International Review of Psychiatry (1998), 10, 119± 122

Mental health teamwork in primary care

MARTA BUSZEWICZ

Department of Primary Care and Population Sciences, University College London, Archway Resource Centre, 2ndFloor Archway Wing, Whittington Hospital, Highgate Hill, London N19 5NF, UK

Historical context

The historical context is important when consider-

ing developments which are relatively recent and

still in the process of being developed. Traditionally,

general practitioners dealt on their own with their

clinical workload but, following the doctor’ s charter

of 1965, there was a rapid move towards GPs work-

ing in group practices. This predated the concept of

a primary health care team, but was associated with

a rapid growth in the number of community nurses

and health visitors with clear links with local GPs.

The increase in formal and informal links with men-

tal health professionals has been much slower, al-

though this is currently a growth area. However,

even now, it is important to remember how much

variability there is in working arrangements; al-

though the national average for single-handed gen-

eral practitioners is 10%, it is much higher than this

in many inner-city areas.

Research over a similar time frame, i.e. the last 30

years, has established the range and extent of psy-

chological morbidity presenting to primary care.

There is now general agreement that 25± 30% of

those attending their GP will have some psychologi-

cal component to their presentation, and this means

that the average GP with a list size of 2,000 patients

will see an average of 460 patients per year with

mental health problems (Goldberg & Huxley,

1992).

Mental health professionals working in pri-

mary care

This number of patients has implications for the

diagnosis and treatment of patients with mental

health problems in primary care. It is known that

only 5± 10% are currently referred on to secondary

care (HMSO, 1995), leaving large numbers for the

GP to treat. Even though many GPs have both

particular interests and skills in psychological treat-

ments and there are successful initiatives to help

them improve these skills (Gask, 1992), it would not

be possible or appropriate for GPs to do it all, and

many of the patients seen would probably not merit

or bene® t from referral to secondary care settings.

This has led to an increase in the numbers of mental

health professionals working alongside GPs in pri-

mary care (Briscoe & Wilkinson, 1989; Strathdee &

Williams, 1984).

Initially, these attachments were largely depen-

dent on secondary care staff choosing to spend a

proportion of their time working in primary care.

Following the new G P contract of 1990

(Chisholm, 1990), GPs were allowed more

¯ exibility in the categories of staff which they could

reimburse under the attached staff scheme, result-

ing in an increase in the number and variety of

mental health practitioners working alongside gen-

eral practitioners in primary care. A survey in 1992

of every general practice within six randomly se-

lected health districts in England (Thomas & Cor-

ney, 1992) found that 50% of the 261 practices

had a speci® c link with a community psychiatric

nurse, 21% with a social worker, 17% with a

counsellor, 15% with a clinical psychologist and

16% with a psychiatrist. If a practice had links with

one professional, then they were much more likely

to have others, while some sim ilarly sized practices

had no links.

M ore recently, Corney examined whether GP

fund-holding had had an impact on the number

of links with mental health professionals (Corney,

1996). She found fund-holders often made

mental health work a priority, sometimes using

their resources to have more attached workers

and in other instances to reduce the number of

psychiatrists with which they had links, concen-

trating on improving communication with those

remaining with whom links were fostered. Fund-

holding practices had signi® cantly more links

than nonfund-holders with mental health profes-

sionals.

The types of link being considered vary and may

include liaison, attachment or employment. The

employment distinction is particularly important as

the fact that the general practice may be employers

of some, but not all, of the attached mental health

practitioners, is likely to have important conse-

quences for the individual roles within any team

which is set up.

Teamwork in primary care

The issue of teamwork in primary care was recently

debated at a joint conference of the Royal Society of

Medicine and the Royal College of Nursing (Van-

clay, 1997). Their conclusions are generalizable and

likely to be of bene® t to all those attempting to set

up teams which involve health professionals from a

0954± 0261/98/020119± 04 $7.00 Ó 1998, Institute of Psychiatry

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120 Marta Buszewicz

variety of backgrounds. The perceived obstacles to

effective teamwork and components of effective

teamwork are listed in the tables below.

Table 1. Obstacles to effective teamwork

· Interpersonal differences

· Fear of change

· Intra- and inter-professional rivalries and misun-

derstandings

· Differentials in power, income and status

· Different conceptual approaches

· Lack of training in teamwork

· Different lines of accountability

Table 2. Components of effective teamwork

· Shared goals and clear aspirations

· Clearly de® ned, complementary roles, understood

and respected by all members

· Clear procedures and agreed protocols

· Regular and effective communication

· Commitment by all team members

· Support for and recognition of contribution of all

members

Given the increasing emphasis on effective team -

work throughout both prim ary and secondary

health care, it makes sense to tackle some of these

obstacles at an earlier stage and there is very inter-

esting work taking place in the ® eld of medical

education. Clearly, the various professions need to

have a better understanding of each others roles

and a programme offered by City U niversity pro-

vides joint learning for medical and nursing stu-

dents at undergraduate level, with the students

undertaking a community project together. M edi-

cal undergraduates at Leicester are currently in-

volved in a community-based, multi-agency course

which involves them talking to members of each

agency involved in the care of a patient (Lennox &

Petersen, 1998).

Other initiatives from universities both in this

country and abroad will, hopefully, help us to train

the practitioners of the future to work more effec-

tively together, but in the interim we need projects

which will enable those already in practice to collab-

orate better.

Mental health teamwork in primary care

Mental health practitioners working in primary care

have a variety of working arrangements, with impli-

cations both for the care of patients and communi-

cation between disciplines. It is not always clear

which professional is best suited, in terms of training

or experience, to treat a particular patient and the

criteria by which patients are allocated to particular

therapists needs to be established. There is particu-

lar concern that counsellors may sometimes get

inappropriate referrals (Sibbald et al., 1993). In

addition, not only will the training and experience of

different practitioners vary, they are also likely to

have little idea of the particular skills or training

undergone by other professionals with whom they

are being asked to forge links (Duggan et al., 1997).

Currently, the mechanisms whereby patients are

referred by GPs to other mental health professionals

vary greatly between practices. There is little docu-

mented evidence about this, but it appears that in

many practices referrals may take place on an `ad

hoc ’ basis with the GP making all decisions for

referral and to whom, while other practices have

regular meetings to discuss potential referrals and

feedback about clinical outcomes. Thomas and Cor-

ney (1993) found that a formal link was no guaran-

tee of regular face to face contact between

professionals.

The potential advantages of teamwork when look-

ing after patients with mental health problems are

clear and are shown in Table 3.

Table 3. Opportunities provided by teamwork in look-

ing after patients with mental health problems

· To share background and management infor-

mation about patients

· To decide on the appropriateness of referrals and

to which team member

· The chance for members to learn about each

others’ roles

· To increase skills in dealing with mental health

problems and knowledge about appropriate re-

sources, including in the voluntary sector

· To provide support for participants

There are, however, real dif® culties in the way of

setting up effective teams in primary care and these

need to be recognized if progress is to be made.

They are basically those associated with barriers to

health care teams in general, as shown in Table 1,

but there are some particular features associated

with mental health work. A much-voiced fear is that

meetings are very time-consuming and there may be

reservations about what is seen as an undue empha-

sis on mental health problems. Evidence shows that

effective teams tend to have ¯ at rather than hier-

archical structures, but the medical tradition leads

to both GPs and psychiatrists tending to see them-

selves as leaders, rather than team members, and

this may need to be addressed within the group.

Much useful work has been carried out on the topic

of effective teamwork in primary care (Pritchard &

Pritchard, 1994), but it is clear that a signi® cant

commitment of time, effort and ® nancial resources,

as well as a willingness to consider alternative ways

of working, is necessary for the recommendations to

be carried out.

Following the success of facilitators in working

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Mental health teamwork 121

with general practices at improving their detection

of risk factors for strokes and working with patients

to improve their lifestyles, a pilot study of the role of

a mental health facilitator was carried out in Central

London (Armstrong, 1992). The aim was to im-

prove the early detection and prompt treatment of

people with anxiety and depression in the six inter-

vention practices and to devise ways of identifying

and supporting people at risk of these conditions.

She worked with members of the primary care team

to improve their mental health skills and to help

them ® nd out about other possible resources that

were available, such as in the voluntary sector. This

work highlighted the dif® culties of working in prac-

tices which do not have regular team meetings. The

facilitator encouraged collaboration within the prac-

tices, by initially spending time with all the individu-

als concerned and conducting an audit of the care

received by patients with signi® cant psychological

morbidity (as assessed by the General Health Ques-

tionnaire) as a basis for discussion.

The Department of Health, in conjunction with

the Royal Institute of Public Health and Hygiene,

ran a primary care mental health team training

programme in 1996. This encouraged practices to

develop a team strategy for the early recognition of

anxiety and depression within the practice popu-

lation and included the giving of information on the

recognition and management of these disorders in

primary care, as well as ways of developing a team

approach to these problems (Royal Institute of Pub-

lic Health and Hygiene, 1997). A limited number of

practices were involved in the initial venture and

have reported good outcomes, but have stressed the

importance of one particular individual encouraging

other team members to get involved; in these prac-

tices the CPN was often very effective in this role.

Since the vast majority of patients with severe and

long-term mental illness are now also cared for in

the community, effective collaboration and com-

munication between primary and secondary care is

also crucial in the care of patients with mental

health problems. A project involving a community

mental health team in southwest London and two

local general practices reports that six consecutive

monthly meetings were well attended by both GPs

and members of the CMHT and were valued by

both, being used particularly for the sharing of

information about patients who were causing

concern rather than new patient referrals (Midgley

et al., 1996).

Outcomes

If teamwork am ongst mental health professionals is

to be recommended, we need to be clear about the

desirable outcomes of this approach. Concern has

been expressed as to whether the concentration of

mental health professionals in certain general

practices may result in inequities in care for pa-

tients, with a concentration on the less severely ill

and the possibility that working in large team s may

reduce continuity of care for the patients (Corney,

1994).

Data is lim ited, but there is certainly no clear

evidence that increasing the am ount of mental

health work done in primary care reduces the num-

ber of psychiatric admissions or referrals to second-

ary care. The question is whether we would be

expecting it to, as much of the discussion above has

been about the detection and treatment of mental

health problems which have, up to know, probably

received limited interventions in a primary care

setting. What we urgently need to know is whether

the earlier detection and treatment of conditions

such as anxiety and depression by a mental health

team in a primary care setting can improve the

long-term outcome of these disorders, since

chronic mental health problems impose enormous

® nancial and social burdens. A study in 1989 re-

vealed that the annual costs of neurosis in prim ary

care, when the indirect costs of certi® ed and un-

certi ® ed sick absence and early retirement were

taken into account, were three times those for

schizophrenia (Croft-Jefferys & Wilkinson, 1989).

These patients present initially, and often long-

term, to prim ary care and we need to be clear

about the most effective ways of helping them and

how the primary care team should function in

achieving this. This is likely to require appropriate

support and training for all those working in the

primary care setting with whom these patients

come into contact.

Acknowledgement

I would like to acknowledge the very helpful contri-

bution of Liz Armstrong in planning this paper.

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