Beyond a Spin of the Wheel – GPs and mental health care

The crisis facing GP services in Northern Ireland has been well documented, including in previous posts on Slugger O’Toole.  Increasing patient lists, ‘red tape’, underfunding, an ageing workforce and the compounding of health issues in deprived communities due to austerity policies, are only some of the problems faced by the service. The British Medical Association has mooted the unwelcome spectre of GPs walking away from the NHS, while the Royal College of GPs NI, in an open letter, has highlighted the growing waiting lists and plummeting morale among GPs. On an almost weekly basis there are media reports of GP practices under threat of closure. In Fermanagh for example it is predicted that almost half of GP practices in the county will close within a year.

We know what the impact of all of this is on GPs, both personally and professionally, but what of the impact on patients? And what about those patients seeking help from their GP for mental health problems?

GPs are the entry point to primary care and over 90% of people with mental health problems will be treated within the primary care system by their GP.  People experiencing mental health problems have a fundamental right to be able to access both timely and appropriate mental health care from their GP.  On average at least a third of all GP consultations relate to mental health problems. In deprived communities this ratio will be even higher, where rates of mental ill health are double the regional rate.  In a society where rates of mental ill health and suicide are going in the wrong direction, the critical importance of getting primary care services right for people experiencing mental ill health hardly needs to be pointed out.

Yet the harsh reality of people’s experiences in 2017 is very far from the standard of care they are entitled to expect. A new report, produced by the Mental Health Rights Campaign, a coalition of mental health groups across Northern Ireland, documents those experiences in some detail. It doesn’t just stop there however. It also identifies the key issues underlying these experiences and proposes a range of solutions to improve things.

The campaign report is entitled ‘Beyond a Spin of the Wheel- Ensuring timely and appropriate mental health care from GPs and was published in early June with the support of human rights group PPR ,  to mark the launch of a campaign to improve mental health care from GPs. The foreword for the report was written by Dr. John Kyle, the well-known East Belfast GP and PUP Councillor on Belfast City Council and contributor to Slugger.

 

Three issues were identified as top priorities for change, as follows.

  • Lack of mental health expertise among GPs

The lack of mental health expertise among GPs was identified as a major issue

“I feel my GP surgery is very good most of the time but with mental health they struggle to understand and they aren’t trained to deal with it”

People recognised that GPs currently have limited opportunities either during training or ongoing professional development to develop the expertise required. They also acknowledged that this lack of expertise was compounded by the ’10 minute’ appointment rule.

Those experiences and observations of patients and carers are corroborated by information provided by the Health and Social Care Board to PPR.  A Freedom of Information response  indicated that only half of the annual cohort of trainee GPs have to undertake a placement in a mental health facility. The mental health charity Mind has highlighted the fact that practicing GPs are not obligated to undertake mental health training as part of their mandatory continuous professional development.

  • Difficulties with getting GP appointments

Difficulties securing an appointment when needed, coupled with lack of transparency around the appointment booking system were highlighted

we can only make appointments on a Monday, when you try to ring to make appointments the line is busy all day, by the time you get through there are no appointments left and then you have to wait until the next morning to try again

While acknowledging that securing a GP appointment is a widespread one, the report noted that the impact on people with mental health problems can potentially be more serious and can serve to exacerbate an existing problem. The Royal College of GPs has repeatedly expressed its extreme concern at the soaring waiting times for appointments.

  • Over prescription of medication by GPs

Finally, the over reliance by GPs on prescribing medication for mental health issues was highlighted by the research:

if people go in and say they are depressed, they write you a prescription, they don’t question anything, like how do you think things are, what would help you, it’s not like a conversation they have, it’s just like well here’s tablets , go ahead

The long waiting times for psychological therapies were identified as one possible reason as to why many GPs rely on providing medication only for mental health problems “ many GPs end up prescribing drugs as the waiting lists are too long”.

Potential solutions put forward by the Mental Health Rights Campaign include:

  • Mandatory mental health training for GPs and other relevant practice staff
  • Other health professionals with the necessary expertise and skills to work alongside the GP
  • A separate, designated phone line for making mental health related appointments with the GP
  • Introduction of an ‘auto alert’ system so receptionists know a patient has mental health issues
  • Longer appointment times including a default option of a double appointment for mental health issues

The Mental Health Rights Campaign now intends to campaign for the changes proposed in their report. The Health and Social Care Board, as the contracting body for GP services, must play a lead role in bringing about the necessary changes.  While, as pointed out by Dr. John Kyle in his foreword to the report ‘greater financial investment is unavoidable’, not all of the proposed solutions are necessarily costly in monetary terms. The longer term benefits, both human and economic, of ensuring that people with mental health problems receive timely and appropriate care from their GPs will be immense.

The Mental Health Rights Campaign is keen to hear your views on the findings and recommendations set out in its report. You can contact the campaign by telephone 90 313315,  email sara@pprproject.org or via facebook

Sara Boyce is a Development Worker ( Mental Health) with PPR (Participation and the Practice of Rights)

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  • hgreen

    The way we allocate GP services seems to be pretty inefficient. Why for example do we need to make an appointment and visit the specific surgery we are registered with? Why not have larger local 24hr GP surgeries that anyone can attend that could also take the strain of A&E?

    It took me two weeks to get an appointment the last time a needed one. Not urgent but a pretty pathetic service level.

  • Doctor M

    One of the strengths of NHS GP is the continuity of care given by multiple visits over the years. i accept that continuity of care may not be necessary for minor ailments but I was taught by “old-school” GPS who would say that that you might potentially prick up your ears when the patient who rarely attends comes in with a headache (a very common and usually not worrying symptom), while knowing that someone attends weekly with an assortment of minor complaints can sometimes be useful information. The traditional GP mode also allows for a better recognition of social circumstances which can have a huge impact on health.

  • hgreen

    I can understand the need for continuity of care for chronic conditions. The rest of us don’t care who we see. In fact I see a different GP each time I go which is no problem provided my notes/record is up to date. We lead very different lives today than years ago yet GP services don’t seem to have adapted.

  • Brian O’Neill

    I am with you. The last time I seen my GP was 20 years ago.

    I phone up for an appointment and they tell me it will be a month with my GP or next day for a locum.

    I go with the locum option as I don’t care who sees me as long as they have a medical degree and wash their hands.

    Its the 21st century patient records should be online. You should be able to rock up to some local health centre and get seen. These health centres could be lead by a GP but most of the work done by GP trainees and nurses.

  • I think it is generally accepted that a doctor who knows you will usually do a better job than a locum will. No offense to the stand-in doctor, but he won’t have the time to absorb your medical history. The problem is that GPs have become completely overburdened, objections were not listened to, solutions were not found. The problem got worse. I think the word for that situation is travesty. Still, I guess it isn’t important as flegs.

  • Brian O’Neill

    Oh I understand the concept of continuity of care but these days for most patients that is a fantasy. Fine if you are in every other week but there is a lot of people like me who go once every 5 years.

    With an average of 5000 patients per practice it would be next to impossible for a GP to know all his patients.

    For people like me I would delighted if I could FaceTime or IM an appointment rather than taking time of work etc.

  • Absolutely, but I suppose therein lies the problem – the GP is overworked and everyone suffers as a result. These days we are actually asked to visit our GP more often, but how can we!? It’s a disgrace that makes me think the NHS really has to start asking for some small (capped?) percentage contributions for treatment from those can afford them. Either that or we scrap Trident and PFI repayments.

  • notimetoshine

    Management and treatment of chronic problems is appalling. It isn’t just the GPs though, I pay nearly £50 a week to pay for my own intensive therapy, because the waiting time for bog standard CBT is very long and in any case isn’t necessarily very helpful. My GP himself made it clear that if I could do it privately, I should. The difference in the quality and nature of my treatment programme against what my GP could provide is amazing. But this isn’t the case for everyone. I am so lucky that I am able to pay for treatment privately and benefit from the right kind of support, but many could not possibly afford to pay. This means that deprived communities where mental health problems are endemic and the need for support is highest will of course suffer.

    Having said that, acute treatment and support has improved immeasurably. Look at the difference a few years made for me.

    A couple of years ago I did something very stupid and took a hundred odd paracetamol. I had been having a horrendous time at school and frankly I just couldn’t cope anymore. In my teenage naivety I was convinced that I would go to sleep and not wake up, but paracetamol is much less pleasant than that. Cut a long story short I woke up the next day very, very sick and ended up in hospital. So, was there specialist treatment available? Was I seen by a psychiatrist or a mental health team? There certainly wasn’t and I was seen by a nurse from the medical ward I was on who filled out a standard form, asking me intrusive and pretty difficult questions with no empathy, no understanding, it was almost a pro forma exercise. I was left on a ward full of very sick old men, many of whom obviously had dementia, on my own. The old guy next to me was in severe distress and was screaming in pain or fear as the doctors tried to perform some sort of procedure on him. Not the place for a vulnerable 17 year old. The next day I was discharged with a referral for counselling that took SIX months to come through. No follow up, nothing. I don’t know what more exactly I needed to do to be taken seriously, the notes I had left were pretty explicit in my desire to die, I had made it quite clear to the medical staff and my parents how much distress I was in. Yet I was not once seen by someone from mental health.

    Fast forward to this year. My doctor and I had decided to try to take me off the medications I had been taking for nearly ten years, to see if I could manage without them. Unfortunately (like many with mental health problems who will always need some form of anti anxiety/anti depressant medication) it soon became obvious that I needed to stay on them, as my mood dropped to levels I hadn’t experienced in years, and my anxiety became crippling. Long story short I ended up in a crisis, a breakdown you might call it. The service was astonishingly different. My GP referred me to the community mental health team, who had me come see them 2 hours later, I was with them for several hours, was re prescribed my medication and given some other ones to help me manage until normal service resumed. The building they were in was quiet, pleasant and welcoming, with superb staff. They didn’t let me leave until they felt I had stabilised and when I went home, they checked in on me all weekend, making it clear I was contact them at any time if needed, and continued their follow up for a week. Couldn’t fault this response, It really shows that improvements have been made in acute services. It is time now for the support of chronic and long term mental health conditions to be given the same treatment.

  • Brian O’Neill

    Thanks for sharing your story. I think the more we normalise mental health the better. 1 in 4 of us are going to have a problem with it at site stage in our lives so it is great to know you are not alone.

    Your private session is that with a CBT therapist? Just curious what you think works for you. For some eating healthy and exercise seem to work well. Also mindfulness is all the rage.

    Also a reminder to anyone who does need help.

    Samaritans can be contacted for free on 116 123 – the same number works in both UK and Republican of Ireland

    Contact’s Lifeline is open 24 hours a day on 0808 808 8000 – calls are free from UK landlines and mobiles.

  • notimetoshine

    My therapy programme uses tools from CBT, psychodynamic therapy, Gestalt and others combined with a focus on improving lifestyle including things like diet and exercise. For instance I have found since cutting out sugar (as much as possible) that my anxiety is much more manageable.

    The article makes a very good point about GPs and the need for training. Thanks to research my GP did for me he was able to point me in the direction of the right therapist and he had an extensive knowledge of mental health conditions. I have wonder if there should be a way for direct referral to mental health services for patients, especially as GPs can often be under educated in the field.

    I haven’t found CBT to be as useful, though certain CBT techniques are good for me. There is a growing concern now that CBT is being overused by the NHS, as it is more useful for certain conditions than others, yet is being prescribed as a catch all device.

  • Doctor M

    I do think there’s a place for new ways of working, and not every problem needs a face-to-face appointment. That said I know of some practices that have moved away from telephone triage as it’s very inefficient – patients won’t answer the phone!

    At the end of the day, a lot comes down to how we value our health. I don’t hear so many complaints about having to visit bank manager, lawyer or accountant during office hours or that they want to meet you face to face.

  • Korhomme

    “With an average of 5000 patients per practice it would be next to impossible for a GP to know all his patients”

    Perhaps. Decades ago I did some summer locums for a GP practice; one partner would go off for a while, then the other one.

    It was as alarming as it was surprising as it was impressive just how much detail they both knew about the patients — and not just the GPs, but their receptionist also. Mrs so-and-so had forged her prescription for Mogadon; that man, he never comes here, I think his symptoms might be such-and-such (when I went, they were exactly that). One poor man whom I saw in the middle of the night had a major problem; when I mentioned him to the GP in the morning, the response was, I thought he had lung cancer, but I had to refer him three times before the diagnosis was confirmed (and sadly, it was then too late, as my night visit showed).

    Perhaps it was old fashioned, but it’s how I think general practice ought to work, even today.

  • Korhomme

    Follow the money. This is the major problem in the health service — there simply isn’t enough for all that ought to be available. You only have to look at what’s happening in England to see what will come here; and this is all by choice, an austerity driven retrenchment of services. The austerity is the handmaiden of neo-liberalism, the doctrine to which all major UK parties are signed up to. And the result is ‘fire fighting’, and the ‘death by a thousand cuts’ syndrome in the health services.

    You don’t need to be a believer in conspiracy theories to see where this is leading; the English Secretary of State co-authored a pamphlet a decade or so ago about privatising the health care.

    Here, in NI, we haven’t quite advanced so far; if we had politicians in an Executive we might expect them to be active to retain the principles of an NHS (even if they permit their religious dogma to infect their decisions). But we don’t, we drift, and as we do we come ever closer to loosing what must be one of the most civilised and humane inventions of the 20th century.

  • Brian O’Neill

    Indeed. The issue with GP visits is the wait time in the waiting room. If you are working you basically half to take a half day off. Tough on people who might not get paid for that time off.