Dr Sophie Kilmartin describes how recruiting a mental health practitioner at her GP surgery improved patient experiences and made the practice more efficient
With a growing list size in the face of reduced funding, our suburban, 17,000 patient practice was finding it challenging to provide enough GP consultations. We considered appointing a salaried GP, but with a shortage of GPs nationally and cuts in our budget over five years following a PMS review this looked impossible.
Looking at the numbers of GP consultations for mental health issues in a typical week (30+), I realised we had enough work for a full time mental health practitioner. The alternative was to try to employ a GP for an additional day a week – but that would only give 10-minute appointments.
The aim was to recruit someone who could see patients with a range of mental health concerns, provide treatment and follow up for those needing ongoing general practice support and signpost or refer on other patients. It was not to provide ongoing counselling, as there is already a local service for this. However, there are long waiting times for individual therapy so the mental health practitioner would also act as a support for patients on the waiting list.
What we did
We put together a job specification, advertised on NHS jobs and quickly recruited an experienced mental health nurse who took up the post, which we titled ‘Mental Health Practitioner’ in December 2016. Initially she offered 10 appointments of 40 minutes length a day, four days a week. After a period of adjustment we reviewed the appointment length and created a mix of 20 and 40-minute appointments to suit follow-ups and new patients. Typically she currently has four shorter and three longer appointments per half day.
We already have a skilled reception team who check what the patient’s concern is and book the patient into the most appropriate clinical team member. For the first couple of months the appointments were not fully filled, but take-up rapidly increased in 2017. We advertised her service in the waiting room on a notice board and the TV screen, in the practice newsletter and website and in a local newsletter for the area. She joined GP meetings to explain how she works with the team and promote her services.
Our mental health nurse is not a prescriber but follows the local CCG formulary guidance in making recommendations regarding antidepressants or other medications to the duty prescribing GP, or for seeing the on-call GP for support with any urgent issues. There is a practice system already for the mental health nurse to make routine fit note and repeat medication requests.
She makes a robust risk assessment of all patients which is fully documented in the notes and has taken on the annual mental health care plans for patients with severe mental illness – an important QOF area for us with 60 patients on our register.
She is also happy to do home visits and has taken on the annual dementia reviews as she has extensive experience of this – another bonus for our QOF targets.
When setting up this new post I was mindful that it could be stressful for a practitioner seeing patients with mental health concerns intensively, and that she may feel unsupported as the role is somewhat separate from the standard nursing and GP teams. I therefore have weekly 30-minute mentoring sessions with her, in which we discuss cases and practice or personal development issues.
The mental health nurse is included in all relevant practice meetings and teaching sessions and she has made links with counsellors based at the surgery and with the secondary mental health care team. She also makes onward referrals to secondary care, which has proved very useful. After initial negotiations, the team is now happy to accept her high quality referrals. We are mindful of her safety and have sited her clinical room close to other GPs and have a procedure for summoning help in an emergency.
After 18 months I started to analyse the impact of this new post on patient care. There has been a 7% decrease in antidepressant prescriptions (down from a peak of 114 scripts per 1,000 patients in 2016, to 106 per 1,000 patients in 2017) and a fivefold increase in consulting time available for mental health issues – from five hours per week in 2016 to 25 hours a week in 2018.
Patient satisfaction questionnaires show 100% of patients were happy with the treatment they received from the mental health practitioner and found it easy to get an appointment. In addition, 76% would have booked a GP appointment if they had not had access to this service.
The number of referrals to secondary care dropped immediately the year after employing the mental health practitioner – previously referrals had been rising steadily from 80 per 10,000 patients in 2014, to 90 in 2015 and 100 in 2016. Referral rates dipped to 76 per 10,000 patients in 2016. This is great news for effective use of local resources and is in line with our CCG’s aims.
In short, our mental health practitioner is a key member of the primary care team who has had a positive impact on patient satisfaction, amount of clinical time dedicated to mental health issues and in decreasing prescribing of antidepressants and referrals to secondary care.
We plan to continue the core service in its present form. Our mental health nurse has reduced her hours to three days a week now which works very well for our practice. We aim to promote mental health issues and wellbeing more widely in the practice with publicity and events for World Mental Health Day in October and Mental Health Awareness Week in May. We have considered setting up some friendship groups for our patients with mental health issues for tea and a chat and may look at this in the future. We decided to fund our mental health practitioner from our core funding, but there may be other schemes starting. NHS England has further case studies and information about the benefits.
Sophie Kilmartin is a GP partner in South Gloucestershire