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Ways of working at the interface between primary and specialist mental healthcare

  • Linda Gask (a1) and Tarun Khanna (a2)
Summary

Ways of working at the interface between primary and specialist care are considered with discussion of the limits of available evidence and the potential for a new role for psychiatrists in providing supervision and consultation in novel models of care.

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Copyright
Corresponding author
Linda Gask, PhD, FRCPsych, National School for Primary Care Research, 5th Floor Williamson Building, University of Manchester, Oxford Road, Manchester M13 9PL, UK. Email: linda.gask@manchester.ac.uk
Footnotes
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Declaration of interest

L.G. has received payment for speaking from Lilly, Wyeth, Lundbeck and Pfizer, and research funding from Servier and Pfizer.

Footnotes
References
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1 World Health Organization. Integrating Mental Health into Primary Care: A Global Perspective. WHO, 2008.
2 Burns, T. Influencing community mental health team practice to improve care outcomes. In Choosing Methods in Mental Health Research: Mental Health Research from Theory to Practice (eds Slade, M & Priebe, S): 138–46. Taylor & Francis, 2006.
3 Layard, R. The case for psychological treatment centres. BMJ 2006; 332: 1030–2.
4 Kendrick, T, Simons, L, Mynors-Wallis, L, Gray, A, Lathlean, J, Pickering, R, et al. Cost-effectiveness of referral for generic care or problem-solving treatment from community mental health nurses, compared with usual general practitioner care for common mental disorders. Randomised controlled trial. Br J Psychiatry 2006; 189: 50–9.
5 Cape, J, Whittington, C, Bower, P. What is the role of consultation–liaison psychiatry in the management of depression in primary care? A systematic review and meta-analysis. Gen Hosp Psychiatry 2010; 32: 246–54.
6 Gilbody, S, Bower, P, Fletcher, J, Richards, D, Sutton, AJ. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med 2006; 166: 2314–21.
7 National Institute for Health and Clinical Excellence. Depression in Adults with a Chronic Physical Health Problem. NICE, 2009 (http://guidance.nice.org.uk/CG91/Guidance).
8 Meadows, GN, Harvey, CA, Joubert, L, Barton, D, Bedi, G. Best practices: the consultation–liaison in primary-care psychiatry program: a structured approach to long-term collaboration. Psychiatr Serv 2007; 58: 1036–8.
9 van Straten, A, Tiemens, B, Hakkaart, L, Nolen, WA, Donker, MC. Stepped care vs. matched care for mood and anxiety disorders: a randomized trial in routine practice. Acta Psychiatr Scand 2006; 113: 468–76.
10 Raine, R, Carter, S, Sensky, T, Black, N. ‘Referral into a void’: opinions of general practitioners and others on single point of access to mental health care. J R Soc Med 2005; 98: 153–7.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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Ways of working at the interface between primary and specialist mental healthcare

  • Linda Gask (a1) and Tarun Khanna (a2)
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eLetters

Models of Access

Dr Mukesh Kripalani, Consultant Psychiatrist
08 March 2011

We read Linda Gask’s timely editorial published in the British Journal of Psychiatry this January with a great deal of interest (1). Withthe trust deciding to convert traditional Community Mental Health Teams (CMHT) to Psychosis and Affective teams, the need for a single point of access was realised.

We have in Middlesbrough, gone through a number of phases in order toaddress the resulting situation once the Psychosis/Affective split in 2007-8. We had a number of “Attached Professionals” as described in the article, with GP practises but the numbers took a major hit when ImprovingAccess to Psychological Therapies hit town (http://www.iapt.nhs.uk/regions/north-east/).

The “Consultation-Liaison” model as described in the article does suffer once services have been split to specialist in-patient and specialist community services and the re-organisation meant that a varietyof psychiatrist were communicating with GPs and as mentioned by Linda Gask, I agree it works usually for well known service users.The ideas around collaborative care including advantages are many but as described “case managers” including their supervision arrangements and contractual obligations, would be a challenge and does not exist in our neck of the woods.We hence decided to adopt the “Matched-Care” model as mentioned in the editorial and employed 2 experienced senior nurses (Band 6) with experience in both in-patient psychiatry and crisis and home treatment to triage referrals from primary care. This model would apply the stepped care approach and was in place October 2009.However, Gps were dissatisfied with the triage approach and hence we changed the nature of this “Access” in April 2010 when it was now performing a full assessment service, the outcome of which was described specifically in BIO-PSYCHO-Social Paradigm following a formulation discussion with a consultant psychiatrist. The Psychiatrist personally does assess 20% of all referrals and most of them have already been seen by a Band 6. The outcome is conveyed back personally by the assessor following a formulation.

This model seems to have gone down well and a full evaluation is currently ongoing via personal face to face visits to all GP practises in the region. Anecdotally, Gps are tending to respond well with this single point of access, since it shares the same premises as with the Crisis and Home Treatment services. We agree with Linda Gask about the potential of “Primary Care Psychiatrist” might be realised soon with the new health andsocial care bill (http://www.publications.parliament.uk/pa/cm201011/cmbills/132/11132.i-v.html).

References:

1. Gask L. and Khanna T. Ways of working at the interface between primary and specialist mental healthcare Br J Psychiatry 2011; 198: 3–5.

Acknowledgements:To the Patients and Hard working Middlesbrough Access Team members who make us all proud.
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Conflict of interest: None Declared

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Working at the interface between primary and specialist mental health care

Vishal S Vyas, Medical Student
09 February 2011

Professor Gask and Dr Khanna’s recent paper1 succinctly evaluates different models of working at the interface between primary and specialist mental health services. While the authors have not taken a stance in supporting a particular model for mental healthcare provision, we argue that the evidence behind a collaborative model of care (which also incorporates elements of other models), is strong enough to warrant its implementation for the management of depression in the community.

Considering just how common depression is and the fact that it takes a chronic course in a sizeable proportion of patients, efforts to improve the structure of care are clearly needed to reduce the number of depressive symptoms in patients and their rate of relapse. The evidence indicating the effectiveness of collaborative care is significant with Gilbody et al.2 demonstrating in a major meta-analysis that there were statistically significant improvements in depression outcomes at 6 months,which extended to 5 years. Similarly, Katon et al.3 found that the treatment adherence and symptoms of patients are significantly improved. Furthermore, collaborative care has also been shown to be modestly more cost-effective for patients suffering from major depression4. From our ownexperience in Luton, UK, where community mental health nurses were deployed to be part of both the primary and secondary care teams, both general practitioners (GPs) and patients demonstrated high levels of satisfaction. 87% GPs felt that the presence of case managers (mental health workers who were responsible for regular patient contact, psychosocial support and medication management) reduced the need for referral to other mental health services as well the need to prescribe anti-depressants5. Moreover, 86% patients found that the psychoeducation received from case managers was useful and enabled them to solve their problems5.

We envision the adoption of a collaborative care model similar to theone we trialled in Luton. A community health nurse could act as a liaison between primary and secondary care teams, thereby enabling difficult-to-treat depressed patients to be discussed at community mental health team meetings with advice offered from consultants and other specialist mental health care professionals. The community mental health nurse would then beable to liaise with the relevant primary health care team members (e.g. GPs and practice nurses) and offer appropriate advice. Additionally, they could act as case managers running their own clinics, much like diabetes or hypertension clinics, in a primary care setting. Ultimately, the aim would be to optimize the treatment of depression in the community, while also serving to reduce the burden on the primary health care team.

In light of the new health care reforms to be instituted across the National Health Service in England, GPs will have the power to commission services according to the deemed needs of their local area. This could potentially be an avenue to introduce collaborative care for the treatmentof depression, with appropriate measures introduced to incentivize its adoption across GP consortia.

References

1. Gask L, Khanna T. “Ways of working at the interface between primary and specialist mental healthcare.” Br J Psychiatry. 2011 Jan;198: 3-5.

2. Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. “Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes.”Arch Intern Med. 2006 Nov 27;166(21): 2314-21.

3. Katon W, Rutter C, Ludman EJ, Von Korff M, Lin E, Simon G, Bush T,Walker E, Unützer J. “A randomized trial of relapse prevention of depression in primary care.”Arch Gen Psychiatry. 2001 Mar;58(3): 241-7.

4. Von Korff M, Katon W, Bush T, Lin EH, Simon GE, Saunders K, LudmanE, Walker E, Unutzer J. “Treatment costs, cost offset, and cost-effectiveness of collaborative management of depression.” Psychosom Med. 1998 Mar-Apr;60(2):143-9.

5. Drinkwater S. “Improving mental health liaison in primary care. Anevaluation of a pilot project.” University of Luton Institute for health services research. Luton: Luton HAZ; 2003.
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Conflict of interest: None Declared

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