Análisis de la varianza de un factor

The standard route into NHS psychiatric care is by referral by a GP. In some cases general practices within the UK employ counsellors or psychologists. Only a minority of practices have any formal arrangements for the delivery of more intensive psychological therapies such as CBT, although this should change with the IAPT initiative in England and Wales and comparable efforts in Scotland such as Doing Well by People with Depression (2003–2006).

If the GP feels that a student’s mental disorder cannot be effectively managed within primary care, the student will sometimes be directed to the counselling service within their academic institution. Arrangements for referral and communication between medical practices and counselling services vary from institution to institution. Where higher education institutions have a university medical service (see pp. 53–55) this is far more effective and straightforward than in those institutions that do not have this close relationship with a single primary care provider. In such cases there may be no facility for GPs to make formal referrals to counselling services and no reporting back to GPs in the course of, or at the end of, counselling. It is helpful if clear channels of communication are established and relevant information is shared. Students are generally happy to consent to this.

The GP may also make a referral to the local secondary care CMHT. These teams are multidisciplinary and can provide a range of interventions such as psychiatric assessment, expert pharmacological management, occupational therapy and more formal treatments, for example CBT. In the case of a student who has acute psychosis or is acutely disturbed there may other options such as referral to early intervention for psychosis teams or intensive home treatment teams.

Where appropriate, individuals can be referred by CMHTs to specialised tertiary services such as psychotherapy, drug and alcohol services and eating disorder services. The provision of these services varies widely from one area to another.

In general, there is limited access to NHS secondary care directly to potential patients or to non-NHS referrers such as counsellors and other university staff, and there are good reasons why this should not be overridden. The first is that the GP can coordinate and provide continuity of care for patients as they proceed through the system. The GP remains responsible for prescribing rather than this responsibility being dispersed across a range of specialist services. This means that there is less risk of drugs being prescribed that have adverse interactions. Finally, GP referral is a major factor in promoting efficient use of secondary and tertiary services.

In countries in which there is direct access to specialist services, healthcare costs are generally much higher and resource utilisation less efficient.

There are nevertheless some specific situations in which direct access to secondary care can be of enormous help to troubled students. In many institutions mental health advisors and counsellors have developed good links with early intervention and crisis assessment and treatment teams and direct referrals to these have proved very beneficial to students.

In rare cases, students will require care within in-patient psychiatric settings either on a voluntary basis or as a consequence of being detained under the Mental Health Act. In recent years there has been a trend away from in-patient treatment towards community-based treatment within the newly developed services such as crisis resolution teams, home treatment teams and early intervention for psychosis teams.

It is important that services are tailored to the time constraints of stu- dent life. Because a student may not be staying in the area for a long period of time there is a temptation by local services to avoid involvement as they may fear, rightly or wrongly, that little can be achieved within a short time- frame. There are often long waiting lists, especially for services such as clinical psychology. A student may come to the top of the waiting list towards the end of an academic year. He or she will usually then return to their home area or go elsewhere for the summer vacation and be unable to attend. Appointment letters or questionnaires may go astray as a result of changes of mailing address. The consequence is that the student may be dropped from the waiting list and then has to be re-referred and start the whole process again.

It is important that higher education institution personnel have some insight into how the NHS services work and the pressures and constraints that exist in the health service. It is equally important that NHS personnel have a better understanding of the systems and structures of higher education. In recent years NHS psychiatric services have come under increasing pressure to focus their resources on patients with severe and enduring mental illnesses such as schizophrenia and bipolar disorder. In some cases, there has been a corresponding decline in the availability of services to those with less severe conditions such as mild to moderate depression, and the burden of caring for students with these conditions may fall on counsellors and mental health advisors.

general

meDical

care

of

stuDents

It is very important to emphasise the major role that primary care plays in the management of mental disorders in the general population. Most mental disorders are managed at the level of primary care without referral to specialist services. This role is reflected in the NICE guidelines for diagnosis and management of depression (for example, in the stepped-care model of care; NICE, 2009a) and the monitoring of patients on antipsychotic medications (NICE, 2009b).

In GP practices with a significant cohort of students on their patient lists, there is an involvement and experience in the management of mental disorders which is considerably greater than that provided in routine GP settings. In such cases, GPs often liaise directly with student counselling services, disability services, mental health advisors, academic staff and support services. The general practice often exercises a pastoral and advocacy role as well as the core clinical role.

All students should register with a GP when they first come to a university or college and, in fact, most do so in the first weeks following matriculation. Most university health practices make active efforts to have new students fully registered in the first few days following enrolment and screen for pre-existing medical conditions, including mental illnesses. Sometimes students register with a university GP only when they first develop a medical problem, which may be a mental disorder. General practitioners are usually involved in the care of patients with the full spectrum of mental illnesses, whether this is at first presentation or with ongoing care. In the vast majority of cases, higher education institution services will involve the student’s GP as the primary link with NHS services. Furthermore, in crisis situations the GP is often the first port of call either by the student or the higher education institution (or even the student’s parents). Practices used to dealing with students and higher education institutions are well aware of the particular issues related to the student group and have systems in place to cater for their specialist requirements.

In the past, many universities were direct providers of primary care health services to students. Although these services were funded by the NHS, the university employed clinical staff such as doctors and nurses. This model has now been largely abandoned and primary care services are nearly always provided by mainstream general practices. In some cases these are former student health services which retain links to the higher education institution and the majority of whose patients are current or former students, university/college staff and their families. They may also, for example, have contracts to provide non-NHS services such as medical certificates and opinions on fitness to study abroad. In other cases, practices attract large student populations because they are located in close proximity to a university or college campus. Such practices may have no formal link with the higher education institution and primary care services for students are provided as for non-students.

This diversity of provision was confirmed by a recent survey carried out by AMOSSHE (L. Foley, 2010, personal communication). Of the 57 institutions which responded to the survey, only 2 were direct providers of medical services. Thirty had a service-level agreement with a general practice on or near to the campus for provision of services to students. Twenty-three stated that they had a local practice that provided treatment to the majority of students but that there was no formal contract with the practice. In the other two institutions there was no arrangement or understanding of any sort with a primary care provider.

One intention of the current GP contract was to achieve improved assessment and management of chronic diseases such as coronary heart disease, kidney disease and diabetes. This was taken forward under the auspices of the Quality and Outcomes Framework (QOF). A substantial proportion of the income of GPs is now achieved by attaining adequate performance against a range of targets for specific diseases. The diseases targeted by the QOF have a low prevalence in young people in general and in students in particular. As a result, practices with a high number of students and few patients over the age of 25 have been unable to attain income levels that are comparable to that of the average GP. This could lead to disincentives to GPs becoming involved in the care of students. At the very least what is likely to happen is fewer and fewer trained clinical staff being available to provide primary care services including support and treatment for mental illnesses to more and more students. Unless this situation is remedied the future of student health services will be uncertain

and is potentially precarious. There is a risk that the expertise in dealing with mental health difficulties that has been developed in some practices will be diminished or lost.

collaborative

working

between

health

anD

higher