Over a few short years, I have witnessed this man’s health and self-confidence collapse. Having been fit and healthy all his life, he was hit in quick succession by chronic lung disease, a heart attack and renal dysfunction. Like countless people in low-wage jobs who are ‘just about managing’, he found himself living with multiple health conditions early in life. This is a common story in places like Thanet, the area of Kent where I work as a GP – much more so than in more affluent communities where people tend to reach their 70s or 80s before experiencing anything similar.
It was abundantly clear that his life span and life quality were both beginning to be seriously curtailed. He was no longer able to work. Depression had precipitated significant weight loss and his relationship with ‘the love of his life’ was coming to a juddering halt. To add insult to injury, his newly increased dosage of beta-blockers had added erectile dysfunction to his woes.
When I saw him he was upset and tearful. A proud man, brought low, depressed and inconsolable. ‘I’ve never been out of work my whole life’ he said, ‘Now look at me.’
This tragedy is what happens day in and day out in poorer areas of the UK – intertwined physical and mental health problems exacerbated by hard life circumstances. The evidence pointing to large swathes of people with long-term conditions also having co-morbid mental ill health is incontrovertible and overwhelming. To provide holistic care in these circumstances means making mental health everyone’s business, but sadly this is often not the case.
So, why are we still here in 2020? How have we created so many gaps between our well-intentioned services? And what are the opportunities ahead in the new world of primary care networks (PCNs)?
I have been a doctor for 17 years, a GP and mental health commissioner and ex-Chair of Thanet Clinical Commissioning Group. From a GP perspective, community mental health teams have been over-stretched for some time, with high barriers to access. In our locality, 50–80 per cent of referrals to community teams were rejected according to one audit. We have access to Improving Access to Psychological Therapy (IAPT) services in primary care, but secondary care psychology is hugely under-resourced.
This well-described and frankly lamentable ‘psychology gap’ has resulted in a burgeoning cohort of hard-to-treat, in-need people that any GP working in an area like mine would recognise in an instant. The people we support in our practices need responsive services that work flexibly across primary and secondary care rather than dividing people into ‘your patients’ and ‘our patients’.
The approach we have taken in East Kent to address the gaps in mental health provision has been to invest in a range of targeted group services and a new primary care mental health service covering a population of almost a million people. We developed the service at scale to minimise variation and to have a service big enough to build on in future. We also invested in the data-sharing ‘MIG’ (Medical Intra-operability Gateway) that allows GPs access to secondary care patient records and vice versa. This has had significant benefits.
It took almost five years to bring our primary care mental health service into being and we have learnt a lot along the way. One lesson has been that primary care mental health workers need a high degree of autonomy and competence. Our patients very rarely present with a single circumscribed problem such as ‘anxiety’, and primary care caseloads can involve vulnerable adults, child protection, debt and housing problems, plus people with several long-term conditions. Primary care mental health workers need to be adept at dealing with this complexity within the inevitable time constraints in general practice.
One of the questions posed by the report on mental health in primary care by The King’s Fund and the Centre for Mental Health is whether the PCNs established last year can play a role in developing new primary care mental health services, such as the one we have commissioned in East Kent. For me, the jury is out. PCNs can and do provide a level of local mental health provision. However, providing mental health services on this footprint runs into difficulty on several fronts. Having multiple small-scale services runs the risk of destabilising vulnerable secondary care services, and may widen inequalities though ‘postcode lottery’ provision.
PCNs may not yet be a suitable delivery vehicle, but I believe that if they are given a chance to mature and coalesce they could help to create more integrated patient pathways in mental and physical health in future. As ever, their success will depend on whether policy-makers give them time to grow and to learn. Far too often in the NHS, national bodies try something new for two or three years, lose patience and then move onto the next thing without ever learning from the process. We cannot allow this to happen again with PCNs – our patients deserve better.
"We have access to Improving Access to Psychological Therapy (IAPT) services in primary care, but secondary care psychology is hugely under-resourced. ... The people we support in our practices need responsive services that work flexibly across primary and secondary care rather than dividing people into ‘your patients’ and ‘our patients’." This could be achieved by re-establishing an organisational form that has been lost over the last 20 - 30 years, i.e. departments of psychology or psychological services with integrated management of the currently organisationally unintegrated, sometimes even outsourced groups of staff. Concerning the shortage of clinical psychologists, the training courses have been turning away 85% of applicants for over a decade because of shortage of training places. In short, the people have been there to train, there has been an urgent need for the services they would provide when trained, but training commissioning did not link the two. Perhaps this year will see a change?