Mental health education and resources for general practitioners in the UK

The UK Royal College of General Practitioners recognises that mental health problems in primary care are common, and that the range of mental health problems encountered by a GP is large.¹ Around 30% of people who see their general practitioner (GP) have a mental health component to their illness.² While 80% of all contacts in the British National Health Service (NHS) take place in primary care, which receives 20% of NHS resources, 90% of people with mental health problems are cared for entirely within primary care, but use less than 10% of the total expenditure spent on mental health. Those with severe mental illness, who may have their mental illness cared for in secondary care, have a high prevalence of physical co-morbidity that should be looked for and treated by GPs.

Curriculum statement

The recent college curriculum on which training of all future GPs will be based recognises that the vast majority of depression, anxiety and adjustment reactions are seen and dealt with entirely in primary care,¹ and therefore GPs need to be trained how to recognise and treat these common mental health problems as well as having the skills to pick up and manage psychosis, schizophrenia and manic depression.

Currently there is also increasing interest in effective treatment for medically unexplained symptoms (MUS) and psychosomatic disorders, as treatment for these is often recognised as being ineffective and patients with these disorders often undergo costly investigations which may be unnecessary, unpleasant and not without risk. Handling these, as with the other mental disorders, requires good empathy and communication skills and this is recognised in the recent college curriculum statement where it is recognised that the continuous improvement of communication skills and patient-centred practice is likely to be the single most important factor in improving recognition and effective management of mental health problems. The new college examination includes a practical assessment of communication skills, and all those in GP training now have to pass the college examination to enter general practice. Because of the depth and breadth of the new curriculum, the college is pushing for the GP training schemes to be extended from three to five years.

Instigating national policy and guidelines

The college has also had to recognise and factor into its policy and curriculum advice the fact that there are different political strategies and commissioning structures in each of the four countries (England, Northern Ireland, Scotland and Wales). It also has to take into consideration recommendations from the government-sponsored body, the National Institute for Health and Clinical Excellence (NICE), a body that examines the evidence base and cost-effectiveness of treatments, as these recommendations are generally the basis on which clinical pathways are based. The college provides GP representation on NICE guideline groups and implementation activities. NICE guidelines for most mental illnesses are available on www.nice.org.uk. The college also sponsors and organises educational meetings and workshops around the UK to dissipate best practice. Members were also highly influential in producing, with the Care Services Improvement Partnership (CSIP), the document New Ways of Working for Primary Care in Mental Health,³ a guide to commissioners and providers for the redesign of primary care mental health services and roles in the context of an NHS in transformation. Another useful resource on the CSIP website is the ‘Ten High Impact Changes for Mental Health Services’, the ten areas of service improvement in mental health that have the greatest positive impact on service user and carer experience, service delivery, outcomes, staff and organisations, together with case study evidence for the changes.⁴

Practice-based commissioning

In England, health policy is going through dramatic changes with the introduction of practice-based commissioning. Groups of general practices can join up as consortia and manage the budget for commissioning services from secondary care. Services in most acute hospitals are now given a tariff and are paid on a cost per service item, rather than the block budgets that were more common previously. Any savings made in reducing referrals and follow-ups in secondary care, by practice-based consortia, can be invested in improving services generally, and it is hoped that this will lead to services that are of better quality and closer to home for the patient. However, because of the difficulties of costing individual treatments in mental health, these vary significantly from patient to patient for the same disorder, and the tariffs for mental health have yet to be calculated, few practice-based commissioning consortia are concentrating efforts on primary care mental health, with the result that there is little investment in these services.

Improved access to psychological therapies

However, it is not all bad news, as the college under its new chair has made mental health one of its top three priorities, and strong links are being forged at the highest level with the UK Royal College of Psychiatrists. Also the government is investing £170 million in improving access to psychological therapies, with 22 pilot sites already in progress, and it is planned that the programme will be rolled out across half of English health authorities over the next three years. So far the programme has been based on increasing the amount of cognitive behavioural therapy for the population, and is often linked with schemes to help patients back into work. The college will launch its support of the roll out of the programme this month, its main message being that the increased investment should be made in supporting primary care and community services, where the majority of patients with mental health problems are looked after, rather than in the expansion of secondary care psychology services.

The mental health expert advisory group

The college supports an expert advisory group on whom it calls for advice on policy and the curriculum. A mental health champion helps to co-ordinate all this activity. Members of the group are GPs, with a broad range of experience and affiliations. Some are academics with expertise in research, and others represent charities such as Primhe (Primary mental health and education, www.Primhe.org) and Sainsbury's Centre for Mental Health (www.scmh.org.uk), or the government-sponsored CSIP (Care Services Improvement Partnership; www.nimhe.csip.org.uk). All three organisations have useful resources through their websites and publications. Changing Minds has courses and distance learning for primary care services through its link with Northampton University is also represented (www.changingmindscentre.co.uk), as is the Welsh Royal College of General Practitioners through WAMH in PC (the Welsh Association of Mental Health in Primary Care).

Primhe and WAMH in PC hold regular conferences focused on Mental Health in Primary Care, and this year sponsored a joint conference.

Following a summit about the mental health of our elders held in conjunction with the Royal College of Psychiatrists last January and led by a member of the group, two notable pieces of work have come together, one of which is to raise the awareness of the problem of suicide and depression in the elderly, and the other the need to develop early intervention in dementia. A consensus statement on depression in the elderly has been put together for a launch soon,⁵ and similar work is now being undertaken for early intervention in dementia.

Gold standards in primary care

WAMH in PC has been particularly active in producing the Welsh Declaration for Mental Health and Well-being,⁶ a declaration of gold standards for mental health in primary care, standards of care that they believe patients have a right to expect and that we should be aiming for. They have been put together by a think tank, and since their launch, WAMH in PC has been lobbying their politicians, including the Welsh Health Minister, to sign up to this standard, with some success. Readers may sign the declaration on their website.⁶

GPs with a special interest in mental health

Primary care trusts have been encouraged by national policy to develop GPs with a special interest who can then help expand the number of services closer to the patient. The college led on the development of a diploma course for training GPs with a special interest in drug addiction, and this has greatly increased the number of practices nationally doing shared care of addicts, in conjunction with their local secondary care addiction services. Training courses in the medical specialties are relatively easy to develop and run, but primary care mental health specialises in different illnesses from secondary care psychiatry, so a modified psychiatry course was not appropriate. Primhe, who is affiliated to the college, took a lead on developing the course. On scoping needs, it discovered that if we are to raise the profile of mental health, leadership skills are essential, so that GPs can lead on developing and improving primary care services in mental health. The course is now successfully running as a joint venture between Primhe and Stafford University, and a scaled-down version is being used to develop leads in the first wave ‘Improving Access for Psychological Therapies’ (IAPT) sites.

The future

With the college making primary care mental health such a high priority, and led by the mental health champion and a strong advisory group, we aim to ensure that mental health sits on par in primary care with diabetes, cardiology or cancer within the next few years. The college has strengthened its internal processes in order to attract more money into researching mental health, as well as improving education and support. Building on the success of a joint educational advisory group with the Royal College of Psychiatrists, there are plans to build a partnership between the colleges, with a primary care forum, and thus increase our voice. The ultimate aim is that we can genuinely declare that our patients are getting a gold standard service that we are proud of.