The core activities of generalists and mental health specialists with patients with mental health problems are summarised below, under the headings of Referring in, Assessment, Intervention, Liaison, and Other roles.
Referrals in: Mental health problems were often identified as a side issue by generalists
when they were seeing patients for other reasons, with the exception of GPs who had patients self-referring or referred to them for mental health problems. Referrals to mental health specialists were reported to be through formal routes from GPs to Primary Care Mental Health Workers (being piloted in a small number of GP surgeries), or more frequently to the Community Mental Health Team (CMHT), comprising community psychiatric nurses (although not all held the community qualification), occupational therapists and social workers. Referral to the team also provided access to psychology (although with a long waiting list), psychiatry and physiotherapy. Patients were referred to the CMHT as a whole rather than a particular team member, and would be given a general assessment by one of the team members before being assigned to the appropriate part of the service.
Assessments for mental health problems might be carried out by any of the generalists
as part of core lifestage assessments, for example, with mothers in the postnatal period, with elderly people, or when a patient was suspected of having mental health problems. Validated assessment schemes such as the Edinburgh Post Natal Depression Score, locally developed tools including one created to identify depression in elderly people, and a personally-devised system, were all used. However, assessment tools were sometimes considered as only one aspect of making an assessment. For example a feeling that all is not well would be taken seriously:
“yeah I know it’s a well validated, you know em validated and everything, but you will get girls that will score nothing and your gut feeling is that it would be a lot higher[…]. It depends what I know about the family”.
Generalist P8
Building relationships with patients was regarded as an important component of ensuring early detection of mental health problems. For example, respondents described situations when they had spent time building trust with patients or carers, or in one case with another member of staff, using empathy, exploration to find out more information,
drawing on other team members’ knowledge, and offering support to a patient until they were ready to agree to act on the practitioners’ concerns.
In contrast, mental health specialists usually carried out assessments using validated and established assessment tools with additional exploration of symptoms. Assessment tools mentioned included the Hospital Anxiety and Depression Score (HADS), Patient Health Questionnaire, Work and Social Adjustment Scale and Canadian Occupational Performance Measure. Some of the respondents would see patients who had already been assessed by others, in which case they used the report from that assessment as the basis for further exploration. The assessment tools were mostly used at the first or second appointment to assess the patient’s needs for referral on or for intervention although one participant used four scoring systems at the first appointment and repeated them at the last appointment following four structured intervention sessions to identify any changes in the patient’s mental well-being. Some respondents stated that they also used the assessments to stimulate discussion, and to help the patient understand better their mental state. For example, the HADS was used in this way:
“it often was good because you’re able to say well look anxiety is the major thing here it isn’t low mood, but low mood, there’s a wee bit of low mood and that was generally very enlightening for folk to see, because obviously they were sometimes not clear whether they were anxious or stressed, but some of their responses would indicate that hey you are struggling with that. So it’s further encouraging them to decide that they needed to do something about it” Mental Health Specialist P7
Interventions from generalists once a mental health problem had been identified might
include listening, prescribing, treating, referring or a complex set of actions involving many partners to solve a social dilemma. An example of the latter was where one respondent wanted to encourage a patient to take up a place at a day centre. This involved negotiating with the patient and the carer when one was keen and the other reluctant, organising transport, cancelling or re-organising other home based services, ensuring the patient can get help to get dressed on time on the day in question, as well as other logistical concerns. Direct intervention for mental health problems was occasionally offered as part of a primary care generalist role, including structured stress management, support for carers, support to resolve social issues, and prescribing or monitoring pharmaceutical treatment:
“In fact one of the gratifying things we do is to have someone come in here who is really quite depressed and we have known before and you know this is a totally different person and within two or three weeks you can see them just suddenly coming back again”. Generalist, P5
There was some overlap suggested with interventions by mental health specialists within the new model of primary care mental health, but generally they were distinct from primary care. Mental health specialists’ interventions were usually in the form of structured, pre-set sessions lasting between four and eight weeks or in fortnightly appointments. These sessions could be therapy oriented or for guided self-help followed by review then discharge, or referral either back to the referring GP or on to a more specialist service. Some of the mental health specialists described their service within the stepped or tiered approach. One respondent explained the tiered approach as starting with community level with information and general health and well-being messages or through voluntary organisations or clinicians for support such as a book prescription scheme or lifestyle coaching. The next tier was for moderate symptoms of depression which could be dealt with by the Community Mental Health Team (CMHT) or the new primary care mental health workers. Patients with moderate to severe problems would be referred for assessment through the psychology services.
Signposting or referring on by generalists could be to a GP for further referral to NHS
mental health specialists, referring to social services, or referring or signposting to voluntary sector organisations. However, generalists were clear that if they suspected that a patient might have a mental health problem, they would refer them to their GP in addition to other routes for help if appropriate. Most of the generalists also emphasised that building links with specialist mental health services was important in order that they could learn about specific mental illnesses, clarify their own limits of knowledge about mental health problems, and be in a position to negotiate a position of shared care after referral if necessary. Another element was to know what mental health services might offer their patients.
Mental health specialists would refer patients on to other services, including those in the NHS and in the voluntary sector, for specialised or social support. Most mental health specialists also talked about building relationships with other service providers such as the GP or other members of the CMHT in order to agree treatment, or at least to ensure that the GP was aware of the treatment the patient was receiving. Mental health specialists often appeared keen to maintain patients within a primary care service or to divert patients away from mental health services:
“you go along with government philosophy and local philosophy, you know, about not stigmatising people with regards to mental health needs and diverting them away from mainstream mental health services”. Mental
Health Specialist, P3
Voluntary sector organisations particularly those providing specialist services such as counselling or help with alcohol problems, appeared to be used regularly and valued highly by both generalists and mental health specialists. However, some were concerned that the funding problems suffered by the voluntary sector meant that they were not always assured that the organisations would be available.
Liaison was a core part of both generalists and mental health specialists’ work. For
example, respondents worked to co-ordinate care across generalist and specialist input; engaged in formal partnership working, such as in carrying out single shared assessments; worked in joint funded posts; or developed informal partnerships or networks, for example:
“it’s communications, who you know, networking I suppose you would call it
[…]. I made a point of going out and shadowing them, phoning them up
and going to see them and, you know, I get on really well with social workers that are in our area because I know them all, you know, I know that if I phone them up and I ask them for something that they will give it to me, you know, because they know that I’m not just doing it to be bolshy.
[…] I think it’s a communication thing and if you scratch my back it means
I’ll scratch yours further and it works, it works for me.” Generalist, P6.
Mental health specialists also talked about liaising with other services in order to improve access to services, to teach generalists more about mental health, to share learning and practice, and to augment a medical model of treating mental health problems with a social model.
Other practice-related roles included management responsibilities in addition to
clinical roles, either in managing small teams, or membership of strategic working groups or LHCC or CHP governance groups. Some respondents also participated in teaching or advising other staff, trainees or staff from other statutory or voluntary organisations.