powerful way of bringing about change. Mental health professionals working in general practice will be in a stronger position to improve the quality of care and alleviate pressures if they are unambiguously part of the primary care team, with an active exchange of information, knowledge and skills between mental health workers, GPs and other team members. Without this, there is a risk of missing an important opportunity to increase the ability and confidence of primary care professionals to both manage mental health issues within general practice, and ensure that the physical health needs of people with mental health problems are met.

The second consideration is getting the training and supervision arrangements right for mental health therapists working in general practice. The implementation plan explains that much of the new capacity will be targeted at people with co-existing mental and physical health conditions or other complex, overlapping symptoms. Working in this area takes a high level of skill, and it is not clear whether the ‘top-up training’ envisaged in the plan will be sufficient. The most evidence-based models for working with these patient groups tend to involve ongoing supervision from mental health specialists with specific expertise in the area. A key task for the ‘early implementer’ sites described in the plan will be testing different approaches to this.

General practice is entering a period of change, in part triggered by the intense pressures many GPs are encountering. The proposals in the General practice forward view build on the ongoing trend of GPs coming together with other professionals, in practice groups, federations and the new care models being tested in the vanguard sites. Given the high levels of unmet or poorly met mental health care need among people using GP services – and the impact of this on both patients and staff – it is important that new approaches towards joining up primary care and mental health care are integral to efforts to strengthen general practice.

The five year forward view for mental health implementation plan places responsibility for bringing about many of the planned changes at the feet of those leading the 44 sustainability and transformation plan (STP) footprints across England. The plan is right to identify STPs as a critical lever for change – but there is a clear danger that both general practice and mental health care are overshadowed as STPs focus on the challenges facing the acute hospital sector. While these challenges cannot be ignored, STPs also need to serve as a stimulus for transformation of services outside hospital. And in bringing about this transformation, we need to think about the future of general practice and the future of mental health care as being part of the same conversation.

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Comments

#547989 Dr Malcolm Rigler
GP within the NHS / Policy Adviser Partners in Health ( Midland ) Ltd.
Partners in Health ( Midland ) Ltd.

The need for the integration of mental health services with General Practice is urgent . It's great that Chris is working on this issue. As usual I write this in haste before the morning surgery but from meetings earlier this week it is on my mind that we must no longer ignore the profession of Pharmacy when we talk about General Practice. A quick "Google" search on the topic of "Social Pharmacy" reveals over 7 million hits or websites ! Some Pharmacy firms such as Rowlands Pharmacy are already "on the case" so to speak in the UK. It would be good if Chris - and others at The Kings Fund - made a start in trying to learn about "Social Pharmacy" and how the Pharmacist working with Town and Parish Councils and Trained Volunteers such as "Dementia Friends" could transform Primary Health Care in the years to come. Malcolm Rigler

#548006 BRIAN GUMBLEY
Director
MATM cic MH RECOVERY ORG

While reading the article from Chris-----some of it I advocated many years ago I wonder if having MH as one aspect of a combined physical and MH surgery I wonder as a sufferer of BP for many years I find it will not work properly unless the MH therapists are experienced and not just given a quick course on MH illness ---I'm also concerned about MH patients having to seek advice at GP surgery's ------ mixing both types of s/user in waiting rooms needs to be thought through extensively ---- if the idea is to keep these s/users separate may increase some costs ------------ fact that patients may be disturbed by being seen with MH S/USERS creating problems around the big problem of STIGMA --- there are still GP's who either do not want to know about MH or who lack the will to learn about these issues -------MH is a major illness creating people with distinct different symptoms and behavioral problems especially BP

#548010 Paul Jarvis-Beesley
Senior Manager
StreetGames

The Taskforce report puts very strong emphasis on prevention, especially for children and young people. 75% of all adult mental illness has its onset before the age of 24. How many times is prevention mentioned in the 5YFV? Absolute zero! Inevitable result - even more pressure on over subscribed services

#548054 Dr Jenny Ure
Researcher

Integrating the services would be easier if GPs had some training in mental health or its treatment. A couple of lectures does not help. Given that at least a quarter of the people they see will have a MH illness......

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