The middle way

A man goes into a GP surgery. He tells the doctor he is feeling low and may lose his job. It is clear that he is depressed, and the doctor finds that he also has hypertension. In the 10 minutes he can spend with the man, there is little that the GP can do, other than prescribe medication. Three weeks later the man goes back still depressed and says his home is at risk. Again there is little the doctor can do. A month later, the doctor – still suspecting depression – orders tests on the man who is now complaining of stomach problems. The tests rule out anything sinister and the doctor tells him that nothing more can be done.

Unfortunately for the man, there is no punchline. While his circumstances may be too much for the GP to handle, his mental health problem is not bad enough to warrant specialist help. There is nowhere for him to go so he must sit it out alone until his depression either passes of its own accord or deteriorates so much that he ends up in hospital.

It would be of little comfort to tell him that he is not alone. Figures suggest that in an average-sized primary care trust covering 200,000 people, about 1,177 have a mental health problem that cannot be managed properly in primary care but which is unsuitable for referral to specialist services. Under the terms of the National Service Framework for Mental Health, specialist services prioritise people with severe and enduring mental health conditions, such as schizophrenia and manic depression, and GPs, with inadequate time and training, are left to deal with the rest.

Alan Cohen, a practising GP and director of primary care at the Sainsbury Centre for Mental Health, says of these patients: “They can’t be managed with confidence in primary care as they need more than can be provided in that one consultation. Primary care can handle some of the issues but it can’t manage all of them, such as getting people back to work, providing cognitive behavioural therapy or getting them rehoused. People do not fall neatly into the bureaucracy of the NHS. They are whole people with whole people problems.”

Sometimes, with options limited, GPs will refer patients to specialist services even though they do not have a psychotic illness – with the referral often sent back.

Cohen says: “Specialist services become frustrated with what they perceive to be inappropriate referrals. They are not inappropriate but the service can’t help them, so everyone gets fed up. These are ‘heart sink’ patients. No matter what you do in primary care they continue to come back and you run out of options to offer them.”

In Ipswich, a pilot project is catering for such patients. Structurally it offers another tier of support, sitting as it does between primary care and specialist mental health services. Its clients have anxiety or depression, have usually seen their GP several times and have tried medication unsuccessfully. They also tend to have complex housing, employment and relationship issues.

Mary Roberts, co-ordinator of the project – known as the primary care intermediate mental health service – says her team tries to gain an overall picture of the client in terms of mental state, employment, accommodation and lifestyle.

“It’s not a medical or nursing model. It’s a holistic model,” she says.

Given this approach, you would expect the team to include social workers, but it doesn’t. “A social worker did not apply although we’d have been happy if they had. We’d love to have one,” says Roberts.

As it is, the original team comprised Roberts, an occupational therapist with experience in acute adult mental health; two primary care mental health link workers who were nurses by background; a graduate mental health worker; seven hours a week from a mental health worker from East Suffolk Mind; two hours a week from a consultant psychiatrist; and an administrator.
Each month a housing advisory officer from Ipswich Council holds a session for clients. Links are also developing between the service and Jobcentre Plus – employment advisers have been given training in mental health awareness and there are plans for a joint referral system whereby Jobcentre Plus can refer directly and vice versa.

The project began in January, since when it has received 637 referrals. Most have come from primary care, as the service covers 18 practices, and it has undoubtedly taken the pressure off GPs. But it has also affected the workload of community mental health teams (CMHTs): between January and August there was a 12 per cent reduction in referrals to Ipswich CMHTs compared with the same period last year whereas in all the other East Suffolk CMHTs the referral numbers were up – by as much as 52 per cent in one case. It appears that CMHTs in Ipswich are passing on about a quarter of their referrals to the intermediate team.

The team has also taken referrals from psychiatric liaison workers at A&E, often for people who have taken an overdose.

“Usually they are people with relationship or eviction problems who are not deemed to have a severe enough illness to go to the community mental health team, so they refer them to us,” says Roberts.

So far the service has carried out 427 assessments and 600 face-to-face follow-up appointments – the most offered to an individual would be eight sessions.

Roberts says: “We work at the other end of the market to CMHTs, at the preventive end with people who are just developing a mental health problem. We’re putting in resources to prevent people getting ill. Before people had to wait to get better on their own or get worse and end up in hospital or a CMHT.”

The future of the service is unclear – it is now funded by Suffolk East PCT and an evaluation is to be carried out in March. However, a report from the Sainsbury Centre for Mental Health suggests that intermediate care teams could be the way forward.1 Not only do they provide a solution for people whose needs fall in the gap between primary care and specialist services, but the costs involved in setting them up “are not excessive”, primarily because the people needed to staff them are already working in the sector. Obviously this would mean recruiting staff from current teams, but perhaps this would be feasible if a more preventive approach resulted in less pressure on acute teams.

Roberts recommends that other PCTs think about setting up a similar service, although if she were to start again she would want to have a cognitive behavioural therapist on the team.
The government has hinted at expanding talking therapies. Delivering them through intermediate care teams would certainly be one way to achieve this. Given the thousands of adults who every day fall through the gap between primary care and specialist help, it would be daft for such a model not to at least be considered.

EXPERT OPINION
Members of an intermediate mental health team could include: