The family doctor is often the first port of call for people with mental health problems. Yet many patients find their GP lacks the time or specialist knowledge to do more than prescribe psychiatric drugs. As a result, however mild their condition, they are referred on to specialist services - and such inappropriate referrals can not only strain relations between GPs and hospital staff, but also lead to patients waiting months for treatment.
This state of affairs poses a big challenge to GPs in light of the national service framework for mental health, the government's initiative to improve services in England. The framework states that patients with common mental health problems, such as anxiety and depression, should have their needs identified and assessed by primary care staff and be offered speedy and effective treatment.
A pioneering partnership between GPs in Scarborough, North Yorkshire, and the South Tees and North East Yorkshire NHS trust has managed to achieve precisely this by establishing a primary care mental health team of community psychiatric nurses (CPNs) based in doctors' surgeries. Only those GPs who completed training to identify and manage people with mental health problems were eligible for the extra help. But, within three years, all 29 practices in Scarborough, Whitby and Rydale were involved.
Under the scheme, modelled on a project established by London GP Alan Cohen, director of primary care at the Sainsbury Centre for Mental Health, the CPNs carry out assessments, organise referrals and help GPs manage people even with severe - but stable - conditions, rather than sending them to specialist services. Within weeks of its launch in autumn 1998, waiting times for the local hospital's community mental health team (CMHT) had fallen from up to 14 weeks to between one and three.
Nine nurses now provide short-term counselling and other psychological therapies from the local practices. Denise Fisher, a CPN and mental health primary care team leader, reports that only 4.6% of the 1,800 people assessed last year required referral to the CMHT, psychologists or psychiatrists.
"Prior to the project, the CMHT was overloaded with people who only had mild problems, as well as those with more serious mental illnesses," Fisher says. "Patients were deteriorating while waiting for treatment and required psychiatric admission, rather than just preventative help. Some GPs stopped making referrals because waiting times were so long.
"But the mental health workers advise GPs on making appropriate referrals and carry out a full assessment of patients' needs, not just in relation to their mental health problems but also their physical health and general wellbeing. Because each nurse sees about 20 patients a week, we have time to uncover the underlying causes behind patients' symptoms.
"If someone is depressed because of a marital problem, we can refer them to Relate; or if they have not got over the grieving process, we can send them to the local hospice for counselling. We even referred one woman to an IVF clinic. We then see about a quarter of those we assess for short-term counselling and support, which lasts from three to six weeks."
Traditionally, CPNs, who work closely with primary care teams, have focused on helping people with common mental health problems at the expense of those with more severe and long-term illnesses. But the Scarborough team also targets patients with more serious conditions, such as schizophrenia and bipolar disorder (manic depression).
"We felt this made sense, as the Sainsbury centre found that 30% of people with severe mental illness were in contact only with primary care," Fisher says. "In this area, we found the rate was even higher, at 57%, and in some isolated rural practices on the North Yorkshire moors it's up to 80%."
By establishing a register of people with severe illness, the CPNs were able to check whether patients were taking their medication and could monitor any side effects they suffered. They also encouraged GPs to prescribe newer drugs with fewer side effects, which increased patient compliance. "We can't treat those in acute crisis, but we can prevent relapse by helping them with short-term, co-existent problems such as depression," says Fisher. "Often a person with schizophrenia may be responding well to medication, but feel socially isolated, which can aggravate their recovery. We provide help with housing, education and employment to tackle this."
Every six months, patients with mental health problems undergo a complete check-up of their mental and physical health and social needs. Research has suggested that people with schizophrenia are 50% more likely than average to develop late-onset diabetes and have higher rates of coronary heart disease and respiratory problems - as do those with bipolar disorder.
"Because we develop a greater rapport with the patients, we've picked up serious problems," Fisher says. "We were able to persuade one lady who had a history of sexual abuse to have a cancer smear test for the first time. The test was positive, but the problem was spotted early enough for treatment to prove effective."
Charles Saffman, a GP and medical lead on the project, says it has reduced the stigma surrounding mental illness, because problems have been treated in the context of patients' general wellbeing. "And because patients can access help in their doctor's surgery, rather than having to be referred to a specialist service, they're more willing to confront their problems," he says.
Although the team now falls under the remit of Scarborough, Rydale and Whitby primary care trust (PCT), the CPNs are still employed by the local hospital trust. But this may change - especially as several other PCTs in the region have exploited their new status as healthcare commissioners and providers in adapting the Sainsbury centre's model.
David Brown, director of mental health services at the Craven, Harrogate and rural district PCT, says: "We suddenly become a big fish in terms of mental health provision. We've been able to adapt the Scarborough model and employ a mental health nurse or social worker in every GP practice, as well as counsellors. We've also set up separate teams providing health and social care to those with severe mental illnesses."
These developments will be the focus of discussion next week at the Sainsbury Centre's primary care conference in Manchester. And they are proving popular with people with mental health problems. Duncan Herrington, service coordinator of Scarborough Survivors, a self-help group that collaborates closely with the primary care mental health team, is urging the extension of similar services across the country.
Herrington says: "The problems I had were not just about depression - I also suffered from recurrent sinus infections. But my nurse helped me to recognise that it was related to the stress I was under at work. Together, we were able to identify the triggers to an attack and help manage them effectively.
"It's a much more user-friendly service now. It keeps me well knowing that someone is there to check up on me. I feel I've regained control of my life."
