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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