Peter McNelly is a mental health nurse and David Fowler is a practice manger in Northern Ireland
In an attempt to deal with the shortfall of GPs in the UK, the various devolved health bodies have all promoted the concept that having other health professionals in the practice to support GPs will be beneficial to all; some benefits and limitations have been discussed.1 Pharmacists and physiotherapists were among the first group of staff made available by the various schemes of the four countries of the UK to undertake the task of supporting GPs.2
Reports of mental illness are increasing3-5 with and an acknowledged lack of GPs to manage the rise. In addition there has been an overall increase in workload of GPs for a variety of reasons.6-8 and we argue that having additional health professionals to help manage such pressures should aid most GPs. Thus, mental health practitioners (MHPs -often mental health nurses by background) are starting to be added to this increased health professional workforce.
Pharmacists and physiotherapists were among the first group of staff made available by the various schemes of the four countries of the UK to undertake the task of supporting GPs.
MHPs and GPs have traditionally seen patients face to face (F2F). The question of whether remote consultations or F2F should be used for MHP consultations2,9 is a question following on from COVID. There is some evidence on Why F2F appointments are the best.10 What is often overlooked in the discussion above is how patients lose out on the benefits of the use of the ‘Therapeutic self’ that the health professional such as GP or MHP brings in face to face consults with patients.11
Just how well the various schemes are working and what role the MHP plays within Practices is still evolving, Physiotherapist and Pharmacists appear to have helped GPs the most to date, and are often seen as an integral part of the Practice Team now.12 Having a Multidisciplinary Team (MDT) can increase the practice capacity to meet patient needs. A moot point, however, is whether any individual GP perceives that including a mental health practitioner in the practice MDT as reducing their daily workload. The risk is that any work undertaken by MDT staff frees up GP appointments are quickly filled by other patients, as demand for GP services and appointments always exceed resource.
MHPs should be able to offset workload with little additional oversight from a GP. So they need to be both experienced and knowledgeable in the field and their grade under ‘Agenda for change’ employment guidance must reflect that. The request for sick lines (notes), medication and the occasional review of patients who have complex needs but fail to engage is the main clinical interaction that occurs between the GP and MHP (Mental Health Practitioner). These interactions should not burden GPs with additional unnecessary oversight13 of the clinical practice of a mental health practitioner. Supervision of MDT members is felt by some to be disincentive to such developments.14 We think it is important that additional mental health work that would not currently being done by the GPs is is not “made up” and given over to the MHP. This leaves GPs with no real noticeable impact on their daily workload.15 We would go further and argue that MHPs should not be creating their own internal/in-house caseloads with practices patients, other than those patients sanctioned (identified or referred) by the GP
Practice Managers who have the oversight of Mental Health Practitioners in their practices have the difficult challenge of finding space within surgery buildings that have little spare room capacity to host the MDT personnel. Also have the unique situation of having embedded staff in the surgery whose contract of employment is held either at Trust or Federation level. This creates challenges on how to best integrate these staff into the practice and for them to feel part of the surgery team. We contend that this can be achieved with a clear understanding of everyone’s role within the organisation, ongoing dialogue with all staff and ensuring that the MDT staff are treated as members of the wider practice team. For example, the admin team role has changed: The receptionist, whose core function is to book appointments for patients, takes on the role of “Care Navigator”; who asks the patient questions to best direct them to the most appropriate clinician to deal with their medical problem. This may not be the GP, but rather the pharmacist, physiotherapist, MHP or social worker. Initially, there may be push-back from patients who are reluctant to tell the receptionist their medical problems. As patients became familiar with the MDT personnel and the care they could provide, we have seen a move to patients actively requesting appointments with the MDT staff.16
A moot point, however, is whether any individual GP perceives that including a mental health practitioner in the practice MDT as reducing their daily workload.
Despite these challenges and the recognition that it has taken some time for the MDT services to become fully operational within the surgery, we clearly see the benefit that the MDT model and Mental Health Practitioners bring to primary care – patients can avail of specialised clinical input and care at an early stage. Mental Health Practitioners can reduce GP workloads. The overall the care provided to practice patients is enhanced both by freeing up GPs to address more urgent and medically complicated patient presentations, and by the additional skills and experience that an MHP brings to a GP practice.
We recognise that MHPs are not universally perceived as beneficial by British GPs (with particular criticism in England). However, the use of MHPs employed by the GP Federations appears to be regarded by the GPs as being of benefit. It may be that MDT members being employed by Trusts, and then seconded out to GP Practices, as is the case with PCNs in England is less beneficial. We think a review of why that is the case should be undertaken.17 Learning from of Federations and PCNs that have positive experience of Mental Health Practitioners working in Surgeries/Practices rather than reinventing the wheel would seem a sensible task.
- Imelda McDermott el al. Scale. Scope and impact of skill mix change in primary care in England: a mixed-methods study. Health and Social Care Delivery Research Vol 10. Issue 9 May 2022
- P.McNelly N.Magee. Obstacles to the effective introduction of mental health practitioners into the GP surgery. BJGP Life 8 February 2013 (accessed 13/11/23)
- Mental Health Pressures in England, BMA, 9 March 2023
- Why is our mental health getting worse? Great British Life 21 March 2022
- Jim Folk. Why is Mental Illness on the Rise? 27 March 2021. www.anxietycentre.com (accessed 13/11/23)
- B. Bird, A. Charles, M. Honeyman, D. Maguire, Preety Das. Understanding pressures in general practice, The Kings Fund May 2016(accessed 13/11/23)
- Croxson CH, Ashdown HF, Hobbs FR. GPs’ perceptions of workload in England: a qualitative interview study. Br J Gen Pract. 2017 Feb;67(655):e138-e147. doi: 10.3399/bjgp17X688849. Epub 2017 Jan 16. PMID: 28093422; PMCID: PMC5308120.
- A. Colivicchi. Scotland needs 2000 new GPs to solve workforce crisis. Pulse Journal. January 2023
- Remote versus face-to-face: which to use and when? RCGP November 2020, https://elearning.rcgp.org.uk/pluginfile.php/154305/mod_page/content/17/Remote%20versus%20face-to-face_Nov%202020.pdf (accessed 13/11/23)
- L Walker. Why F2F GP Appointments Are The Best. Digital aesthetics, 16 May 2022
- Therapeutic Use of self. www.therapybuzz.co.uk June 26 2019
- E. Hurley el al. General practitioners perceptions of pharmacists working in general practice. Family Practice Vol 40, Issue 2. April 2023
- The GMC Delegation and Referral guidance, for GPs when you delegate care you are still responsible for the overall management of the patient.
- Dr.E. Mulla. We need higher pay, not lower standards. Pulse Journal 13 September 2023.
- J. Hacker PCNs meet milestone of hiring over 26,000 ARRS staff Pulse Journal 18 May 2023
- J. Hacker. ICB Launches campaign to promote ARRS staff. Pulse Journal 19 September 2023.
- B.Gowland. Embedded ARRS staff to future-proof your practice. Pulse Journal 2 October 2023