A Highland GP on life the universe and anything…

This blog was written to support the session to run at the NHS Highland QoF QP event on 19th November 2013 at the Drumossie Hotel

I wish to share a the 5 Areas model as an easy to use resource to structure a GP consultation for a mental health problem. It provides a means to introduce a Cognitive Behavioural  approach and records the details of a holistic, patient focused Bio-psychosocial assessment.

This session was organised in response to concern about meeting these Quality & Outcome Framework (QoF) criteria of the 2013 GMScontract for GP: –

Dep001-2

This details of what is expected in a Bio-psychosocial Assessment (BPA) are: –

Slide6

In addition, many practices in Highland continue to provide a Local Enhanced Service (LES) for Depression within a “bundle ” of previous LES. Those criteria are: –

I believe that as GPs we have a number of responsibilities when we are faced with mental health issues in GP: – 

  1. Spotting mental health issues, even when the present with somatic symptoms or complicate chronic ill health
  2. Make a diagnosis
  3. Consider patients in a holistic context including physical, emotional, cognitive, behavioural and life situation components
  4. Agree an evidence based treatment plan
  5. Organise follow-up

Making a diagnosis of depression in GP is not straight forward in view of the short appointment length. It depends on the recognition of these symptoms: –

ICD depression

I know how unpopular the PHQ9 has become (see my post here)  but I value its assistance in: –

  • Assisting in making the diagnosis
  • Giving an objective assessment of severity
  • Providing a baseline for future objective measurement of treatment response

I fill it in with the patient on screen using the ESCRO software: –

PHQ escro

I then want to inquire into the the other parts of a holistic approach that I listed above. Since about 2004 I have used the 5 Areas model that I have developed from the work of Chris Williams from Glasgow. This basic CBT model has been the basis of “Livng Life to the Full” and self-help treatments. It was also easy to adapt to develop and record a BPA. I have this blank form saved as a word document on my desktop: –

Blank 5 Areas

The answers to the PHQ9 can easily be inserted (violet) and the other components of the BPA (blue) neatly fills in many of the gaps: –

5 Areas with PHQ, BPA

A completed form might look like this: –

5 Areas completed1

This then allows an exploration and understanding of that patient’s unique circumstances and the opportunity to come to an agreed treatment plan. For instance: –

  1. There may be scope for appreciating that some of the life situation/relationships/practical problems are amenableto a problem solving approach while others may need to be accepted as being unchangeable
  2. Severe emotional symptoms may require medication
  3. Altered thinking can be challenged and measures taken to minimise the risk of self harm that could arise for suicidal ideation
  4. Physical symptoms  can be seen to be modified by emotions
  5. Advice on avoiding inappropriate coping mechanisms and attending to the “building blocks for a healthy life” can be offered.

If completed on screen it is then easy to give a copy to the patient and file another to Docman. It is then

  • There as evidence for payment verification
  • Provides a convenient way to record the details of much of your consultation
  • Can be referred back to at review appointments or further in the future
  • May be attached to referrals

Please comment below or via Twitter (@milesmack using hashtag #QoFQP and #CBT)

Resources:-

My BPA 5 Areas presentation

Blank 5 Areas Bio-psycho-social

5 Areas BPA and PHQ inserted

5 Areas example Completed

How to File BPA in DocMan

BioPsychosocial from Portree

Vision Bio-psychosocial

RCPsyc CBT leaflet

Book Prescription Scheme – GP Pad

Breathing space & MoodGYM

Depression Alliance food advice

 Prof Freeman’s study of 5Areas type approach in GP

Life’s building blocks

LivingLifeToTheFull

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Comments on: "Incorporating Bio-Psychosocial Assessment into GP" (2)

  1. Simon Harrison said:

    Dear Miles, thanks you for your presentation yesterday. Always interesting to learn how other people assess patients with depression.
    ……. Whilst I’m sure that your method works for you and your patients, and may work for other doctors and other patients. I wish to voice dissent at the idea that there could or should be the one method of assessing depression that suits all. It cunjors up in my mind a vision of a sad and increasingly frustrated individual, going from doctor to doctor. As soon as he mentions the word ‘depression’ each doctor pulls out the same bit of paper and starts writing down the same phrases in each box….. Technicians or artisans ! I didn’t think that providing the same level of service meant that we all had to provide exactly the same menu!

    Regards
    Simon / Munlochy

  2. Alistair Appleby said:

    Hi there Miles,

    Great presentation. Doctors and others interested in an holistic model of approaching depression may like to look at some of the growing evidence on spiritual factors that relate to mental health.
    For example the Royal College of Psychiatrists website

    .http://www.rcpsych.ac.uk/healthadvice/treatmentswellbeing/spirituality.aspx

    Their publication ” Spirituality and Mental Health” also available thro the RCPscyh takes this further.

    Many psychiatrists belong to the Spirituality special interest group.

    Alistair

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