Better wellbeing and mental health care in general practice and the community

Purpose and context

Patients with mental health concerns and patients with formal diagnoses form a significant proportion of those presenting to primary care, and many living with mental ill health experience care that does not meet their expectations. Patients with common mental health long-term conditions (LTCs) deserve high-quality long-term care, similar to that provided for the mostly physical conditions more typically referred to as LTCs.

An increasingly high proportion of the population is being prescribed antidepressants. Around 21.4 million prescriptions were issued between July and September in 2022 in England (NHS Business Services Authority, 2022). GP DiTs need to gain expertise in diagnosing and treating depression, and in de-prescribing when the time is right.

The primary care workforce, including GPs, has a key role in supporting individuals with mental health conditions to fully realise the NHS ambitions laid out in the Mental Health Forward View (MHFV) and the NHS Long Term Plan.

GP DiTs already gain significant understanding of the impact of mental ill health and its management, especially in their general practice placements. The RCGP has renewed its curriculum and there is a strong focus on mental health disorders, learning disability and other related conditions, including through the adoption of the GMC’s generic professional capabilities (Royal College of General Practitioners, 2022).

The number of people presenting with mental health problems has dramatically increased since the pandemic and secondary services are not able to offer treatment to everyone who needs it. This has been widely recognised as an enormous challenge, not least because primary care will likely need to manage the majority of this pent-up demand. As the true extent of the mental health impact of the pandemic emerges, it is vital that the future GP workforce is well equipped to manage it.

Working remotely and having fewer face-to-face consultations with patients during the pandemic has affected GP DiTs’ experiences of managing patients with mental health issues. While requiring a different approach, this has not all been negative.

Additionally, HEE has partnered in the development of resources for eating disorders, and also in the development of the Oliver McGowan Mandatory Training in Learning Disability and Autism (HEE, Learning Disability Programme, 2022). Oliver McGowan was an autistic teenager who was admitted to hospital having focal partial seizures. Oliver was known to be intolerant to all forms of antipsychotic medication, however he was administered antipsychotic medication against his and his family’s wishes. This led to Oliver’s brain swelling, resulting in his death. Oliver’s parents, Paula and Tom McGowan, believe his death could have been prevented if the doctors and nurses had been trained to understand how to make reasonable adjustments for him.

The Learning Disabilities Mortality Review (LeDeR) Programme (now known as the Learning from lives and deaths – People with a learning disability and autistic people programme) has consistently shown that people with a learning disability have a lower life expectancy and are more likely to have preventable, treatable and overall avoidable medical causes of death compared to the general population. In 2017 the LeDeR Programme’s annual report recommended that: “Mandatory learning disability awareness training should be provided to all staff, and be delivered in conjunction with people with a learning disability and their families.” (LeDeR Programme NHSE, 2017, p. 8) Every subsequent LeDeR annual report has made further reference to training needs.

We heard...

Patients told us they want to know their GPs have the required knowledge and skills, but that they perceive mental health knowledge among GPs to be not as strong as it is for physical conditions. This is supported by the GP mental health training survey (Mind, 2018), although this focused on secondary care mental health placements. 

At engagement events and in focus groups, some trainees reported negative experiences of acute psychiatry placements, which often were of little relevance to regular general practice and involved trainees providing medical care to psychiatric inpatients. However, we also heard of positive placements in community and psychiatry for the elderly.

Engagement with trainees and educators indicated a desire to learn about conditions they felt were not well covered, such as complex conditions with concurrent physical, mental and emotional symptoms, and non-condition aspects of mental health care including the medicalisation of normal emotions, brief interventions, working with the wider team and risk assessment. They also provided suggestions for additional learning experiences such as eating disorder services, addiction services and third sector services.

As part of a place-based pilot in the North West, a GP DiT developed skills and confidence by working alongside mental health nurses in primary care. The first-year GP DiT spent six months working 1.5 to two days per week alongside three band 6 part-time mental health nurses at a general practice, gaining understanding about the links between mental health and physical health, linking with community mental health and third sector services, and learning how to do brief but safe clinical assessments. The trainee reflected on improved confidence in understanding and managing the links between physical health issues and emotional wellbeing, and less reliance on prescribing medication or referring patients on.

Priorities and action

National figures suggest that only around half of GP trainees undertake training in a mental health setting. The inclusion of mental wellbeing in this reform programme is an indication of the importance we place on enhancing care of citizens with mental health disorders, learning disabilities and neurodiverse conditions.

We see an opportunity for healthcare professionals, including GP DiTs, mental health nursing students and NHS Talking Therapies professionals, to learn together in and with the communities they seek to serve. This might include team-based learning, co-located placements, or sessional secondment. We will work with NHS England and mental health providers to create new learning opportunities.

Our primary care deans will further explore innovative training placements, which could include:

• services not typically used, such as CAMHS, eating disorders, addiction, crisis and dementia provision;
• national charities such as Mind and Beat – The UK’s Eating Disorder Charity;
• local charities and third sector organisations;
• homelessness services.

A place-based pilot in the Wirral area saw GP DiTs spend half the week in general practice and the other half in a community service, such as substance misuse services and early intervention psychosis services, supporting people with mental health conditions and those who misuse alcohol and substances. As well as boosting trainees’ knowledge of the area and ability to provide holistic physical and mental health care, the experience had the potential to influence their future career plans.

We will work with HEE’s mental health leads and key partners to address the additional educational content requirements that have been identified, and support mental health services, charities and third sector organisations to provide training in future.