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May Ezine
We’re back! Firstly we would like to thank Katie Law for all her hard work, wise words and enthusiasm, on the ezines so far.
Unfortunately Katie is unable to continue with the ezines and we have not been able to find anyone to take on the mammoth task! So the ever-enthusiastic trustees have offered to contribute some shrewd words! However if you would like to contribute by writing a few words on something topical in primary care mental health please do not hesitate to send it to us as We look forward to hearing from you.
Thank you Helen, Cathy, Paul and Ian for contributing to this ezine
Aislinn Enright (Primhe Trustee)
The Process of Submitting Evidence to the Quality and Outcomes Framework
The Quality and Outcomes Framework (QoF) is an innovative way to reward primary care teams for providing good quality care for their patients and a way of funding the work needed to improve the health care delivered to people across the United Kingdom. It was introduced as part of the new GP contract in April 2004.
The QoF has four “domains”: clinical, organisational, patient experience and additional services. Each domain is divided into areas (ten clinical, five organisational, two patient experience and four additional service areas) that are then further divided into individual indicators or standards.
Payments are linked to achievement of individual indicators and standards in the four domains, each of which has a number of points allocated to it. The points in the original QoF reflect the amount and difficulty of the work required by the primary care team in each area.
In early 2005, the NHS Employers was mandated by the Department of Health to review the GP contract, including the QoF, in conjunction with the General Practitioners Committee. As part of this process, they appointed an expert panel to support the review of evidence and good professional practice. This expert panel is led by the Department of Primary Care at the University of Birmingham, working in partnership with representatives from the Royal College of General Practitioners and the Society of Academic Primary Care.
Submission of evidence is invited for both existing and new areas of the QoF. Ideas for additions or modifications need to be
All ideas for changes and/or additions to the QoF need to be submitted to the expert panel through the following website: https://www.midrec.bham.ac.uk/qof
All submissions will be collated by a team in the Department of Primary Care at the University of Birmingham and then forwarded to a number of experts whose role it is to review the evidence, talk with other experts in their field including patient groups and other stakeholders, and then produce a series of summary reports. Each expert will also work closely with a Process Group, many of whom were involved in developing the GP contract in 2003, to make sure that ideas can be turned into indicators that are feasible and can be collected using primary care IT systems. Summaries of the evidence will then be used to inform the ongoing negotiations between the General Practitioners Committee and the Department of Health.
The timescale for submission is limited to 6 weeks since the Review process, subsequent negotiations and development of supporting IT for the next iteration of the QoF need to be in place by 1.4.06. The submission process lasts from 9.00 am 18th April 2005 until 5.00pm 30th May 2005.
For further information about the submission process, please visit the QoF website or contact the Department of Primary Care at the University of Birmingham on:
Dr Helen Lester
Research roundup
An interesting couple of months for primary care mental health research with a number of relevant papers being published. In the BMJ, Bower and Gilbody discuss conceptual models for managing mental health in primary care. They provide a useful summary of existing ways in which primary and secondary care mental health services interface They integrate these models within the existing evidence base by way of a systematic review of published research. Unsurprisingly they conclude that there is insufficient evidence to provide policy makers with definitive answers about which models of primary-secondary care interfacing are the most cost effective and efficient.
In the Archives of General Psychiatry, Roy-Byrne et al report the results of their randomized effectiveness trial of cognitive-behavioural therapy (CBT) and medication for panic disorder in primary care. They found that using a collaborative care model both CBT and medication were significantly more effective than treatment as usual. Also in the Archives of General Psychiatry DeRubeis et al report the results of a study exploring cognitive therapy versus medication in the treatment of moderate to severe depression. They found that cognitive therapy can be as effective as medication for the initial treatment of moderate to severe major depression , but that this may depend on a high level of therapist experience and expertise. The same team also found that cognitive therapy had an enduring effect that lasted beyond the end of treatment and was as effective as keeping patients on medications.
From Australia, Jorm et al report the impact of the ‘beyondblue: the national depression initiative’ in the Australian and New Zealand Journal of Psychiatry. ‘beyondblue’ is a national initiative to ‘Provide a national focus and community leadership to increase the capacity of the Australian community to prevent depression and respond to it effectively’. There were five components to the initiative: community awareness and destigmatisation, consumer and carer support, prevention and early intervention, primary care training and support, and applied research. This five year project found that in states that funded the initiative had higher levels of awareness than those in which it was not funded, and in states with high awareness of the project there was a change in beliefs about some treatments especially counselling and medication, and about the benefits of help seeking in general. They also found that recognition of depression improved greatly at a national level. These results are in contrast to the Defeat Depression campaign in the UK, which resulted in little change at the population level.
Dr Paul Walters
Sad but true
I had just seen a 60 year old retired HGV driver. He smelt of alcohol and admitted that he had been drinking to drown out his sorrows, but he had also taken a quantity of Paracetamol. I was not sure who had brought him to the A&E department, there was no-one with him. Tears rolled down his cheeks as he described his loneliness and despair, which had caused him to take this drastic action. His wife had left him and he had just retired. His children were living in different parts of the country and he had recently moved down south as his wife wanted to be nearer to her own relatives. He had never attempted to harm himself before. He had not seen his GP. He did not see any point, after all, what could anyone do? He felt that his sadness was purely due to his circumstances and since there was no hope that they would change, he had no desire to carry on living.
As I sat writing my notes feeling burdened myself by the wretchedness of this man’s situation, I was interrupted by one of the nurses. “Rod ‘em” he said. “I beg your pardon!” I responded. This older nurse then expanded on his comment. He had worked in A&E departments in the days when all overdose patients were “rodded”. He was of the opinion that the cruelty of the stomach washouts would soon persuade patients not to return again.
Every time I come across these stigmatising attitudes, anger arises within me and yet I know that my response must be appropriate and ‘educational’. I carefully explained to him how stomach washouts were detrimental clinically and furthermore they had no deterrent effect whatsoever. I carefully tried to explain how any patient presenting with any act of self harm would be suffering from a low self esteem and therefore any action which makes the patient feel even worse about themselves, would be far more likely to make them repeat the act. To put it another way, boosting the patient’s self respect is the only way of helping them back to recovery. He was not convinced, but I hoped at least he would start to think about his thoughtless comments.
My patient needed admission for treatment of his toxic levels of Paracetamol.
After my shift, I could not dismiss this event from my mind. Frustration turned to fury. Suddenly I wanted to shout the message. “What if it was your brother or father or husband, your sister or daughter or lover, would you still want to ‘rod ‘em’?”
However it is a message to all of us. We cannot afford to become hardened to the plight of our patients. We are their advocates. Indeed if we cannot rid the health service of stigma and discrimination, there is no hope that society will do so. This battle is far from over.
Dr Cathy Wield
SpR Accident & Emergency
A Day in the Life of a GP with Special Interest in Mental health
Seventy five percent of us prefer a relatively stable life, but I’m one of the twenty-five percent who love constant challenges and a varying lifestyle. I therefore love the fact that half my life is spent being paid to organise the development of mental health services locally and regionally, with input into the national level. During the other half of my life, my feet are kept securely on the ground, dealing with the constant challenges of General Practice.
I became interested in organisational development, when I was elected the lead GP of a PMS consortium of practices in Tipton seven years ago, realising that my leadership experience was restricted to being a patrol leader in the boy scouts. I have learned that organisations, like people, can be healthy, if their needs are looked after and will flourish and grow with the right investment of time, energy and resources. The successful organisations in today’s information based world are those where each individual’s skills and talents can be freed, so that the total output from the organisation is greater than the sum of each individuals input. Pooling and share our resources and ideas and listening to those working and receiving care at the coal-face is the key. The greatest satisfaction I get from my job is seeing the talents liberated in individuals, who were previously denied the freedom to develop their roles, in the hierarchical structure of the NHS.
Every day, I now meet at least one of these individuals, each excited about their future, as we bring them together with other individuals of like mind, sharing a common goal. The goal is to develop an integrated primary care mental health service in General Practice where 93% of mental health care is already done. We are currently aligning the counsellors and the CPN’s, social worker, occupational therapist and psychologist of the Primary Care Mental Health team and moving them into the practices. They will be part of the greater Primary Care team, like district nurses and health visitors are now.
We have mapped our current workforce and the training in mental health that is going on borough wide. We have found that we already have a lot of training going on in the borough across all the sectors, including education itself, but it is uncoordinated and often duplicated. Mapping workforce against educational needs will allow us to direct the training much more appropriately and use our own expertise more frequently.
Around the patch I have discovered frustrated individuals doing ground-breaking work, in areas like manic-depression and post-natal depression. Some of these projects will die if a certain individual leaves, so we need to give the right support, so that such projects can be mainstreamed, having shown their obvious benefits. Part of my job is to champion these.
In Sandwell we have a major project to redesign the whole of our health services by 2010 and the PCTs are pushing for a reduction in acute hospital beds linked with a huge investment in local and community services. Our mental health model leads the way and I am hopeful that mental health will no longer be seen as an add on. We have research showing the benefits of an all round approach to those with physical illness, another project I champion.
Our team of service users, many of whom have undergone leadership training, are our greatest advocates. They have helped us in the change process, as they compare their stories of often feeling helpless in the old system and see the benefits of our redesign.
So my day is often spent in meetings, I am chair of the mental health LIT and sometimes I am training, sometimes being trained. I am mental health lead for the PCT and need to continuously remind them that mental health should be at the centre of everything. I give advice and speak to various bodies. Occasionally I am asked to use my mental health skills on an individual basis and to see a patient who may benefit from my skills in medical hypnosis and Neuro-Linguistic Programming and do so. But I could not possibly fulfil the demand locally, so I feel it is more important that we integrate these skills into the mental health teams where appropriate. Alternative medicine is also increasingly popular, particularly amongst the mentally ill and our service mapping has shown a number of the team have trained themselves in such disciplines as aromatherapy, acupuncture and homeopathy that we should be able to integrate these into the teams too.
All the time I am an advocate for Primary Care Mental Health. I believe that the major strength of general practice is that we deal with the whole patient, their physical and mental problems. Properly done they leave feeling better. Specialist services have become increasingly more so over the years, looking closer and closer at less of the patient and often miss the bigger picture. GP’s have been doing 93% of mental health, with little support or training, to a high standard for many years, imagine how good Primary mental health will be when we get that training and support.
Dr Ian Walton GPwSI
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