Resources are out there for better acute mental health services - GPs just need to take them
Primary care can and should provide better care for people with serious mental illness, writes Professor Helen Lester
Want to know more about why you should bother about patients with acute mental health needs? Professor Lester in the RCGP James Mackenzie lecture this year argued that GPs should make people with serious mental illness their ‘core business’. Watch the video below.
We’ve all had them: those heartsink moments when you ring the buzzer and in comes your patient with a BMI of 33, who smokes 30 a day, for his QOF review.
You dutifully mutter something about cutting back on chips and maybe the fags too but probably not much more than that, because what’s the point? He’s always been like that - overweight, unresponsive to your banter. You’re not sure he’s really listening or wants to change, or can understand your arguments. Now you’ve given him the blood form - so there we go, tick, thanks. You don’t really know him, and you don’t mind it.
Serious mental illness affects around one or two percent of the population. People with psychosis live 15-20 years less than the rest of the population dying largely from cardiovascular and respiratory illness.¹ They are also more likely to live in poverty, both socially and financially than the rest of us. However, some 50% of patients make a good social recovery and 15% a complete recovery, something that’s rarely emphasised perhaps because once well, few people want to recall such a difficult episode in their life. We are paid through QOF to provide annual physical checkups and it looks like some of that extra health prevention is making a difference in terms of better recording of important cardiac risk factors.² But I still think the battle for the profession’s heart and mind has yet to been won with this patient group, and that often stops us going the extra mile.
I think the lack of engagement, of bothering, starts in medical school. We see patients with serious mental illness in less than perfect contexts - perhaps confused in casualty, during a section, or in the community mental health team clinic struggling with the side effects of medication that slows them up, makes them put on weight (often rapidly) and slur their speech.
There’s also a big overlap with other groups who challenge our concept of the perfect patient. Around half of all people sleeping rough, for example, have or have had a psychotic illness. I was once told by a boss to not bother using local anaesthetic to sew up such a patient’s head wound and to leave him ‘til last, “Because he’s not going to complain, is he?”
I developed a scale to measure medical students’ attitudes to homeless people and found that the attitudes of an entire year group, trained in Birmingham and now out there practising as GPs and hospital doctors, was more negative at the end of the course than when they skipped up the medical school driveway with the ink still wet on their A level grades.³
The media portrayal of people with schizophrenia is still of someone who’s mad, bad and dangerous to know. Recent complaints to Ofcom about Frankie Boyle’s Tramadol Nights spoof of the Time to Change anti-stigma video were not upheld. A man sits in his kitchen drinking tea and talking about how he’s coping with his diagnosis and getting on with life in both videos, but Frankie’s concludes by panning away to four dead children on the floor, covered in blood. So portraying people with schizophrenia as child killers is apparently OK. We are not immune to these images just because we’re GPs. We still watch television, read the papers, see people with serious mental illness on an almost daily basis: perhaps inevitably some of the stereotyping rubs off. There’s certainly evidence that we see serious mental illness as a low prestige condition.4 We’d far rather deal with patients with heart disease and diabetes in our morning surgeries.
We also still seem to think that serious mental illness is someone else’s business: the psychiatrist, the CPN, the social worker, but not the generalist.
But the GP knows enough about psychosis and can pick up a phone for advice or look it up, who is particularly skilled in the physical problems most commonly experienced by this group (high prestige diabetes and heart disease as it turns out), knows the family, can network across the system and can now, with their latest hat, even commission the most appropriate services.
Whilst we’ve been busy denying it’s got anything to do with us, secondary care has been quietly discharging over 70% of people with serious mental illness back to us, with no follow-up at all for half and very occasional ‘light touch’ appointments for the rest.5 It’s a jolly good job that people with serious mental illness themselves think we’re the cornerstone of their health care, even if we don’t.6
So what would bothering to go that extra mile look like? We need to move beyond the negative stereotypes that leave us with a sense of hopelessness; focus on the evidence for recovery; download the template on steps to mitigate side effects of antipsychotics; set up practice systems to ensure interpersonal continuity of care rather than leaving follow up to pot luck at the front desk; smile; ask a personal question that builds a relationship over the long term.
These patients are our business and they deserve the same treatment as the patient before and the patient after. Next year you might even greet that overweight patient with genuine warmth and a hug when his BMI hits 30?
Professor Lester in the RCGP James Mackenzie lecture this year argued that GPs should make people with serious mental illness their ‘core business’. Watch the video below.
Professor Helen Lester is the clinical QOF indicator development lead, RCGP mental health commissioning lead and a GP in Birmingham.
1 Chang C, Hayes R, Perera G, Broadbent M et al. Life Expectancy at Birth for People with Serious Mental Illness and Other Major Disorders from a Secondary Mental Health Care Case Register in London. PLoS ONE 2011; 6(5): e19590.
2 Osborn D, Baio G, Walters K, Petersen I et al. Inequalities in the provision of cardiovascular screening to people with severe mental illnesses in primary care: Cohort study in the United Kingdom THIN Primary Care Database 2000–2007. Schiz Res 2011;129:104-110.
3 Masson N, Lester HE. Medical students’ attitudes towards homeless people – does medical school make a difference? Med Educ 2003; 37:869-72.
4 Album D, Westin S. Do diseases have a prestige hierarchy? A survey among physicians and medical students. Soc Sci Med 2008;66(1):182-188.
5 Reilly S, Planner C. Hann M, Reeves D, Nazareth I, Lester H. The role of primary care in service provision for people with severe mental illness in the United Kingdom. PloS One 2012 7(5) e36468 doi:10.1371.