There will be few GPs out there who have not had the grim experience of systems and specialists pinging patients around while arguing over responsibility. It must be noted that this is almost never because they want to keep the patient. There can be a myopia here, an inability to think beyond the notional boundaries of a specialty, one that is difficult to fathom as a generalist, and one that is incomprehensible to patients for whom it defies all logic and compassion. This might be called ‘duel’ diagnosis, though it now has a wider manifestation with care being increasingly shifted towards primary care.
Dual-diagnosis clinics in people with severe mental illness who also use drugs have been established but have variable success and remain reductive, if not outright combative. In some regards, discussion of dual diagnosis is almost quaint and does not reflect the challenges of managing multimorbidity, indeed mega-multimorbidity, that is now so common. The generalist is needed more than ever, and especially for people with mental health conditions.
We know that people living with severe mental illness die younger than the general population. How do we address this? A systematic review, published in this issue, looked at a dozen studies of various interventions to increase uptake of physical health checks. Perhaps most promising were two randomised controlled trials (RCTs) that used a case-management approach — when people are individually supported with physical health checks — though neither of these RCTs were conducted in a general practice setting.1
Oliver and colleagues conducted a mixed-methods study on complex mental health difficulties that refer to people with problems including personality disorders and complex trauma. The study has admirable involvement of people with lived experience and they describe the frustrations of being ‘bounced around’ systems. This has immediate resonance but can scarcely be considered new. The mentality of bouncing patients was brutally skewered by psychiatrist Stephen Bergman, under his pseudonym Samuel Shem, in the 1978 novel The House of God. The ‘buff and turf’ mentality is still there.
Bergman spoke at the RCGP Conference in 2015 and wrote an article for BJGP Life in which he emphasised that ‘connection comes first’, and he also noted: ‘GPs are lucky — you get to actually be with patients in this way.’
2 We do, but often that morphs into a catch-all approach where there is scarcely any domain outside of our remit. One of the most common phrases used in these pages is ‘GPs are well placed to …’ or one of its many variations. We generally discourage its use as it is now a cliché and, however true it might be, it can reflect lazy thinking. We encourage authors to move the thinking forward as they, ironically, are best placed to offer meaningful solutions. This remains the key to any ‘left shift’ policy, whether it is the NHS 10 Year Plan, or in any other healthcare system striving to promote generalism and continuity in communities.
Highlights
Research and editorials this month lean heavily into mental health: predicting psychosis; complex mental health in primary care; antidepressant prescribing in pregnancy; people with intellectual disabilities; and re-thinking excluded patients. In Analysis this month we offer a short essay on ontology and epistemology. Clinical Practice has articles on how we can best care for forcibly displaced young migrants and on bile acid diarrhoea. And Life & Times provides a baker’s dozen of fine articles ranging from super-AI to drug allergies to ketamine to reflections on racism. All told, a mid-winter feast, probably best suited to fireside reading with a warming beverage in hand.
Notes
- © British Journal of General Practice 2025
