Experiences of delivering primary mental health care

Experiences of delivering
primary mental health care
A report by the Wales Mental Health
in Primary Care network
March 2015
M
P
C
H
About WaMH in PC
The Wales Mental Health in Primary Care Network (WaMH in PC) was established in 2003
to help promote and improve primary mental health care across Wales. We are set up as
an RCGP Wales special interest working group under the guiding principles and aims of
our Constitution, which was adopted in October 2008 and updated in February 2011.
WaMH in PC aims to provide a Welsh forum for like-minded individuals to work together to:
• Improve the profile of mental health care services
• Promote primary mental health care services
• Develop new ways of thinking about and working with mental health problems in a
primary care setting
The Royal College of General Practitioners (Wales) is a network of over 1900 family
doctors working to improve care for patients. We work to encourage and maintain the
highest standards of general medical practice and act as the voice of GPs on education,
training, research and clinical standards.
Royal College of General Practitioners (Wales)
Regus House, Falcon Drive, Cardiff Bay,
Cardiff, CF10 4RU
Telephone: 020 3188 7755
Fax: 020 3188 7756
Website: www.rcgp.org.uk/wales
Royal College of General Practitioners is a registered charity in England and Wales
(Number 223106) and Scotland (Number SC040430)
Contents
Introduction
3
Executive Summary
4
Recommendations
6
Demographic of respondents
8
Experiences of delivery
9
Challenges facing delivery
18
Broader context
22
Introduction
Welcome to the third Wales Mental Health in Primary Care (WaMH in PC) survey of
Primary Care mental health. WaMH in PC is a working sub-group of the Royal College of
General Practitioners in Wales and is made up of individuals and organisations that have
an interest in Primary Care mental health.
This report is independent and we have received no funding to produce it. We sent an
email request to all GP practices in Wales in February 2014 asking GPs and practice
nurses to complete a short internet-based ‘Survey Monkey’ questionnaire. This year we
also invited workers from the new Local Primary Care Mental Health Support Services to
also give us their opinions. The site was open from February 2014 to May 2014 to give
maximum opportunity for staff to enter their views.
The survey was intended to supplement previous surveys (2011 and 2009) with some
previous questions asked again. The results we present in this report are those from the
2014 survey with occasional reference to the 2011 survey where relevant
However, there were also some new areas we were keen to hear about; in particular
practitioner well-being, the impact of welfare changes, and the effectiveness of Part 1 of
the Mental Health (Wales) Measure for Primary Care staff. We also wanted to mirror some
of the evidence from Gofal’s reports on the patient experience in Primary Care.
The survey was conducted 16 months after the introduction of Part 1 of the Mental Health
(Wales) Measure, and is therefore a snapshot of opinion about the early stages. WaMH in
PC is very supportive of the Measure, and the fact that mental health legislation is taking
account of the needs of Primary Care. We are therefore disappointed that at the time the
survey was carried out that Primary Care practitioners were less than enthusiastic about
the impact of the Measure. However, we hope that as the new services bed-in and mature,
they create more positive outcomes for patients and Primary Care practitioners.
This report communicates the views and perspectives of practitioners working in Primary
Care settings. It is not trying to describe a “truth” but gives another side to the dialogue
on mental health services in Wales. The survey was open and inclusive, but we can only
capture the views of those who engaged with it. They may be the enthusiastic ones, or
they may be the most dissatisfied. Or more likely a combination. This report will be shared
across Wales with the practitioners who completed the survey, Welsh Government, Health
Boards, Public Health Wales and Third Sector organisations and will be freely available to
download from our website.
We wish to thank all those who responded to the questionnaire, as well as those
members of the WaMH in PC Core Group who collaborated in developing this report. Any
correspondence should be directed to Lesley.Hills@rcgp.org.uk
Dr. Mark Boulter
Chair, Wales Mental Health in Primary Care
3
Executive Summary
Some key themes have emerged from this survey, which need to be heard by as wide an
audience as possible. The four main headings provide a framework to deal with the issues
raised.
Workforce
Primary Care is under immense pressure. Our survey shows that the mental health
workload is perceived to be increasing and that GPs often do not feel it is an easy subject
area to manage. 70% say it is either ‘Difficult’ or ‘Very Difficult’! It has been identified that
GPs feel more confident recognising, diagnosing and treating mental health problems
compared to last time, but that they feel much less confident in managing complexity, and
where there are significant issues outside of their control which may be causing emotional
distress and mental health problems. It would appear that the medical model that has
underpinned medical training and professional behaviour may be of little help when
dealing with these situations. Another area to be addressed is the low level of confidence
in promoting mental well-being and the scope for joint working with health promotion
bodies to increase levels of knowledge and competence.
It is apparent that the areas GPs feel less confident about are also the areas where
they feel the least supported. Traditionally there have been poor lines of communication
between Primary Care and Local Authorities. The same can be said for the Third Sector.
This has to change if we are to improve the welfare of Welsh patients. This chimes well
with the Together for Mental Health, which recognises that health services alone cannot
deal with the mental health needs of Wales, and that this is everyone’s business.
Many GPs have indicated that their own mental health and well-being has been affected
by the pressure of increased volume and complexity of workload; this should be a major
concern to Government and Health Boards. The combination of a rising workload,
perceived lack of support and low levels of confidence will lead to poor performance and
poor patient outcomes. Without a well-functioning Primary Care sector, Mental Health
Services will suffer greatly.
Workload
Over 50% of respondents identify that they are spending over 20% of their working days
dealing with Mental Health issues. This is far greater than for any other area of their
broad case-load; the time spent on Mental Health seems to be getting greater. To add
to that, there have been other issues such as changes to the Welfare Benefits System
which have introduced major stress to large sections of Welsh society. If there is no effort
to support Primary Care then we can foresee greater mental health problems within this
essential primary care workforce, as well as a concomitant reduction in the service given
to patients.
Practitioners will struggle to listen, be empathetic and holistic when they are in distress
themselves. There is an urgent need to look at ways of supporting teams to become more
resilient, the LPMHSS teams may be one way to deliver on this by training and supporting
primary health care teams and giving them key skills in managing stress. The area that
GPs feel least confident is in promoting mental well being. We propose that mental health
promotion bodies in Wales work together with Primary Care to develop these skills.
4
Wider mental health economy
16 months before we ran this survey, the Mental Health Measure was introduced in Wales.
WaMH in PC has been highly supportive of the Measure, and feel it is a step in the right
direction. From our survey, it appears that it is taking some time for LPMHSS teams to fully
form and collaborate with other services, with some areas taking shape more quickly than
others; as a consequence , it has not been as effective for Primary Care (in the short-term)
as GPs had hoped. This is not necessarily a reflection of the success of the Measure, it
may be because the expectation of Primary Care was too high, or that expected outcomes
were not deliverable via the Measure.
Comments within the Survey show significant concerns about Mental Health services
across Wales. Particular concerns exist relating to CAMHS services, the boundary with
Secondary Care, waiting times, and most significantly access to Psychological Therapies.
There has been an apparent focus within the new LPMHSS on assessment, and this
has led to other aspects of Part 1 of the Measure receiving less support and recognition;
yet they are enshrined in Law. There is an urgent need for greater engagement with
the LPMHSS teams, particularly regarding support and training for the Primary Care
workforce. In addition, the treatment aspects of the service have often been neglected, and
the new teams need to develop the skills to provide appropriate Psychological Therapies
at a community level. Respondents to the survey have identified that investment in
Psychological Therapies would have the greatest impact. In addition, they feel that Service
Capacity and timely access to Secondary Care services are also key areas for investment.
Outside pressures
Society is changing. There is a greater level of expectation of the types of support
and treatment people should have access to. Primary Care will need to catch up with
these expectations, and help and support is required to promote confidence in utilising
alternative avenues of support and treatment. The financial downturn and reduced budgets
for Health and Social Care in Wales however has created a pressure at Primary Care
level. There have also been changes to social security imposed on Wales, creating an
additional level of work for GPs and their teams.
Primary Care is a central point of contact for all people in Wales. It is local, nonstigmatizing, accessible and highly popular. However, over the last few years there
have been increasingly negative depictions of Primary Care in the media. This and the
workload/workforce pressures have had a marked effect on morale and recruitment/
retention. We feel there is an urgent need for a political cease-fire, as well as overt support
and recognition for work carried out in Primary Care.
Wales’ approach to improving mental health has to include mental health promotion and
positive mental health, the recognition and management of mental health problems,
and a system that allows a smooth flow from presentation, through to assessment,
support/treatment, and recovery. A well supported primary care system is central to early
intervention, health promotion and supporting the prudent healthcare agenda.
Many of the key social determinants of mental well being are outside of the control of
Primary Care teams. If we are to have an impact in these areas, there needs to be closer
collaboration between Primary Care, Local Government and the Third Sector, especially in
areas of social and economic deprivation. This will require concerted efforts to bring these
services as close as possible to Primary Care teams as well as simplify communication
channels and foster trust.
5
Recommendations
WaMH in PC welcomes and recognises the potential of Part One of the Mental Health
(Wales) Measure, however, more focus is required in the implementation of this legislation.
In particular, it is important that the ‘spirit of the Measure’ is delivered across Wales, not
just the letter of the law.
Based on analysis of the survey data, and the comments made by primary care
practitioners across Wales, the following section offers a series of achievable and prudent
recommendations.
Access to psychological therapies
The data indicates that waiting times for psychological therapies are unacceptable in
many areas of Wales. Feedback indicates that services have prioritised processing
assessments in order to meet the Welsh Government’s 28 day target; as a consequence
the focus, and in some cases funding, has been diverted away from delivering
psychological therapies.
While we welcome Welsh Government funding announced in June 2014 for training
in psychological therapies, however this will not deliver improved access unless the
workforce is increased through funded posts. We believe that this is the responsibility of
Health Boards, which need to ensure that access to psychological therapies is a priority
in the strategic development of local primary mental health services across Wales. To
support this change, we recommend that a more relevant target be created for access
to psychological support reflects outcomes for patients, not processes.
Support for GPs and the primary care workforce
Part 1 of the Mental Health (Wales) Measure is designed to provide support and advice
to GPs and other primary care professionals, to enable them to safely manage and care
for people with mental health problems. It is essential that this component of the Measure
is delivered and that GPs receive the advice and support to enable them to feel confident
in understanding and signposting. Additionally, they will require support to develop
enhanced skills, allowing them to manage patients more effectively and use resources
more prudently. If there is no change in the skills, knowledge or behaviour of Primary Care,
then there will be no change in the workload for LPMHSS and CMHTs. We recommend a
re-balancing of priorities within the LPMHSS teams, to ensure that support for the
primary care workforce is delivered.
We also believe there should be a focus on improving and maintaining the wellbeing of
primary care practitioners. Our survey demonstrates that they are under a lot of pressure,
and we recommend that Health Boards become more proactive in protecting the
health and wellbeing of primary care practitioners.
6
GP involvement and democratic participation
We believe that GPs need to be fully involved as partners in the decisions that determine
the development and delivery of mental health services in primary care. We recommend
that Health Boards and Local Authorities ensure that GPs are fully engaged in the
development of local primary mental health care schemes alongside service users.
Integration
Some of the comments made by primary care practitioners indicate that there are still
problems with integration across different parts of mental health services, such as referrals
to CAMHS, secondary care teams and specialist clinicians. It is crucial that the Measure
does not inadvertently reinforce barriers between different parts of mental health services
and that all sectors providing mental health services review and improve the interfaces
between their services.
We know that many social factors affect mental health and wellbeing, and that the health
service cannot deliver improvements to whole population wellbeing alone. The survey
also shows that GP confidence is dropping and they need more support, when it comes to
promoting wellbeing and being aware of services in other sectors that can help deliver this
agenda. The development and delivery of the new Social Services and Well-being (Wales)
Act and the Well-being of Future Generations (Wales) Bill need to address the issue of
supporting and working with Primary Care more effectively in order to deliver holistic,
person centred care.
We recommend that Health Boards and Local Authorities consider ways to better
integrate services that support mental health and wellbeing. For example, locating
some Local Authority and Third Sector services within GP surgeries on certain days, or at
certain times so that referrals to housing or welfare reform advice services is both easy for
the GP, and accessible for the patient.
7
Demographic of respondents
152 people working in primary health care responded to the 2014 WaMH in PC survey.
The following charts illustrate the professional background, age, gender and Health Board
of the respondents.
The majority of respondents (nearly 75%) were GPs, over 85% were aged 41 or older and
nearly 60% of respondents were female. People working across all of the Welsh Health
Board areas responded to the survey, with the highest proportion working in the Betsi
Cadwaladr, Abertawe Bro Morgannwg or Aneurin Bevan University Health Boards.
Age
Professional background
100%
90%
80%
>51
70%
60%
41-50
50%
31-40
40%
GP
Practice Nurse
Local Primary Health Support Service Worker
Other
Which Health Board do you work in?
<30
30%
20%
10%
0%
Gender
35%
30%
25%
20%
15%
10%
5%
0%
ABM
UHB
AB
UHB
BC
UHB
C&V
UHB
CT
UHB
HDd P tHB
UHB
8
Male
Female
Experiences of delivery
Mental health case load
Q
Looking at your mental health case load: what proportion of your practice time
is spent on mental health related work?
• There was a 9.3% decrease in
respondents who reported that
their mental health workload
was less than 11%, compared to
2011.
100%
90%
80%
> 50%
70%
31-50%
60%
• There was a 7.6% increase in
respondents who reported that
their mental health workload was
over 20%, compared to 2011.
21-30%
50%
11-20%
40%
• T
here was a 4.7% increase in
respondents who reported that
their mental health workload was
over 30%, compared to 2011.
30%
5-10%
20%
< 5%
10%
0%
2011
2014
Compared to the previous survey, there appears to have been an increase in the
proportion of time spent on mental health related work. This could in part be due to raised
awareness of mental health problems and related services, and more of a willingness from
the general population to visit their GP to discuss mental health. It could also be related
to the external environment and the difficult financial circumstances and pressures facing
people at home and at work.
It appears that the mental health workload in Primary Care is increasing; we believe
that resources and planning need to respond positively to this strain, on an already over
burdened area of the health care system. We need greater understanding of the causes
of this increase in work load, especially as other data from the survey shows that this is an
area that GPs find challenging.
9
Practitioner confidence
Q
How confident are you personally about dealing with each of the following
steps in the patient’s pathway?
These results are similar to previous surveys and illustrate that GPs still feel they lack
the confidence to intervene outside of the more medically-defined areas of mental health.
As previously (2009), the results indicate that practitioners feel least confident when
promoting mental well being. To ensure an effective service, more resource are required to
help Primary Care practitioners develop skills in promoting mental health and wellbeing as well as treating mental illness.
It also appears that confidence is lacking when there are complex and co-morbid physical
and mental health problems. Working in a holistic patient-centred fashion is a corner stone
of WaMH in PC’s values, and it is concerning that colleagues find this provision of care
challenging. There is evidence to suggest that where mental and physical health problems
co-exist, morbidity, mortality and physical health outcomes are improved, if mental health
issues are addressed1.
We know that some of the main determinants of mental well being are housing,
employment, social isolation and financial constraints. We believe there needs to be
stronger links with other organisations to help Primary Care to deal with these issues. The
development and delivery of the new Social Services and Well-being (Wales) Act and the
Well-being of Future Generations (Wales) Bill need to address the issue of supporting
and working with Primary Care more effectively, in order to deliver holistic, person centred
care. It is clear that the NHS in Wales is not solely responsible for supporting the mental
well-being of the citizens of Wales, and that better collaborative working is required across
many sectors. Support needs to be directed towards Primary Care to help it cope with the
increasing level of complexity it is expected to deal with on a daily basis.
1 Long-term conditions and mental health: The cost of co-morbidities, The Kings Fund and Centre for Mental
Health, 2012 http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/long-term-conditions-mental-health-cost-comorbidities-naylor-feb12.pdf
10
How confident are you personally about dealing with
each of the following steps in the patient’s pathway?
100%
90%
80%
1 (low
confidence)
70%
2
60%
3
50%
4
40%
5 (high
confidence)
30%
20%
10%
0%
A
B
C
D
E
F
G
H
Key:
A Early / proactive detection of signs of mental health issues
B Assessment and diagnosis of mental health issues
C Treatment and referral decisions
D Follow up and reassessment
E
Patient support and engagement
F
Managing patients with co-morbidity of mental and physical ill-health
G Understanding and signposting for the social factors related to mental well-being –
for example housing, diet, employment, social inclusion and others
H Promotion of mental health and wellbeing in the patient community including social
and economic interventions, e.g. debt counselling and third sector /social enterprise
initiatives
11
Support for primary care practices
Q
How much support do you feel your practice has overall in dealing with each of
the following steps in the patient pathway?
It appears that the areas where practitioner confidence is the lowest, are also the areas
where perceived support is most lacking. For example, respondents have indicated mental
health promotion as an area lacking in confidence, a neglected subject requiring more
effective support.
It is surprising that the introduction of the Mental Health (Wales) Measure has not helped
to increase support more effectively. This may reflect a focus on assessments, rather than
other aspects of Part 1 of the Measure. There is a possibility that the 28 day assessment
target has distorted the priorities of the service, but our study also shows there are
concerns about capacity and waiting times. We suggest that there is a recalibration of the
emphasis of the various functions of Part 1 primary care services. This must include the
stated role of the service in supporting and training primary care teams.
Part 1 of the Mental Health (Wales) Measure is meant to provide support and advice to
GPs and other primary care professionals, to enable them to safely manage and care for
people with mental health problems. It is essential that this area of the Measure is not
neglected, and that GPs receive the advice and support to enable them to feel confident
in understanding and signposting for the social factors related to mental wellbeing,
and promoting mental health and wellbeing. In addition, the skills of the Primary Care
work force need further development to enable them to cope more effectively with the
increasingly complex mental health problems that present.
We also believe that further support and connections are required with other agencies
such as social services, housing, education and advice services such as CAB. Primary
Care practitioners are only one part of the whole system that supports citizens in their
communities. We feel that the role of Local Authorities needs re-connecting to Primary
Care, especially as they are supposed to be a partner in the delivery of Part 1 of the
Measure.
In summary, we believe that improved communication between GPs and LPMHSS, and
better support and education for GPs and other primary care practitioners will lead to
better management of patient mental health, and fewer inappropriate referrals to primary
and secondary mental services.
12
How much support do you feel your practice has overall in dealing
with each of the following steps in the patient pathway?
100%
90%
80%
1 (low)
70%
2
60%
3
50%
40%
4
30%
5 (high)
20%
10%
0%
A
B
C
D
E
F
G
H
Key:
A Early / proactive detection of signs of mental health issues
B Assessment and diagnosis of mental health issues
C Treatment and referral decisions
D Follow up and reassessment
E
Patient support and engagement
F
Managing patients with co-morbidity of mental and physical ill-health
G Understanding and signposting for the social factors related to mental well-being –
for example housing, diet, employment, social inclusion and others
H Promotion of mental health and wellbeing in the patient community including social
and economic interventions, e.g. debt counselling and third sector /social enterprise
initiatives
13
Impact on primary care practitioner wellbeing
Q
In the last 12 months have workload pressures / increased complexity / other
practice-related issues had an effect on your well-being?
This is a very important area. Primary Care has undergone a huge increase in pressures
over the last few years. In addition, there has been negative reporting in the media about
Primary Care, which is having a profound effect on GP morale. There are many factors
that have joined together in a ‘perfect storm’ to affect the well-being of practitioners, such
as issues concerning workload, workforce, adverse publicity and demographic and societal
changes.
In the last 12 months have workload pressures / increased
complexity / other practice-related issues had an effect on your
well-being?
Improved (2.0%)
No effect (30.7%)
Detrimental (59.3%)
No comment (8.0%)
There will need to be increased support for Primary Care professionals and their teams
to help them deal with the effects on their well being. We must ensure that they have the
skills and understanding to manage their own mental health problems, or have access to
professional services to support them. It is highly unlikely that Primary Care practitioners
can successfully look after the needs of others, if they themselves are distressed and not
coping with the expectations that society has of them. Distressed professionals will be less
likely to listen effectively and demonstrate empathy and understanding, yet these are often
the key demands of patients of their doctors.
There may be a role for peer networks and locality groups in supporting doctors more
effectively. Part 1 services could also train Primary Care teams in the management of
stress and anxiety to help them develop their own resilience, as well as pass on key skills
and messages to patients.
14
Existing support networks should also be promoted on a regular basis, to ensure their
presence is clear in healthcare professionals’ minds.
• Royal College of Practitioners Peer Mentoring: www.rcgp.org.uk/my-rcgp/find-amentor.aspx
• General Medical Council (GMC): www.gmc-uk.org/concerns/doctors_health_
concerns.asp
• British Medical Association (BMA): http://bma.org.uk/practical-support-at-work/
doctors-well-being/websites-for-doctors-in-difficulty
• British Doctors and Dentists Group (BDDG) website: www.bddg.org
• H
ealth for Health Professionals Wales (HHP Wales): www.hhpwales.co.uk or call
0800 058 2237. Health for Health Professionals Wales is a Welsh Government funded
initiative which offers a free, confidential helpline to any doctor in Wales, access to 8
sessions of CBT and signposting to support resources.
• Doctors Support Network: www.dsn.org.uk/
We also believe that there needs to be greater political support for Primary Care teams,
and the need for more training in resilience at undergraduate and at GPST level.
There should also be local provision of stress awareness and management courses in
recognition of the stress that practitioners are currently facing.
15
Advice, treatment and support options for patients
Q
When dealing with common mental health problems do you refer to or provide
any the following?
When dealing with common mental health problems do you refer
to or provide any the following
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Refer
Provide
We have tried to use the WaMH in PC survey to see what advice, treatment and support
options GPs felt they offered or referred to. This question was designed to mirror a
question in Gofal’s survey of patient experiences of primary mental health services. We felt
there was extra benefit in triangulating the patient experience against the professional one
to enhance to evidence about resource use in Primary Care.
Gofal’s survey demonstrated that prescription medication is the dominant offer (see
graph opposite). Patients who responded to the survey expressed a wish to have more
options presented to them, in particular the offer of psychological therapies. However, the
surveys conducted in 2013 and 2014 indicate that people are being offered a wider rage of
treatment and support options, with marked increases in the proportion of people offered
advice and information, psychological therapies and signposting or referral to another
organisation or service.
16
Comparative data – Gofal survey
In 2012, 2013 and 2014 the mental health and wellbeing charity Gofal conducted
surveys of people’s experiences of primary mental health services in Wales. The
surveys asked respondents which advice, treatment and support services they were
offered.
Were you offered any advice, treatment or support?
80%
70%
60%
50%
40%
30%
20%
10%
0%
2012
2013
2014
Please note: The question about psychological therapies was split into ‘CBT’ and ‘other talking
therapies’ for the second and third surveys following feedback from health professionals.
There seems to be a disparity between what professionals say they offer patients, and
what patients feel they have been offered. This may partially be due to the fact that a GP
may well use the options presented but not for every patient. It may also reflect a disparity
of understanding, for example, patients referred to the LPMHSS, who have an assessment
followed by information and/or a brief group intervention may classify this as receiving
therapy, whereas a GP might not classify this as such. However, it is gratifying to see that
patients feel they are now being offered a greater number of options when they present in
Primary Care; although anecdotal evidence from some GPs suggests that lengthy waiting
times for talking therapies are deterring GPs from offering this form of support to patients.
These results also reinforce the need to ensure that GPs have appropriate information
about alternative support services in the community.
17
Challenges facing delivery
Management of mental health in primary care
Q
In your opinion, how difficult is the area of mental health to manage at primary
care level?
In your opinion, how difficult is the area of mental health to
manage at primary care level?
Very difficult (12.7%)
Difficult (60.0%)
Manageable (26.7%)
Not at all difficult (0.7%)
We have shown yet again (compared to the 2011 survey) that GPs face a large workload
of patients with mental health issues, but also that they see this area as a difficult one to
manage.
Not every patient who presents in Primary Care wants or needs referral to secondary care,
or to the Local Primary Care Mental Health Support Service. These patients still need
holistic patient centred care from their GP, but time and workload constraints can make this
extremely challenging for a GP to provide. This reinforces the point made previously in this
report that Part 1 of the Measure was meant to improve the advice and support to GPs.
This is an essential component of the Measure, and needs to be delivered appropriately.
The new Local Primary Care Mental Health Support Services need to develop GPs’
understanding of how the various care pathways work in their locality, and of other
services available to help patients with mental health problems.
18
Barriers to successful delivery
Q
What are the top three barriers to the successful delivery of Primary Care
mental health services?
What are the top three barriers to the successful
delivery of primary care mental health services?
Other (please specify)
Availability of training in mental health issues
Difficulties working together with other parts of
the mental health services
Low level of professional interest in mental
health in primary care
Treatment protocols
Care pathways
Referral processes
Personal Professional knowledge of mental
health issues
Service capacity
Timely access to secondary-care services
Timely access to psychological therapies
0%
20%
40%
60%
80%
100%
As with other areas of this report, it is clear that the capacity of available services, the time
taken to access secondary care services and access to psychological therapies are major
issues for GPs, but more importantly their patients. GPs had hoped that the introduction of
the Mental Health Measure would improve access to appropriate psychological therapies,
but this has not yet happened and leaves GPs not being able to offer treatments that are
recommended by NICE. However, we are pleased that a low level of interest in Primary
Care is not considered a factor in hindering successful delivery.
19
Concerns about the new primary mental health services
Q
Do you have any concerns about governance issues; waiting times;
communications between services; access to psychotherapeutic interventions;
quality or appropriateness, of the new primary care support services?
We asked respondents whether they had any concerns about the governance,
communication, quality and delivery of mental health services in primary care. As the
question asked about concerns, it is understandable that many of the opinions in this
section are highly critical. However, some have taken time to say how well some of their
services are working, and it is important to capture the honest opinions of professionals
working in primary care. Comments highlight that:
• Access to psychological therapies is a major and continuing concern.
• The introduction of the Mental Health (Wales) Measure has not as yet fully resolved
the interface issues between Primary and Secondary Care for many clinicians.
• The new services are well funded and fully supported with staff with appropriate
skills and with manageable workloads. Hopefully, Health Boards will accept the new
services as a valuable investment, as a means to reduce the demand for expensive
secondary care services, and will commit more than the minimum funding to these
services. Despite the negative comment, it is our belief that the new services brought
in under the Mental Health Measure need time to mature and integrate with other
services.
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“Access to Links has greatly improved in the past few months, however, ‘talking’ therapies have a
woeful waiting list.”
“Availability of psychological interventions is still poor.”
“Long waiting times for all forms of psychological intervention, resulting in patients deteriorating and
feeling bereft of help/support.”
“Referrals being rejected by CMHT without pts been seen.”
“Very poor service for young people locally.”
“Poor transfer care to adult services from CAMHS.”
“Yes - access to mental health services via the CMHT has drastically reduced and been made more
cumbersome in past 2 years.”
“So far we have had access to assessments but no real improvement that I can see in the
provision of psychological therapies, such as CBT.”
“Our local Stress Control training course has been excellent for those with mild/moderate symptoms.”
“If a patient becomes moderate to severe, we have effectively no service until they become
severe or very severe.”
“Hopelessly inadequate CAMHS service, with 80% referrals being returned.”
“Waiting times - service not suitable for crisis intervention (unless immediate risk for life, which is
rare) leads to more prescriptions of antidepressants to bridge the gap until seen.”
“Waiting times are generally long. Services don’t appear to be ‘joined up’.”
“Secondary services try hard to provide timely interventions but are too stretched to do this.”
“The primary mental health team are professional & well managed. The problem I have is with the
secondary mental health provision, which in my experience is elitist and poorly managed & offers a poor
service.”
“Strain on service capacity can result in lengthy/extended waiting times for patients.”
“There seems to be a considerable problem when attempting to refer on for appropriate treatment/
further assessment when patients’ mental health needs cannot be met in primary care.”
“Absence of some services e.g. eating disorders, psychology, PTSD counselling.”
“Very limited capacity for childhood / adolescent services.”
“No adult ADHD service. Big problems with OOH services and admissions.”
“Big concerns about commissioning/ contracting, with consequent lack of inpatient beds, impermanent
consultant psychiatrist causing lack of consistent leadership and continuity of care.”
“Referrals to one part of service being returned for referral to another.”
“No-one wants to know our pts they are either too sick or not sick enough for what is being provided.”
“No one wants to look after mental health in primary care.”
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Broader context
Whilst developing the survey, we believed that it was important to recognise that the
delivery of primary mental health care sits within a broader context of both Welsh and UK
Government policy and legislation, as well as the wider economic context. The Mental
Health (Wales) Measure is particularly relevant, but the UK Government’s programme of
welfare reform has also had an impact on individual patients, their communities, primary
care professionals and general practices. The level of investment in mental health services
also remains an issue. According to an analysis published in the British Medical Journal1,
mental health accounted for 23% of the UK’s “disease burden” (the burden on society of all
diseases and health conditions), but receives only 11.4% of Welsh NHS spending2.
The Mental Health (Wales) Measure
Q
How effective has Part 1 of the Mental Health Measure been on your ability to
manage common mental health problems (for the benefit of your patients)?
How effective has Part 1 of
the Mental Health Measure
been on your ability to manage
common mental health problems
(for the benefit of your patients)?
Highly effective (2.3%)
Moderately effective (46.1%)
Not effective (51.6%)
To date, Primary Care professionals do believe that the introduction of the Mental Health
(Wales) Measure has had a major impact on their ability to manage common mental health
problems. This may well be representative of the gap between expectation and reality,
and in particular that patients with common mental health problems still do not have timely
access to NICE recommended therapies. It may also indicate that the advice and support
for GPs – promised by the Measure – has not yet become apparent to much of the primary
care workforce.
It is important to point out that Part 1 of the Mental Health (Wales) Measure was only
implemented 16 months before our survey took place. When we held our last survey
in 2011, many GPs did not know the Measure existed. We feel that this legislation and
the services it introduced need more time to mature, before we witness the full effect.
However, service managers need to ensure that all aspects of Part 1 are implemented at
a local level. We also feel strongly that patient outcomes and the “spirit” of the Measure
needs to drive its implementation, rather than process driven targets. The role of LPMHSS
teams within the whole mental health system is still developing, but Part 1 services need
continuing support in order to succeed.
1 London School of Economics, 2012 http://cep.lse.ac.uk/pubs/download/special/cepsp26.pdf
2 Welsh Government, 2014 http://wales.gov.uk/docs/statistics/2014/140611-nhs-expenditure-programme-budgets-2012-13-en.pdf
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Welfare reform
Q
Have the changes to the Welfare / benefits payment arrangements had an
impact on your Practice?
The data indicates that changes to the
welfare system have had a marked
effect on the workload of primary care
practitioners. These changes have been
highly stressful for many patients, often
those who are least able to deal with
uncertainty. We believe there needs
to be more support for Primary Care
to deal with the workload demands
surrounding welfare reform. Policy
makers need to understand the impacts
that such reforms have on individuals,
communities and other services,
especially Primary Care which is already
under immense pressure.
Have the changes to the welfare /
benefits payment arrangements
had an impact on your practice?
100%
80%
Significantly
more often
60%
Marginally
more often
40%
No
significant
increase
20%
0%
‘New’
‘Old’
patients
patients
attending presenting
more often in surgery
Welsh Government research has
suggested that a number of aspects of
welfare reform could lead to a negative
impact on the health and wellbeing of
the population, particularly benefit claimants from low–middle income households, and
non-working families with children. It also predicted that the welfare reforms were likely to
result in increased pressure on health services in Wales.
“The welfare reforms could potentially have a direct negative impact on claimants’
health via a reduction or loss of benefit income due to tighter eligibility criteria,
conditionality requirements and tougher sanctions; increased poverty levels;
new, uncertain and stricter medical assessments; appeals and reassessments;
budgeting problems associated with direct, monthly benefit payments; the migration
of claimants into cheaper, poorer-quality and possibly overcrowded housing; and a
combination of less financial resource and increasing demand for support from the
Social Fund and Independent Living Fund (ILF). There may also be indirect income
effects on entitlement to a number of health-related passported benefits. These
impacts are likely to lead to increased pressure on health services in Wales.”
(Analysing the impact of the UK Government’s welfare reforms in Wales –
Stage 2 analysis Welsh Government, February 2013)
In addition, research and anecdotal evidence from third sector organisations and social
housing providers show that welfare reforms are having a negative effect on the mental
health and wellbeing of individuals and communities across Wales.
Although most aspects of social security are not devolved, it is essential that the Welsh
Government continues to make robust representations to the UK Government, and
communicate the negative impact of welfare reform on devolved services. The Welsh
Government should also ensure that the impact of welfare reform is recognised and
responded to in the development of Welsh health services.
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Investment in primary mental health care
Q
Do you feel there should be a greater or lesser level of investment in time and
resources in mental healthcare in Wales, relative to other primary healthcare
priorities in general?
Do you feel there should be a greater or lesser level of investment
in time and resources in mental healthcare in Wales, relative to
other primary healthcare priorities in general?
Much less
Somewhat less
The current level of
investment is right
Somewhat greater
Much greater
0%
10%
20%
30%
40%
50%
41% of respondents have indicated that a much greater investment is required in mental
health resources in Wales, as compared to 30.6% in 2011. Our data indicates that the
proportion of time spent on mental health is increasing, and we therefore conclude that
further investment in mental health is required.
A recent UK Government report ‘No health without mental health’ stated that:
‘Mental ill health is the single largest cause of disability in the UK, contributing
up to 22.8% of the total burden, compared to 15.9% for cancer and 16.2% for
cardiovascular disease.’
In contrast, only 11.4% of NHS expenditure in Wales relates to mental health . The data
from our survey shows that practitioners would welcome an increase in mental health
spending, and the statistics above suggest that we are still some way from achieving parity
between mental and physical health spending.
We have shown that Primary Care determine the main barriers to developing services
are timely access to secondary care, service capacity and most importantly, appropriate
access to psychological therapies. We therefore suggest, that investment in these areas
is prioritised, however, at the same time accept that we are working within a financially
constrained service, and that significant investment of money is unlikely in the near future.
Nonetheless, we believe that patient outcomes can be improved by promoting joint
working with other agencies (such as Local Authorities, Third Sector organisations, Health
Promotion Wales and others). This will help develop a service that can respond to mental
health prevention and promotion, manage more effectively and refer more appropriately.
The main benefit of this would be to improve “flow” within the system as a whole, and
Primary Care is central to this endeavour.
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