Some 23% of the overall burden of disease is due to mental disorder and self-inflicted injury – by comparison, just 16% is due respectively to cancer and to cardiovascular disease. Early intervention is vital, both to improve people’s life chances and reduce healthcare costs, and primary care is where this should happen. Effective primary (identification), secondary (screening) and tertiary (early intervention) prevention may mean specialist secondary care is not needed.
The Joint Commissioning Panel for Mental Health (JCP-MH)1 is a new collaboration co-chaired by the RCGP and the Royal College of Psychiatrists, which brings together leading organisations and individuals with an interest in commissioning for mental health and learning disabilities.
The key to developing patient-centred primary care mental health services is to put the patient’s needs at their heart.
This means ensuring services are conveniently located and easily accessible in primary care. It also means being emotionally available and interested in the patient.
The recommendations here for mental health services are based on extracts from the panel’s guidance for commissioners, published on 6 February 2012 and available in full from www.pulsetoday.co.uk/resources.
The suggestions for the key facets of mental health services are primarily evidence-based, but ideas deemed to be best practice by expert consensus have also been included.
Mental health problems are common and costly. Some 17.6% of the adult population (21.0% of women and 11.9% of men) have a common mental health problem (anxiety or depression). In a group of 2,000 patients, an average general practice will be treating:
• 352 people with a common mental health problem
• eight with psychosis
• 120 with alcohol dependency
• 60 with drug dependency
• 352 with a sub-threshold common mental health problem
• 120 with a sub-threshold psychosis
• 176 with a personality disorder
• 125 (out of the 500 on an average GP practice list) with a long-term condition with a co-morbid mental illness
• 100 with medically unexplained symptoms not attributable to any other psychiatric problem.
This means about one in four of a full-time GP’s patients will need treatment for mental health problems in primary care.
Particular groups are at much higher risk of mental illness and therefore need to be targeted for preventive and early interventions, including:
• people on low incomes
• black and minority ethnic groups (they are at two- to three-fold increased risk of suicide and a nearly four-fold increased risk of psychosis)
• people with a learning disability (they have a two-fold increased risk of depression and a three-fold increased risk of schizophrenia)
• lesbian, gay and bisexual people
• people with a chronic physical illness
• older adults
• children with conduct disorders (a significant proportion of adult mental health problems are preceded by emotional or conduct disorders in childhood).
People with mental health problems have much higher rates of physical illness. Depression is associated with increased risk of coronary heart disease and diabetes.
Evidence-based and outcome-focused
Treatments should be based on clinical judgment informed by NICE guidelines. Treatments should be systematic and their outcomes monitored continuously using a common set of measures appropriate to the patient’s problems. Accurate assessment requires high levels of pre- and post-data completeness. For people with depression and anxiety disorders, this is most easily achieved by routine, session-by-session outcome monitoring. This approach also facilitates the choice of interventions and other clinical decisions.
Care should be personalised. People should be given time to talk, listened to, provided with information and offered a choice about their care, actively participate in decision making, and feel engaged and have a sense of ownership.
For all ages
Services should recognise that opportunities exist for prevention at all life stages, that the origins of most major mental health problems lie in the early years, and that care should not be compartmentalised or interrupted on grounds of chronological age alone.
The primary mental healthcare team needs to have the knowledge and skills to understand how best to provide appropriate services for people with mental health problems. This may require additional education and training opportunities.
Commissioning primary mental health care services should be integrated with the commissioning of specialist mental health services. The interfaces between different parts of the system and with other agencies (such as social services) need to be seamless, because people’s needs straddle health and social care.
Primary care mental health services should be linked to a range of voluntary-sector and community services that patients can choose – in other words, they are not limited to what commissioners choose to fund – and that either work alongside or are integrated with the primary care mental health team.
Care pathways should include treatments that can be accessed through self-referral and should address diversity in local communities. This includes making reasonable adjustments for people with special needs. Patients should be treated promptly. They should not have to wait until they become ill or their condition becomes more complex and they require more intensive treatment.
A recovery focus is essential to effective service delivery. Practitioners should support patients to help themselves and reinforce the message that recovery is possible, and that they can regain employment and social networks.
This is particularly important for people who have been out of work for some time. Recovery is not simply about a reduction in, or removal of, symptoms. It is about communicating hope and restoring opportunity and a sense of urgency to patients.
Interventions should be targeted at individuals identified from Read codes as at risk of developing mental health problems.
Professor Helen Lester and Dr Neil Duchar co-lead the JCP-MH, and the article is based on the work of the panel’s expert reference group. Professor Lester is a GP in Birmingham and Dr Duchar is a consultant psychiatrist and medical director at NHS West Midlands
1 JCP-MH. www.jcpmh.info