Mental Health: How GPs need to change

Winning commitment from politicians to address it is one thing, achieving the necessary change is quite another. A report published this week starkly demonstrates the scale of the challenge.  

Beyond the Spin of the Wheel has been brought out by Belfast-based Participation and the Practice of Rights (PPR).  Its publication marks the start of a campaign to improve the services offered by GPs to people with mental ill health.

PPR was founded by the late Inez McCormack the celebrated trade unionist and human rights campaigner. It uses a human-rights based approach for its campaigning and states that it measures success when change is seen on the ground, not when government makes a commitment. As many lobby groups have discovered to their cost, words are easy which is why so many apparently successful campaigns do not deliver results.

This latest initiative is likely to test its formidable campaigning skills to the limits, not least because the problems it uncovers go right to the heart of our faltering Health Service with all its interdependencies and fragilities. And whilst the last Health Minister pledged the Executive’s commitment to “achieving a parity of esteem between mental and physical health”, there is no substantive evidence of progress towards this.

Under Article 12 of the International Covenant on Economic, Social and Cultural Rights to which the UK is a signatory, all citizens have the right to the highest attainable standard of health. The report highlights what it identifies as key barriers to people accessing mental health services through GPs.

The three it highlights are being most significant are:

• A lack of mental health expertise among GPs.
•  Barriers to accessing appointments for mental health care.
•  The over prescription of medication to deal with mental health issues.

This all has to be put into the broader context of a GP service which is itself in crisis. Mental ill health in Northern Ireland is between 24-44% higher than England, yet per capita spending is 10-30% lower. We also have the lowest GP coverage per head of population in the UK, and a 20% shortage of GPs in the region. Already eight out of 10 GPs say their workload is unmanageable, and 64% of people report not being able to book an appointment with their GP within the same week.

The numbers of consultations carried out by doctors is increasing, so too is their list size and the administrative burden put upon them. The pressure is taking its toll. Up to 20 rural practices are expected to close this year, with Fermanagh especially hard hit. In March of this year GPs voted to resign en masse.

It is therefore unsurprising that PPR research uncovered serious difficulties for people experiencing mental ill health to get to see their GP. It is important to note that people with mental ill health often lack confidence and may have spent some time even getting to the stage of calling for help.

 Barriers identified in relation to getting to see a doctor included the lack of availability of appointments, difficulty getting through on the phone, a lengthy wait between booking appointment and seeing the GP, and receptionists acting as “gatekeepers” presenting barriers to making appointments typically by asking too many questions.

Researchers quoted many of the survey respondents expressing their frustration with the system. This was one typical response: “we can only make appointments on a Monday, when you try to ring and make appointments the line is busy all day, by the time you get through there are no appointments left and then you have to wait until the next morning to try again”

In 2012 the 48 hour target in place for routine appointments with a GP was dropped and not replaced. By 2016 average waiting time had risen to 13 days across the UK. Demand continues to rise and this will inevitably stretch out further.

PPR proposes the following to help ease the problems for people with mental health problems.

It would like to see

• a separate dedicated line into surgeries for people with mental health concerns, this to alert receptionists to minimise the number of questions to ask callers;
• a separate appointments system with a percentage of all appointments reserved for people with mental health problems
• A red flag system for patients’ files so receptionists are aware that patients have mental ill health.

A second issue, and one which many outside the health system will find disturbing is an apparent lack of knowledge/understanding of mental ill health amongst many GPs, compounded by the system of 10 minute appointments.

PPR secured a response to a Freedom of Information request in 2016 which showed that only half of the annual cohort of trainee GPs have to undertake a placement in a mental health facility. Furthermore practicing GPs are not obliged to undertake mental health training as part of their mandatory continuous professional development (CPD).

It would like to see the following:

• Mandatory mental health training for GPs and other relevant GP practice staff (e.g. receptionists)
•  Other health professionals with the necessary skills and expertise in mental health to work alongside the GP as part of a multi-disciplinary team

Finally, PPR lambasts the over-use of prescription medicines which is particularly high in Northern Ireland. This is despite the fact that research shows both no decline in the overall prevalence of depression or anxiety despite dramatic increases in antidepressant use and an increase in vulnerable people abusing legally prescribed drugs. This problem appears to be linked with a lack of understanding of mental ill health amongst GPs and the extremely short appointment times.

To help alleviate this PPR is demanding:

• Longer appointments including the option of routinely booking a double appointment for mental health issues
• More mental health expertise among GPs
• Provision of counselling and or cognitive behavioural therapy units in GP surgeries

The report is clear, well argued and the solutions proposed appear to be simple, proportionate,  entirely reasonable and relatively low cost, a good way to invest some of the £50 million the DUP secured for extra mental health spending in Northern Ireland.  It is hard to think that the BMA would disagree with PPR either. The problem as, always, with health reform is to get politicians and civil servants to move beyond fine, supportive words into action.