Peter McNelly is a mental health nurse.
Nuala Magee is a social worker.
The lack of GPs and the reported increased workload has resulted in all four countries in the UK devising methods/models to enable healthcare professionals by way of multidisciplinary teams (MDTs) to work with and alongside the GP thereby reducing the workload and enhancing the patient experience, but such changes may not bring about these desired outcomes.1 Both authors work as part of these MDTs and share their experience and knowledge on such developments.
The issue of a lack of GPs and increased workloads has been reported on over recent years.2–4 Northern Ireland and England have attempted to address such issues by the introduction of other healthcare professionals, such as physiotherapists, social workers, pharmacists, and mental health practitioners (MHPs) (these might be social workers or mental health nurses) as members of an MDT working with and alongside the GP.5–7 In January 2022, Scotland also committed to a similar type of mental health support to their GP practices.
“The role of the MHP [mental health practitioner] has been particularly unclear”
The aim and objectives of these models are in the main very sound and are to be applauded,8 but such developments are new and yet to be rolled out in many areas of Northern Ireland and England.9 The benefits and knowledge obtained by the authors who have now worked in a number of GP surgeries and have an understanding of possible obstacles are reported here, which may enable commissioners and GPs to plan better for the future.10
The introduction of healthcare professionals not directly employed by a practice is a major change for the GP partner-led primary healthcare service with its private business model. Some GPs and practice managers (PMs) have struggled initially with the concept and even the assimilation of advanced nurse practitioners has not been without its problems.11
The role of the MHP has been particularly unclear,12,13 perhaps due to stigma and poor understanding of mental health, or apprehension due to personal experience or just negative attitudes towards mental health/illness. However, our experience suggests that such developments in the case of MHPs working in GP-led practice is a particularly organic process, and what grows well in one practice may struggle to flower in another, as each practice has its own unique roots and may require a different level of need/nurturing in order that it may in time bloom.
Cross fertilisation by MDT professionals and especially the MHPs with the various GPs and PMs on the role is important, and will lead to a more productive and valued service for everyone. Some MHPs may carry out the following within their role to a greater or lesser degree:
• be first contact practitioner;
• see patients at request of the GPs or other members of the MDT;
• carry out home visits;
• visit nursing/residential homes;
• follow-up patients who have attended an accident & emergency department with mental health issues who have now been reported to the GP;
• signpost to relevant services, for example, the Citizens Advice Bureau;
• refer to community and voluntary sector;
• review patients on the mental health register of the practice;
• review patients on the dementia register of the practice;
• provide short-term therapy/support for a very limited number of patients;
• follow-up on reports of patients sent to the GPs with specific reference to mental health;
• review patients on regular antidepressant medication; and
• refer to secondary care mental health services following MHP assessment and/or at request of GP.
The above is not exhaustive but does clearly show that an understanding between the practice GPs/partners, PM, and the MHP is paramount in what should or should not be done or can be done. Taking into account the core profession of the individual MHP, matters such as time and clinical competence of the MHP to support GPs with patients with mental health issues that may be beyond the GP competence14 may also need consideration.
However, our experience is not that GPs lack the knowledge or skills but lack the time; mental health issues take longer than 10 minutes to address, and as with most skills if you don’t practice them you become rusty — for most GPs it’s less about GP competence but much more about GP workload and time. Many GPs/partners have for some time had issues with estates/premises, and the sudden influx of members from MDTs has resulted in some surgeries being unable to accommodate these professionals due to lack of space.15
“… what grows well in one practice may struggle to flower in another … each practice has its own unique roots … “
In addition, the need for the MDT professional in many cases only being able to attend a surgery on certain days of the week due to room availability or, as is the case with most MHPs, they work across more than one practice, adds to these difficulties. Such issues have no short-term solutions, but again with goodwill such obstacles can be minimised, as might be the case with limited telephone lines by the use of mobile phones (if Wi-Fi is available in the practice).
Health professionals who have never worked in primary health care with the GP partner business model will have no idea or understanding of how such a very major part of the NHS works. With such a lack of knowledge and understanding,16 which was the case with the authors and is still, we believe, shared by most other health professionals and members of the public alike, the commissioning of MDT services to work within GP/partner–led surgeries with their own unique practice is a major learning experience.17
Most MDT members will not have experienced concepts such as risk carrying; clinical responsibility and indemnity insurance are very different and unique in general practice. Continuity of the MHP’s work, both from a patient and practice staff perspective is an issue;18 when the MHPs are working across more than one practice due to funding they can then often be seen to be part-time rather than full members of the practice.
The need for GPs in the UK is unlikely in the short term to change; however, using health professionals in a smarter way in GP/partner-led primary care settings can help enable GPs to better manage an ever-growing workload, have an impact on earlier detection and prevention of both physical and mental health conditions, and achieve greater patient satisfaction.
“… our experience is not that GPs lack the knowledge or skills but lack the time; mental health issues take longer than 10 minutes to address … “
Having MHPs working in a GP practice (if used in the right way) will aid these aspirations, as our personal experience evidences, and like many physical health issues such as diabetes, asthma, obesity, arthritis, chronic obstructive pulmonary disease, and hypertension, common mental health issues do require lifestyle changes and to be managed lifelong by patients to reduce the impact they would otherwise have on the person’s wellbeing.
To reduce workload and maintain patient satisfaction we suggest that in the first instance six first contact slots should be allocated for the MHP (40 minutes duration) each day. The reception staff can fill these. The remaining MHP time can be used to meet the identified needs of an individual practice. Such needs are best considered by GP/partner (with an interest in mental health if possible), the PM, and MHP. These arrangements should be reviewed after 3 months.
The use of physiotherapists, pharmacists, and MHPs is one way to address GP workloads and improve patient outcomes over the next few years. To that end, funding for such posts should be increased. We are aware, however, that recruitment and retention into such posts has its own problems.19–21
Ensure the MHP has office accommodation that is both safe and appropriate to the task in hand, and is respectful to the patient and professional alike. A pragmatic approach towards what an MHP can achieve without them getting bogged down with a caseload and acknowledgment of waiting times for therapy does means that medication, self-help, podcasts, computer cognitive behavioural therapy, and apps, for example, may all have a role in providing help to an individual with mental health concerns, given the less than perfect choice the patient and professional face.22–24
1. Francetic J, Gibson J, Spooner S, et al. Skill-mix change and outcome on primary care: longitudinal analysis of general practices in England 2015–2019. Soc Sci Med 2022; 308: 115224.
2. Baird B, Charles A, Honeyman M, et al. Understanding pressures in general practice. 2016. https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/Understanding-GP-pressures-Kings-Fund-May-2016.pdf (accessed 24 Jan 2023).
3. Northern Ireland Department of Health. Review of GP-led primary care services in Northern Ireland: recommendations of working group. 2016. https://www.health-ni.gov.uk/sites/default/files/publications/dhssps/review-gp-led-primary-care-services.pdf (accessed 24 Jan 2023).
4. Northern Ireland Department of Health. Pressures on general practice in Northern Ireland. 2021. https://www.health-ni.gov.uk/sites/default/files/publications/health/gf-gp-p_0.pdf (accessed 24 Jan 2023).
5. NHS England. Guidance on co-locating mental health therapists in primary care. 2018. https://www.england.nhs.uk/wp-content/uploads/2018/08/guidance-co-locating-mental-health-therapists-primary-care.pdf (accessed 24 Jan 2023).
6. Northern Ireland Department of Health. Regional launch of primary care multi-disciplinary team. 2019. https://www.health-ni.gov.uk/news/regional-launch-primary-care-multi-disciplinary-team-programme (accessed 24 Jan 2023).
7. McCallum M, MacDonald S. Exploring GP work in areas of high socioeconomic deprivation: a secondary analysis. BJGP Open 2021; DOI: https://doi.org/10.3399/BJGPO.2021.0117.
8. McNelly P. Refections on multi-disciplinary teams working in general practice in Northern Ireland. BJGP Life 2021; 17 Nov: https://bjgplife.com/reflections-on-multi-disciplinary-teams-working-in-and-alongside-general-practitioners-in-northern-ireland (accessed 24 Jan 2023).
9. Hacker J. PCNs can deploy double number of mental health practitioners under ARRS. Pulse 2022; 1 Apr: https://www.pulsetoday.co.uk/news/pulse-pcn/pcns-can-deploy-double-number-of-mental-health-practitioners (accessed 24 Jan 2023).
10. Marks L. Supporting staff in primary care must be at the heart of the ten-year mental health plan. 2022. https://www.nhsconfed.org/articles/supporting-staff-primary-care-must-be-heart-ten-year-mental-health-plan (accessed 24 Jan 2023).
11. Torrens C, Campbell P, Hoskins G, et al. Barriers and facilitators to the implementation of the advanced nurse practitioner role in primary care settings: a scoping review. Int J Nurs Stud 2020; 104: 103443.
12. Bower P. Primary care mental health workers: models of working and evidence of effectiveness. Br J Gen Pract 2002; 52(484): 926–933.
13. Pulse. Hiring a mental health practitioner. Pulse 2021; 26 Apr: https://www.pulsetoday.co.uk/resource/pulse-pcn/hiring-a-mental-health-practitioner (accessed 24 Jan 2023).
14. Pulse. How GPs are facing up to a mental health epidemic. Pulse 2022; 9 May: https://www.pulsetoday.co.uk/clinical-areas/mental-health-and-addiction/how-gps-are-facing-up-to-a-mental-health-epidemic (accessed 24 Jan 2023).
15. Hacker J. Lived experience: answering the estates challenge. Pulse 2022; 24 Jun: https://www.pulsetoday.co.uk/views/pulse-pcn/lived-experience-answering-the-estates-challenge (accessed 24 Jan 2023).
16. Pulse. General practice is a business. Pulse 2022; 20 Sep: https://www.pulsetoday.co.uk/views/david-turner/general-practice-is-a-business (accessed 24 Jan 2023).
17. Lind S, Tilley C. Local GP leaders demand renegotiated contract with safe working limits. Pulse 2022; 10 May: https://www.pulsetoday.co.uk/news/workload/local-gp-leaders-demand-renegotiated-contract-with-safe-working-limits (accessed 24 Jan 2023).
18. Pulse. Unhappy headlines because of the stupid ARRS. Pulse 2022; 5 Sep: https://www.pulsetoday.co.uk/views/copperfield/unhappy-headlines-because-of-the-stupid-arrs (accessed 24 Jan 2023).
19. Pulse. What is the next big recruitment plan? Pulse 2022; 1 Jul: https://www.pulsetoday.co.uk/analysis/cover-feature/whats-the-next-big-recruitment-plan (accessed 24 Jan 2023).
20. Carter R. Up to 40% of ARRS funding unspent in first two years of scheme. Pulse 2022; 5 Jul: https://www.pulsetoday.co.uk/news/pulse-pcn/up-to-40-of-arrs-funding-unspent-in-first-two-years-of-scheme (accessed 24 Jan 2023).
21. Hacker J. Non-GP staff could double by 2030 as GP shortfall on course to grow, show projections. Pulse 2022; 27 Jul: https://www.pulsetoday.co.uk/news/pulse-pcn/non-gp-staff-could-double-by-2030-as-gp-shortfall-on-course-to-grow-show-projections (accessed 24 Jan 2023).
22. National Institute for Health and Care Excellence. Depression in adults: treatment and management. NG222. 2022. https://www.nice.org.uk/guidance/ng222 (accessed 24 Jan 2023).
23. Hacker J. No PCN DES exodus as GP practices fear missing out on funding. Pulse 2022; 8 Aug: https://www.pulsetoday.co.uk/news/pulse-pcn/no-pcn-des-exodus-as-gp-practices-fear-missing-out-on-funding (accessed 24 Jan 2023).
24. Khan N. The serotonin theory of depression and why we use antidepressants. BJGP Life 2022; DOI: https://doi.org/10.3399/bjgp22X721109.