This is the transcript of my talk I was asked to give at SAMH‘s Parliamentary Reception at the Scottish Government on Thursday 15th January, hosted by Malcolm Chisholm MSP with the title “Primary care and mental health: making links.” I was delighted to be followed by Aidan, a service user who described how his GP took on his care on his discharge from the army and worked with him to move from a point of desperation to being an active and creative member of society. She gave the time to explore the issues, sought out his service medical records and referred him to agencies to find the support and treatment he needed. This was not about the GP completing the right questionnaire or ticking the right box but about the mixture of skill and care she showed, described by the RCGP motto “cum scientia caritas”.
Minister, Members, Ladies and Gentlemen,
It is very much my pleasure to speak with you this evening, as Chair of RCGP Scotland, in support of SAMH’s work. I would like to begin by wholeheartedly thanking the organisation’s service users, staff and supporters for inviting me to highlight the role of general practice in this way.
RCGP Scotland represents the interests and values of the vast majority of Scottish general practitioners – some 5000 members and more. We work to the nature and leadership of general practice – not only what GPs must do under contractual obligations, not only the training and development of GPs, though we are, of course, deeply involved in those aspects – but work based on the values and qualities that attracted practitioners to the profession in the first place.
Those values are based on care. When one in four of the Scottish population will experience mental distress at some point in their lives, then it is clear that such care must be able to give much of its time to mental health.
Early in my career I became fascinated by mental health, particularly depression, and how to treat it in General Practice. I did not always find my brief time working in Psychiatry as helpful – time spent in an acute secure unit has limited relevance to general practice – but rather I developed ways of working more attuned to the wide presentation of distress I found in practice. I found that seeing my patient’s mental health in the context of their physical health and life story enriched my work as a GP. From 2001 I had the opportunity to contribute to the NHS Highland Depression Guidelines and continued to act as a GP mental health advisor to NHS Highland until 2013.
Mental health has been estimated to take up to a third of a GPs time. Much of this is dealing with anxiety and depression where our treatment can be remarkably effective and extremely rewarding. We are also closely involved with recovery from trauma, substance misuse, borderline personality disorder and the variety of other severe and enduring diagnoses.
As GPs we have a great deal to offer. We are there as a first point of contact in any new episode of illness. We provide comprehensive assessments and care, taking into account peoples physical, psychological and life contexts. We provide long term care that extends from childhood to old age and this continuity, vitally, builds trust and allows disclosure of symptoms that are stigmatised by society. Finally, as the Hub of the NHS, we are able to co-ordinate the care between the various teams that may be involved in any one person’s treatment. As people are living longer and with more long term health conditions this role becomes increasingly important to the viability of the NHS. Patients with severe and enduring mental health conditions are known to have a much higher risk of physical ill heath and, conversely, patients with chronic physical illness have a much higher incidence of mental health issues. In many ways the distinction between mental and physical health may in fact be a false one.
Being closely linked to communities, GPs are increasingly involved in social prescribing; blurring the boundary between health care and healthy living, with “Links workers” being particularly effective in helping people access the community assets to make this work.
There are still big challenges.
• As GPs workload increases we are increasingly struggling to meet the demand for appointments and there is no scope for longer, more detailed assessments.
• RCGP Scotland is concerned that the present GP contract places too much emphasis on measures relevant to individual and limited conditions. Rather, it should acknowledge that high quality health care also depends on explicit demonstration of practice congruent with professional values.
• There is a wide variation across the country in the access to other sources of help, especially talking therapies, usually with long waiting times for treatment
• The “Deep End Project”, based in the most deprived practices in Scotland, has pointed out that the mental health needs in deprived areas are much higher but unfortunately these GPs have less resources to meet this need. They point to the fact that the Heat Targets have not led to the increased availability of talking therapies that were intended; a crucial problem when medication can only be a partial solution. They also report on the personal stress of GPs involved in this work.
The college is not being idle on these matters.
• We are beginning discussions with the Scottish Government and the BMA on a new GP contract for 2017. We hope to see the present quality and governance arrangement that are delivered by QoF being replaced by peer based, values driven arrangements at a local level.
• We have started a work-stream looking at the interface between GP and the rest of the NHS that aims to streamline the patient’s experience of accessing care.
• We are also, through our Put patients first: Back general practice campaign, raising the folly of having reduced GP funding from 9.8% of the NHS budget to 7.8% over the last 8 years when the NHS has never needed the GPs skills as expert medical generalists more and when the number of consultations we undertake has increased by 10% (two million) in the last decade alone..
• We are championing GPs and their staff working in partnership with others in the community, such as SAMH, in initiatives such as “Improving Links”, the ALISS website, and enhancing community assets.
Much could be achieved by the following three key actions: –
1. A reversal of the funding deficit to GP, to allow GPs to spend more time with their patients and build up the primary care infrastructure
2. An investment in practice based mental health workers and “Links” workers to support patients in their transition from health care to healthy living in their communities
3. And seeking a widening of the definition of quality in General Practice from a narrow measurement of criteria to one that is peer based & values driven at a locality level.
RCGP Scotland is particularly grateful for the high level support of SAMH in helping us to raise all these issues and I hope all of us here can soon see changes made that will significantly improve the care of our patients.