The development of primary care mental health over the last 60 years – a witness seminar

André Tylee (retired Professor of Primary Care Mental Health), Alan Cohen (retired GP), Lydia Thurston (psychiatrist), John Hall (psychologist and historian)

Each year, GPs hold around 300 million consultations with patients¹ of which one third have a mental health component. The vast majority of these consultations are for people with common mental health problems, such as depression and anxiety. In an average general practice of 2000 people, around 200 adults will have a mental health problem, and that figure does not include those with dementia, children with mental health problems, those with substance and drug misuse, or those with intellectual disability.

Primary care mental health is a fundamental part of general practice,² delivering care to many more people than specialist mental health services, and yet there is limited documented history of its development.³ We sought to address this gap in the narrative by organizing a Witness Seminar to bring together key participants in the development of the field over the last 60 years, facilitating reminiscence and discussion of lived experiences. Our aim was to record a chronicle of memories which would become a valuable resource to anybody studying the history of mental health in primary care in the future.

The Witness Seminar was held on Friday 17th June 2022, at the Royal Society of Medicine (RSM), Wimpole Street. The day was made possible due to funding from the Psychiatry Research Trust, and Implemental Worldwide who helped to manage the logistics.

In order to structure the day and focus discussions we divided the seminar into the three stages which are introduced below.

Delivering primary care mental health by relationships – swinging 60s and psychoanalysis

After the end of the Second World War, and the creation of the NHS, health services became available to all, free at the point of delivery. Every individual could have their own GP who acted as a “gatekeeper” to hospital specialists. Mental health care was led by psychiatrists through the provision of distant (hospital based) outpatient services, in the same way that gynaecology, or orthopaedics were delivered. About 20% of psychiatrists were doing some form of consultation-liaison service delivery with primary care, tangibly bringing psychology into the consultation room.⁴

During this time society moved from post war austerity to the increasing affluence and freedoms found in the 60s and 70s. These cultural changes were characterised by free thinking, free love, and free ideas – the control, the poverty, the bleakness of post war UK was replaced by prosperity and opportunity. For general practice, this was an important time, as it became recognized as a medical specialty in its own right: The College of General Practitioners was founded in 1952 and granted a royal charter in 1972. The emancipation of general practice was described best in a publication of the time The Future General Practitioner – Learning and Teaching which set out the foundations for the doctor-patient relationship.⁵ The study of this relationship became the bedrock for the success of primary care. Providing the background, the support and the evidence for the importance of the doctor-patient relationship was the work of Michael Balint, and psychoanalysis.⁶ The principles of psychoanalysis and understanding relationships were built into the training and development of new GPs; support for these new GPs was provided by the spread of Balint Groups, case discussion groups which were based on the work of Michael Balint and aimed to help explore the psycho-dynamics of doctor-patient relationships.

Delivering primary care mental health by money – the purchaser-provider split, and fundholding

In 1991, the concept of a purchaser-provider split was introduced to healthcare. The underlying principle was that quality would be improved by competition. The NHS was re-configured to allow for competition, by allowing purchasers (commissioners at Health Authorities) to buy health care from independent providers called Trusts. Quality was not only measured by clinical outcome, but by financial efficiency.

In the 1990s a quinquennial report found that people with psychosis were under-served, and psychiatric teams were withdrawn from primary care so that they could concentrate on the “most unwell” in specialist units.⁷ This was seen as both clinically and financially more effective. However, the consequence of this contraction of psychiatric services into mental health hospitals resulted in a much clearer distinction between the responsibility of primary care and the responsibility of mental health services. Unlike other secondary care services, mental health teams created boundaries, or barriers to referral from primary care. Unless a patient met certain criteria, that they were sufficiently unwell, they would not be considered for advice or assistance. From a primary care perspective, psychiatric teams dealt only with psychosis. Primary care became the repository for every sort of mental health problem apart from severe psychosis. Unable to access psychiatric services, doctors or nurses, psychologists or psychiatric social workers, primary care resorted to the only two alternatives that would work for people with common mental health problems; medication or counselling. Prescribing rates for anti-depressant medication increased significantly, as did the use of benzodiazepines.⁸

While Health Authorities were developing their skills to commission and purchase health care, some practices were given funds to purchase healthcare for their own populations. This was called the General Practice Fund-holding Scheme. The void left by the retraction of psychiatric services to the mental health hospital was dealt with in primary care by a rapid expansion in counselling services, aided by the fundholding scheme. However, not all practices were fundholders, resulting in a huge variety of the availability and quality of counselling services offered by different practices. This was the post code lottery of fundholding.

Delivering primary care mental health by guidelines – NICE and IAPT

The new millennium brought a new Government, new mental health policies,⁹ and a new approach to health care through the development of the National Institute for Clinical Excellence (NICE), which aimed to use guidelines to provide both high quality care and consistent services across the country. The post code lottery that characterised fund holding was to be abolished.

At the same time, a focus on the underlying causes of long-term unemployment revealed that nearly 50% had mental health problems; not those managed by psychiatrists, but the depression and anxiety managed by primary care.¹⁰ A workshop in 2004 held at Downing Street proposed that there was an economic case to be made for investing in training tens of thousands of mental health workers, who would deliver evidence-based interventions to relieve depression and anxiety, so that sufferers could return to work.¹¹ This would reduce the national burden of the long term unemployed, decrease benefits costs, and increase tax revenue, as the unemployed became employed once more. The evidence-based interventions would be based on the guidelines produced by NICE for anxiety and depression. Thus, was born the Improving Access to Psychological Therapies (IAPT) programme, created not as a necessary new mental health intervention to fill a mental health need, but an economic model to address long term unemployment.

The IAPT programme, amongst other things, provided for primary care a route to manage people with depression and anxiety. It rationalized the primary-secondary care interface that was so lacking in the 1990s. People who are severely unwell will go to the mental health services, who will provide long-term care for them. People with common and less severe mental health problems like depression and anxiety will be treated with evidence-based interventions through the IAPT programme instead of the free for all that was counselling. The primary care role was to refer the patient to the most appropriate care provider, returning to GP’s acting as the gatekeepers to secondary care services.

Summary

Each section was introduced by two key speakers, and then opened to the audience for discussion. The invited audience consisted of 23 in-person attendees, and 11 attending virtually via Zoom, and were a mixture of GP’s, psychiatrists and psychologists. The ability to hold a hybrid event was invaluable, as it allowed people to attend who otherwise may not have had the opportunity to contribute. The seminar was recorded and later transcribed into this document which is now held at the Royal College of Psychiatrists (RCPsych) archives (Witness seminar – History of primary care mental health in England 1948-2019 (rcpsych.ac.uk)). We hope that it fills some of the gaps in the history of primary care mental health, and enables further research for those who are interested.

References

1. NHS England (2022) Next steps on the NHS Five Year Forward View, Primary care. Available at: https://www.england.nhs.uk/five-year-forward-view/next-steps-on-the-nhs-five-year-forward-view/primary-care/ (Accessed 06 October 2022)
2. Gask L, Kendrick T, Peveler R and Chew-Graham CA (eds) (2018) Primary Care Mental Health. Cambridge: Cambridge University Press. (2nd edition)
3. Hall J (2022) From poor law lunacy to primary care mental health: a gap in the historical literature. News and Notes: Newsletter of the RCPsych History of Psychiatry Special Interest Group 14: 33-38.
4. Strathdee G, Williams, P (1984) A survey of psychiatrists in primary care: the silent growth of a new service. Journal of the Royal College of General Practitioners, 34. P. 615-618
5. Royal College of General Practitioners (1972) The Future General Practitioner – Learning and Teaching. London: RCGP.
6. Balint M (1957) The Doctor, the Patient and the illness. London: Elsevier
7. Brooking J, Gournay K (1994) Community Psychiatric Nurses in Primary Health Care, British Journal of Psychiatry, 165, p. 231-238
8. Mehdi T (2012) Benzodiazepines revisited. British Journal of Medical Practitioners 5(1): a501.
9. Department of Health (1998) Modernizing mental health services: safe, sound and supportive. London: HMSO.
10. Layard R & Clark D M (2014) Thrive: the power of evidence-based psychological therapies. London: Allen Lane: p.71.
11. Evans J (2013) ‘A brief history of IAPT: the mass provision of CBT by the NHS’, The History of Emotions Blog, 30th May 2013, Available at: https://emotionsblog.history.qmul.ac.uk/2013/05 (Accessed 06 October 2022)

Featured image by C M on Unsplash