Paul Thomas

Promoting mental health and preventing mental illness in general practice

Abstract This paper calls for the routine integration of mental health promotion and prevention into UK General Practice in order to reduce the burden of mental and physical disorders and the ensuing pressure on General Practice. The proposals & the resulting document (https://ethicscharity.files.wordpress.com/2015/09/rcgp_keymsg_150925_v5.pdf) arise from an expert ‘Think Tank’ convened by the London Journal of Primary Care, Educational Trust for Health Improvement through Cognitive Strategies (ETHICS Foundation) and the Royal College of General Practitioners. It makes 12 recommendations for General Practice: (1) Mental health promotion and prevention are too important to wait. (2) Work with your community to map risk factors, resources and assets. (3) Good health care, medicine and best practice are biopsychosocial rather than purely physical. (4) Integrate mental health promotion and prevention into your daily work. (5) Boost resilience in your community through approaches such as community development. (6) Identify people at increased risk of mental disorder for support and screening. (7) Support early intervention for people of all ages with signs of illness. (8) Maintain your biopsychosocial skills. (9) Ensure good communication, interdisciplinary team working and inter-sectoral working with other staff, teams and agencies. (10) Lead by example, taking action to promote the resilience of the general practice workforce. (11) Ensure mental health is appropriately included in the strategic agenda for your ‘cluster’ of General Practices, at the Clinical Commissioning Groups, and the Health and Wellbeing Board. (12) Be aware of national mental health strategies and localise them, including action to destigmatise mental illness within the context of community development.

Community-oriented integrated care and health promotion - Views from the street

Abstract On the 1st and 2nd May 2015, participants at the RCGP London City Health Conference debated practical ways to achieve integrated care at community level. In five connected workshops, participants reviewed current work and identified ways to overcome some of the problems that had become apparent. In this paper, we summarise the conclusions of each workshop, and provide an overall comment. There are layers of complexity in community-oriented integrated care that are not apparent at first sight. The difficult thing is not persuading people that it matters, but finding ways to do it that are practical and sustainable. The dynamic and complex nature of the territory is bewildering. The expectation of silo-operating and linear thinking, and the language and models that encourage it, pervade health and social care. Comprehensive integration is possible, but the theory and practice are unfamiliar to many. Images, theories and models are needed to help people from all parts of the system to see big pictures and focused detail at the same time and oscillate between them to envision-integrated whole systems. Infrastructure needs to enable this, with coordination hubs, locality-based multidisciplinary meetings and cycles of inter-organisational improvement to nurture relationships across organisational boundaries.

Understanding context in healthcare research and development.

This is a review of a paper by Bayliss et al in the Annals of Family Medicine that argues that traditional research methods ‘are not well suited to addressing multi-faceted problems, such as understanding the complex interaction of multi-morbid chronic illness with social, environmental and healthcare systems’. Bayliss et al conclude that research that can be relied on requires methods that are ‘participatory, mixed methods, multi-level, and engage communities’.

Improving access to primary mental health services: are link workers the answer?

Background The incidences of common mental disorders such as anxiety, depression and low-level post-traumatic stress are associated with deprivation. Since 2007, the Improving Access to Psychological Therapy (IAPT) programme in Ealing has made it easier for primary care practitioners to refer patients with common mental disorders for treatment. However, fewer patients of a black and minority ethnic (BME) background were referred than expected. Setting Southall, Ealing, is a diverse ethnic community; over 70% of the population is classified as having a BME background. Aim To evaluate the effect of locating mental health link workers in general practitioners’ (GP) surgeries on referral of BME patients to IAPT services. Methods In 2009, an initiative in Southall helped practitioners and managers that served geographic areas to work with many different agencies to improve whole systems of care. One strand of this work led to mental health link workers being placed in 6 of the 23 GP practices. They provided psychological therapy and raised awareness of common mental disorders in BME groups and what mental health services can do to improve these. Referrals to the service were monitored and assessed using statistical process control. Results The mean referral rate of BME patients for GP practices without a link worker was 0.35 per week per 10 000 patients and was unchanged throughout the period of the study. The referral rates for the six practices with a link worker increased from 0.65 to 1.37 referrals per week per 10 000 patients. Conclusions Link workers located in GP practices, as part of a collaborative network of healthcare, show promise as one way to improve the care of patients with anxiety and depression from BME communities.

Improving patient and project outcomes using interorganisational innovation, collaboration and co-design.

Background Common mental disorders (CMDs) are a leading cause of disability. The Department of Health has launched a large-scale initiative to improve access to evidence-based psychological treatments, such as cognitive behavioural therapy (CBT), through the Improving Access to Psychological Therapy (IAPT) programme. Access to IAPT services by black and minority ethnic (BME) communities is lower than for other groups. Setting The London Borough of Ealing in west London; a diverse borough with areas of high BME population and relatively high deprivation. Aim To compare the outcomes of two linked quality improvement (QI) projects undertaken by Ealing Mental Health and Wellbeing Service (MHWBS), both with the same aim of increasing access to talking therapies for BME communities. Methods Application of QI methodologies supported by the NIHR CLAHRC for northwest London in two different settings in Ealing. One, the ‘Southall project’, was set within a wider initiative for collaborative improvements and shared learning (the Southall Initiative for Integrated Care) in an ethnically diverse area of Ealing; it was undertaken between April 2010 and September 2011. The second, ‘the Ealing project’, operated in the two other Ealing localities that did not have the advantage of a broader initiative for collaborative improvements; it was undertaken between April 2011 and September 2012. Results Comparison of the monthly referral rates of BME patients (standardised per 10 000 general practitioner (GP)-registered patients) show that the Southall project was more effective in increasing referrals from BME communities than the Ealing project. Conclusion Broad local participation and ownership in the project design of the Southall project may explain why it was more effective in achieving its aims than the Ealing project which lacked these ownership-creating mechanisms.

University-linked localities.

In this article, we propose that reframing the old concept of ‘academic general practices’ as ‘university-linked localities’ will help to integrate the work of those leading commissioning, education, research and public health. It will provide a ‘playground’ for different disciplines to creatively interact for the benefit of all.

Infrastructure to support modern primary care: the NAPCRG debate update.

In December 2012, at the North American Primary Care Research Group (NAPCRG) conference in New Orleans (USA), associates of London Journal of Primary Care (LJPC) from London (UK) and Cleveland Ohio (USA) hosted a forum entitled ‘Local Health Communities for Integrated Care’. The forum was attended by senior practitioners/academics from different countries who debated the infrastructure needed to support collaboration at primary/community care level. They drew on lessons from West Londons integrated care pilot1 and Clevelands ‘Promoting Health across Boundaries’ initiative.2 Participants at the forum recognised international need for case studies of community-oriented integrated care (COIC), including primaryand community-care leadership of collaboration for integrated care, and continuous improvements of whole systems of care. n nIn November 2013, at the NAPCRG conference in Ottawa (Canada), LJPC associates from Quebec (Canada) and London (UK) hosted a second forum to continue this conversation. n nIn preparation for the Ottawa Forum, in October 2013 LJPC invited its readers to rank 11 aspects of integrated care in respect of their importance to research. Table 1 shows the results in order of most ‘votes’ overall (weighted formula). It also shows the first four (of 11) ‘votes’ of 61 respondents. Table 2 shows additional comments made by 30/61 respondents. n n n nTable 1 n nPriority aspects of integrated care to research n n n n n nTable 2 n nAdditional comments made by 30 respondents about researching integrated care n n n nWhile ‘Patient Involvement’ and ‘Extended Multidisciplinary Primary Care Teams’ were perceived to be the most important aspects (and indeed 29/61 respondents gave them their first ‘vote’), the overall ranking pattern is more complicated. There is an argument for saying that all of these aspects are important, and their perceived importance may relate to their perceived neglect at present. Recognising the wide range of qualitative comments offered in Table 2, these initial results illustrate the range of research still needed to understand how the infrastructure of primary care can be developed, and, as discussions at the two conferences elaborated, more progress can be made in developing research that examines primary care in context.

Integrating primary mental health care and mental health promotion

The mental health theme in this issue of the BJGP comes at a time of growing awareness of the need to integrate mental health services within the UK NHS. The 2013 Annual Report of the Chief Medical Officer (CMO)1 reminds us that mental illness is the largest single cause of disability, representing 28% of the national disease burden in the UK. It is the leading cause of sickness absence in the UK, accounting for 70 million sick days in 2007. Mental illness costs the UK economy £70–£100 billion per year; 4.5% of gross domestic product. People with mental illness die on average 15–20 years earlier than those without mental illness, often from avoidable causes. About 75% of people with mental illness receive no treatment at all. The CMO Report describes the need for integrated mental health care throughout the life course: children and young people, adults, and older adults.nnArticles in this issue of the BJGP remind us that general practice is involved at every life stage. They come from six European countries and focus on adolescence, older people, healthcare colleagues, and end-of-life care. Haugen and colleagues present a study from Norway and Denmark that found a useful way to screen for depression in adolescents. Their study describes three questions that you may want to ask those who may be depressed.2 Hughes and colleagues present a study of patients in Yorkshire (England) aged 16–40 years who were on antidepressants. Their sample suggests that 7% may have unrecognised bipolar disorder (for whom mood stabilisers may be helpful) and they propose using …

A network of activists for community-oriented integrated care

This Issue of LJPC includes papers written by LJPC editors that challenge primary care practitioners and managers in the UK to lead a renaissance of the NHS through the language of community-oriented integrated care – team-based, locality-based care that has health as its focus as well as disease management. This challenge will be made repeatedly throughout 2016 as LJPC papers explore what it is to be healthy at various stages of life, and how primary care can enhance this. n nIn this Issue, Olivia Martin, a fourth year medical student, felt moved to write about her observation of a GP consultation that was entirely about helping a patient to think through a difficult decision. The role of a GP as facilitator of sense-making is obvious to experienced GPs, because this is how they help people to find health. It lies at the heart of the GP role. Yet it is rarely described either in the popular explanation of what GPs do or, as in the case of this particular student’s training, in content of the professional training curriculum. The challenge is to make this sense-making role widely understood – in training, in strategy and in evaluation. n n nPeter Toon, retired GP and LJPC editor, picks up the theme of GP as sense-maker through the language of flourishing narratives and the lens of virtue ethics. He writes: n nmost ethical problems which practitioners face are not caused by cutting edge technology or extraordinary situations, but by the normal messy complexities of human life and relationships … [people] are not merely looking for a life which is the longest string of pleasurable experiences possible with the minimum number of unpleasant ones, but for a life which makes sense and has a purpose and a shape. n n n n nThe challenge is to use consulting styles that help individuals to make sense of the breadth of their diseases, and help groups of people to make sense of their health as whole communities. Primary care practitioners of the future need to be skilled at techniques that help people to help themselves – things, like family conferences, self-help and community development initiatives. n nAlison While, Emeritus Professor of Community Nursing and LJPC editor, invites us to practice the health promotion we preach. The healthcare workforce, including primary healthcare staff, exhibits the same health behaviours as the general population – like everyone else we struggle to maintain healthy lifestyles, healthy relationships and healthy organisations. We need to give realistic advice; and in doing so, draw on ourselves as human beings and not merely our roles as professionals. We need to be better at putting ourselves into the shoes of others. n nIn 2016, LJPC will continue the theme of ‘putting one-self into the shoes of others’. When doing this it becomes obvious that different perspectives help to see more of the whole picture of health. Valuing and drawing on multiple perspectives underpin the kind of teamworking that is needed to manage complex conditions and to create integrated care. We will examine what primary care can do to orchestrate collaboration for positive mental health at different stages of life. How can we help children to be mentally healthy – able to play and laugh and adventure in the world? How can we help adults to be good parents and citizens who can be alive in the moment and able to engage optimistically with others? How can the system help doctors and nurses and all others to engage with bigger pictures of health, model healthy behaviours, build healthy teams and design infrastructure for healthy organisations and healthy systems? n nIn its seven-year history, LJPC has published many outstanding papers written by visionary people. We encourage authors writing about contemporary developments to link their papers to these past papers, and continue their line of thinking about how to address the complex and human factors that make primary care a place with extraordinary potential. n n nSuch scene-setting papers started in the very first Issue of LJPC. Volume One reminded readers of the modern-day implications of the 1978 Alma Ata Declaration. For example: n n• John Macdonald’s call to hold to the Alma Ata vision: ‘Whatever language we use to describe it, and however hard it may seem to achieve it, we must not lose sight of an old vision – one which sees health systems as both acknowledging the importance of the social determinants and insists that policy and action are directed upstream as well as downstream’. [1] n• Terry Bamford’s ‘A genuinely patient-centred approach would have the patient and family as part of the team…’ [2] n• Kurt Stange’s call for combined horizontal and vertical integration: ‘As a family physician practicing in the world’s most expensive, lowest value, and perhaps most fragmented health care system (USA), I encourage you to listen to the call to build on the great strength of a system that creates space to work towards the common good’. [3] n n n n n n nAnd practical ways to apply that vision: n n• Clare Gerada’s service for unwell doctors ‘Doctors are in fact at an increased risk of developing depression, burnout and anxiety’. [4] n• Kit Oi Chung and Helen McKendrick’s inner city health centre that was co-designed by the local community: ‘The most important thing we have done is simple and difficult at the same time. It is about listening to people’. [5] n• Anthony Harries experience: ‘My long years in Africa have convinced me about trying to keep things simple and defending the stance of providing a good service to as many people as possible rather than excellence to the few’. [6] n• Indarjit Singh’s wisdom: ‘Different spiritual traditions and secular groups use different techniques to improve the ability to be alive in the moment (it is a very difficult thing to achieve). Primary care practitioners can improve health by helping people to find ways that are meaningful to them to do this’. [7] n n n n n nVolume One of LJPC also included extracts from John Horder’s autobiography. John, one of the greatest GPs of all time, inspired people the world over to develop broad-visioned, multi-disciplinary primary care. This journal intends to do what it can to further this vision. n nLJPC is a network of activists. In the next stage we intend to extend this network by complementing academic writing (submitted for PubMed citation) with large numbers of ‘Landscape’ papers that describe the complexities of health in everyday life – papers like Francesco Carrelli’s review in this Issue of the life of the relationship between Wally Neuzil and Egon Schiele, brought to his attention by an exhibition in the Leopold museum in Vienna. n nLJPC also intends to develop Case Studies of community-oriented integrated care to add richness to the debate about the complexities of making things work, and moderate online discussions to distil principles of success in different contexts. n nWe wish you a Merry Christmas and a Happy New Year full of resolutions to become active in LJPC.

A tale of two specialties: primary care and public health.

Two things shout loud and clear in this edition of LJPC. Firstly, primary care and public health partnerships are essential for high quality healthcare systems. In November 2008 LJPC (1.2) emphasised this when we revisited the 1978 Alma Ata consensus. One hundred and thirty four member states of the World Health Organisation and United Nations Childrens Fund (UNICEF) and 67 international organisations agreed that primary medical care on its own would not produce a healthy society – public health, in its broadest sense, is an essential partner.1 Authors in this edition of LJPC remind us of this inescapable fact. n nSecondly, it is not easy. There are inevitable tensions between a discipline that considers individuals within the context of their family and community and a discipline that considers whole populations. This edition includes contributions from senior authors with a track record of resolving these tensions. They argue for mechanisms to facilitate ongoing collaborative projects, from which comes trusted relationships and integrated effort. n nJohn Ashton authored the highly influential 1988 book The New Public Health2 that made the case for local partnership between public health and primary care. In these pages he shows that his energy is undimmed. He writes: ‘Im as passionate about general practice as I am about public health and have spent the last 35 years trying to find the common ground between them’. He describes his recent work in Cumbria, working with GP leaders. He has wise words for clinical commissioning groups about establishing local leadership. n nAnother famous contributor to this discussion is Steve Gillam, who led the Kings Fund initiative on Community Oriented Primary Care (COPC). He is now a GP in Cambridge. In this edition of LJPC he reminds us of the potential of COPC to help general practices to work closely with community development initiatives to improve health. He argues that clinical commissioning needs to look again at this model. n nSteve Field, chairman of the government appointed NHS Future Forum, emphasises that the most difficult task of the Forum is to advise on integration – ‘this vast and complex problem’. He intends that the Forum proposes practical ways to integrate diverse contributions to health improvements, including public health. n nMaha Saeed, head of public health intelligence in NHS Hounslow, continues the theme of integration. She summarises the planned public health reforms, and builds an argument about the best ways to integrate public health and primary care activities. As public health relocates to local authorities she warns of the dangers of fragmentation. For integration to succeed, clinical commissioning groups need to facilitate ongoing joint working that goes beyond the familiar joint strategic needs assessment. n nOur own editors describe one mechanism to facilitate integration between primary care, public health and academia – ‘university linked localities’. Clusters of general practices that serve geographic areas of 20–30 000 population could resolve the personal care and population health tension by providing a geographic area inside which a ‘community of practice’ could collaborate for health promotion, teaching and innovation. n nThe West London Consortium for Research and Innovation (a sponsor of LJPC), adds impetus to the university linked localities idea by proposing increased general practice recruitment into research projects. Resources flow when practices recruit into research projects. By sharing the role with neighbouring practices they could maintain a high level of activity, nurturing relationships between those who think and those who do. n nAungst, Ruhe and Stange move the debate about integration to a higher theoretical level, introducing the concept of boundary-spanning teams to broker collaboration and coordination across institutional boundaries. They describe how a family practice discovered the need to collaborate across several intellectual and practical boundaries when developing personalised care for sick patients. They conclude that ‘health services need high level skill at boundary spanning, including systems-thinking practitioners and managers, and mechanisms that support it, including relationship-building between disciplines and organisations through shared projects’. They invite readers of LJPC to engage in an international debate about these contested and difficult issues. They offer their facility – Promoting health across boundaries (PHAB) for such a conversation. n nNigel (Lord) Crisp, former chief executive of the NHS, also concludes that ‘health professionals in their practice and education need to understand and operate within systems’. His paper brings together the results of reviews undertaken by the Global Health Workforce Alliance Taskforce on scaling up the education and training of the health workforce and the Lancet Commission on Health Professionals for a new Century. He calls for a change in our approach to professional medical education and learning from poorer countries from which ‘we in richer countries have so much to learn’.