As a GP, what led you to developing a specialised interest in mental healthcare?
I have always had an interest in psychology and mental health in general. Approximately 90 per cent of people with a mental health problem present to primary care. I have always thought that we could do things much better when it comes to mental health provision, even within the same budget. For me, an effective mental health service model needs to include better integration between patients’ mental and physical health, particularly for patients with serious mental illness. My aim has always been to influence and change, and to look at what other models of mental healthcare we could implement that would improve outcomes for patients, carers and colleagues.
Can you describe your current role as a strategic mental health clinical lead?
Effectively, this role is very much around developing a mental health strategy for our local Cambridgeshire and Peterborough system, focusing on creating a sustainable mental health service model for the future, which ultimately delivers good patient outcomes.
In our area, three years ago, the service was effectively overwhelmed, with around 16,500 referrals per year for mental health issues. This was one of the highest referral rates in the country. Nine out of 10 of the referrals made were returned to primary care, which is a very inefficient way of doing things, as each one takes several hours to process. My focus has been around redesigning and transforming services to support primary care to manage patients with more complex mental health needs through a multidisciplinary approach (including third sector and social care). This releases capacity in secondary care to actually treat people who will benefit from specialist interventions.
I have also been focused on addressing the gap between primary and secondary mental healthcare; some people with mild to moderate conditions do not meet the threshold for secondary care but need more care and support than a core GP service can provide. This has become an increasing problem as the thresholds for accessing secondary care have increased – a result of demand increasing and finite secondary care capacity.
We have developed a sustainable, integrated, community-based service model for both urgent and routine mental healthcare in Cambridgeshire and Peterborough. The urgent care model includes a First Response Crisis Mental Health Service (FRS) with local sanctuaries (non-health-based places of safety), and mental health professionals situated in the police control room. The service for planned care includes Community Mental Health Teams and a Primary Service for Mental Health (PRISM), which brings together specialist mental health, primary care and third sector/ community services, using a neighbourhood team model.
Strategically in this role, my focus is also on bringing together all stakeholders. This enables us to focus on mental health at a systemic level, rather than working in individual organisational siloes. This partnership working has enabled us to implement an integrated mental health service model. We have moved away from a model entirely focused on specialist treatment, to a population communitybased model focusing on care and support. Treatment is, of course, provided by secondary care for those who will benefit from it.
I’ve also been working hard to get my seniors in the system to recognise that mental health investment (both in terms of financial investment and outcomes for patients) needs a longer-term horizon. Our initiatives do not always yield immediate benefits and improved outcomes overnight; they can be a long haul.
What do you enjoy most about your work?
I enjoy it all! I enjoy making a difference, corny as that might sound. It’s really rewarding to see the results of the transformation, to be able to secure funding, and of course, to witness the difference it makes for patients.
I also really enjoy seeing the changes in people’s behaviour. In our mental health trust, there has been a real change in philosophy from a transactional approach, to one in which mental health services look after the mental health needs of a population, much like we do as GPs. There has also been a culture change in terms of integrated working. Colleagues really seem to value the experience of working within an integrated care model, which includes GPs, physical health staff, the third sector, peer support workers and recovery coaches. I find that really rewarding.
How can we continue to work towards the goal of parity of esteem between mental and physical healthcare?
I believe there are three areas that we need to focus on in terms of parity: access, resources and outcomes. My work around improving access is currently focused on shifting resources into the community and primary care. This will allow staff to manage the mental health needs of the whole population, rather than patients having to go into a separate secondary care system. Early intervention and prevention are a key part of this work. In terms of resources, there is a big disparity. At least 25 per cent of the patients we see in primary care present with mental health issues, but on average only 11–13 per cent of Clinical Commissioning Group healthcare budgets are spent on mental health. The annual economic cost of mental ill health is estimated to be £105 billion, so it is clear that there is a financial case for shifting resources into mental health.
Finally, we need to ensure equal outcomes for patients with mental health problems. It is not acceptable that patients with serious mental illness die 15–20 years earlier than those in good mental health.
What more do you think needs to be done to integrate mental healthcare into primary care?
The biggest thing that I think is needed is policy change to support investment in primary care mental health. The UK Government has ignored primary care and community mental health in the Five Year Forward View – although the Long Term Plan does focus on some aspects of community mental health. We need policies that support primary care mental health and, up until now, they simply haven’t existed. Policy would bring with it levers – financial, political and contractual – which would enable the shifting of resources into primary care mental health service provision.
There also needs to be a change in culture and behaviour. I believe that integrating specialist mental health provision into primary care teams and commissioning place-based population level care are required to achieve the necessary change. This needs to be accompanied by mental health training and awareness for all primary care staff. Some of that will be learning ‘on the job’, such as case discussions, while some might be more formal; for example, workshops and e-learning. This training needs to be made available to all staff, from receptionists, to nurses and doctors of all ages, as well as to medical students.
Finally, there needs to be greater investment in technology. There are some great electronic interventions, but to date, these have not been on the priority list for funding. Greater digital capacity would help integrate mental health into primary care and improve the efficiency of the mental healthcare pathway.
What do you see as the challenges for mental healthcare provision in the coming years?
For me, core mental health is the big one, meaning in particular community mental health services (provided by Community Mental Health Teams – CMHTs) and inpatient provision. These services, which focus on the most vulnerable patients with serious mental health needs, were not included in the Five Year Forward View for Mental Health. Money is being taken out of core services to fund the new initiatives, which is not acceptable and disadvantages the sickest patients. For example, IAPT has completely taken the focus off secondary care psychology. I think we need an ‘IAPT plus’ type service that offers psychological therapies for those with more complex needs, such as patients under CMHTs.
We also need to do some work around demand because frequent users of mental health services risk overwhelming the system and do not always receive the help they need. Related to this, I think we really need a national personality disorder strategy to tackle the issue of complex trauma; these patients currently often require a great deal of resources, which reduces the overall capacity of mental health services for patients with other mental health conditions. We need to really get to grips with evidence-based interventions in this area, and identify the best pathways for patients.
Finally, when times are tight, mental health ends up fighting with the physical health agenda for resources; we need to stop doing that. We need to seek much greater alignment and integration between the two; this will help us to achieve true parity of esteem.
Dr Emma Tiffin is a practising GP in Central Peterborough, and Cambridgeshire and Peterborough STP Clinical Mental Health Lead. She has worked in mental health clinical leadership roles for over 15 years. Emma is currently a national advisor for the NICE programme of work developing a national community mental health pathway. Emma has a weekly radio show, ‘Health Matters’, on BBC Radio Cambridgeshire.
This column showcases the work of our members and others working in NHS and NHS-funded mental healthcare services. If you would like to be featured in this column or can recommend someone else whose work warrants greater exposure, please contact hcpj.editorial@bacp.co.uk