Green and Gowans1 discuss the balance between the community and inpatient care of patients with mental health problems. They provide an analysis of resource allocation in mental health care with which I fundamentally disagree. Their core proposal is for more investment in psychiatric beds, with the possibility of improved primary care mental health as an afterthought. In contrast I suggest that a continued shift in investment towards community-based care is required, but with general practice and the third sector playing strong core roles. Within the confines of a limited NHS budget, following 3 years of decline down to 13%, I concur with others that a higher share goes to mental health care.2
While I agree with Green and Gowans that reductions in psychiatric bed availability have driven the reduction in admissions, there has been considerable investment in home treatment/crisis teams to support the policy.3 In contrast to many policies directing reorganisation of services there is relatively good evidence that home treatment teams can support individuals to stay safely out of hospital and provide a better experience of care during a crisis.4 While practice is highly variable, and this needs addressing, I have witnessed first-hand the benefits of a well-functioning crisis team and inpatient acute care system. Analyses of admission decisions also suggest that many inpatient stays are not necessary.5 The problem is likely to lie in implementation and a risk averse culture in the NHS.
While we need to optimise our response to crises, it is possibly more important to focus on generating positive outcomes; there are a range of community-based interventions, such as early intervention for psychosis, smoking cessation, and support into work which are likely to be cost-effective.3 Community-based mental health services need to be able to perform three interlinked key functions, and general practice has a role to play in each:
promoting better mental health and social outcomes, such as feelings of resilience, hope and wellbeing; having a home, and being in work;
proactively managing specific short and longer term mental health problems, such as bouts of depression with anxiety, relapsing post-traumatic stress disorder with comorbid substance use, and the physical health needs of individuals with psychosis and dementia; and
anticipating and responding to crises.
I suggest that future research should not be centred primarily around the epidemiology of the current inherently flawed diagnostic classification system, as implied by Green and Gowans, but should instead focus on understanding individuals’ needs for services (along with their strengths and resources). Patients’ personal goals, the links between their individual patterns of emotion, thinking, behaviour, and social situation define the services that are needed. Alongside self-management, carers, and family, resources in the community, third-sector and statutory organisations, can all contribute.
For general practice and primary care this will certainly require different training and more resources. The experience for all could be quite different: an individual with ‘stress’ booking straight into their choice of groups run by Improving Access to Psychological Therapies (IAPT) services; a patient with psychosis booking their follow up with the practice-based community psychiatric nurse through GP receptionists; a third-sector practitioner liaising with a GP to discuss the mutually accessible online shared plan for an individual with psychosis; a GP calling a psychiatrist to discuss reducing doses of antipsychotic medication for a patient the psychiatrist had seen as a one off at the practice; the practice-based IAPT practitioner providing cognitive behavioural therapy for anxiety as part of the aftercare plan following community-based alcohol detoxification. All possible with a small shift in allocation of NHS resources.
- © British Journal of General Practice 2015