Rapid Responses to:

GENERAL PRACTICE: Peter Bower and Bonnie Sibbald Systematic review of the effect of on-site mental health professionals on the clinical behaviour of general practitioners BMJ 2000; 320: 614-617 [Abstract] [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

On-site Mental Health Practitioners; Their Influence on the clinical Behaviour of GP's

P A Pennington-Smith, D Miller   (17 March 2000)

Issues that need to be studied

D Venugopal   (24 March 2000)

Mental Health Workers in primary care - just how effective are they?

Mark Ashworth   (17 April 2000)

On-site Mental Health Practitioners; Their Influence on the clinical Behaviour of GP's 17 March 2000
P A Pennington-Smith, RMN & RMN Windsor Medical Services, Liverpool, D Miller Send response to journal: Re: On-site Mental Health Practitioners; Their Influence on the clinical Behaviour of GP's	It is widely accepted that GPs are 'time limited' those who are not fortunate enough to have direct access to Mental Health workers, remain constrained to writing a prescription, with a follow-up referral when required. General practitioners have traditionally been viewed as the 'gate keepers' of the NHS. With the introduction of walk-in practices time limitations almost inevitably will rise in proportionately to public expectations. (Fuelled by government hype.) Positivist ideology dictates that not only should patients have direct access to Mental Health Practitioners (via GPs or otherwise) but also that Mental Health practitioners should be actively involved in service commissioning and development through their inclusion on primary care group boards and clinical governance committees. Ultimately the issue is one of improved collaborative working and increased interdisciplinary knowledge. This requires openness on behalf of all concerned parties and greater integration of ab initio training for professionals.
Issues that need to be studied 24 March 2000
D Venugopal Send response to journal: Re: Issues that need to be studied	Dear Sir - Brown and Sibbald's review of the effect of on-site Mental Health Professionals on the clinical behaviour of General Practitioners suggests implications for planning mental health care delivery in primary care settings. Presence of an on-site mental health professional was associated with reductions in psychotropic drug prescriptions and also specialist referrals at least in the short term, with possible economic implications. The practical applicability of this organizational design (of having an on-site mental health professional) would however, also need to address the following few issues: 1. What is the effect of this organizational design upon the illness status and Quality of Life of patients? 2. Would the economic benefits of having an on-site mental health professional persist in the long term? 3. Because Mental Health Professionals are a heterogenous group, are there any between group differences in their economic impact and patient care. 4. To what extent can it be generalised that on-site mental health professionals can be an alternative to psychotropics drugs and specialist referrals? These issues need to be studied rigorously in a controlled manner to ascertain the logistics of having on-site mental health professionals (and specifically which one, at that) in primary care settings.This would have tremendous implications if found to be cost-effective along the above questions raised. D.Venugopal.
Mental Health Workers in primary care - just how effective are they? 17 April 2000
Mark Ashworth, Research Fellow GKT Department of General Practice, Kings College London, 5 Lambeth Walk, London SE11 6SP. Send response to journal: Re: Mental Health Workers in primary care - just how effective are they?	Editor - The systematic review of on-site mental health professionals 1 was a welcome and long overdue addition to the literature on the effectiveness of the talking therapies in primary care. Rather than focussing upon benefit to patients, the review chose to concentrate on health service related outcomes. One of these outcomes was referrals to secondary care. Six randomised controlled trials (RCTs) were identified by the review of which three showed significant reductions in referrals while a further two showed reductions though the original reports did not record whether these were significant. Although some of the limitations of the studies were discussed in the review, all six RCTs were flawed in terms of generalisability to everyday primary care. One RCT 2 was described as showing a significant reduction in referrals when the stated p was 0.56, which is not significant. Furthermore, the therapy offered was from a primary care based psychiatrist rather than the more usual British model using a counsellor or psychologist. Just 47 patients were recruited to this RCT but lasting seven months, it was the longest of the three ‘positive’ RCTs. The other two RCTs reported as showing significantly reduced referrals 3,4 only did so because those receiving usual general practitioner care had a referral rate to secondary care of over 50%. This was an unusually high proportion 5 which had the effect of placing counselling in an unduly favourable light. The duration of the RCTs also poses a problem in terms of generalisability of the findings. The three positive RCTs lasted just 6 weeks 3, 4 months 4, and 7 months 2. The shorter the duration, the more likely it is that any effect observed on reducing referrals may simply be deferment of referral rather that satisfactory treatment on-site. Trials of at least one year are probably needed. Just one of the RCTs in the review covered a one year period 6 but that failed to show a difference between intervention and treatment as usual groups. In this study, the intervention was by a social worker and only depressed females were included - both factors making it difficult to generalise the results to routine primary care. The review also identified six non-randomised controlled studies reporting the effect upon referrals. These six are well summarised in table E on the website acompanying the article. They are much longer duration studies than the RCTs being at least one year pre and one year post a mental health worker. However, two are in non-peer reviewed publications 7,8. One involved the intervention of a psychiatrist 9 and the remaining three were either not significant or did not state a p value 10, 11,12. Taken as a whole, the results of the six RCTs and six controlled studies do not seem to justify the headline message of the review that on- site mental health professionals “reduced the likelihood of a patient……being referred to secondary care”. Simply to state that three out of the six RCTs showed significantly reduced referrals may be misleading without more critical comment. Now that primary care has been reorganised into Primary Care Groups (PCGs), information on the effectiveness of on-site mental health professionals would, if it were available, be of great importance in guiding purchasing decisions. Within a PCG, the same unified budget may be used to invest in either more specialist psychiatric services or more practice based mental health workers, either as psychologists or counsellors or both. Health economic analysis is urgently needed to guide these decisions which every PCG now has to take, but this review and the studies it draws on do not offer a strong evidence base for determining policy in this area. Mark Ashworth Research Fellow, GKT Department of General Practice, Kings College London, 5, Lambeth Walk, London SE11 6SP. References: 1. Bower P, Sibbald B. Systematic review of the effect of on-site mental health professionals on the clinical behaviour or general practitioners. BMJ 2000;320:614-7. 2. Catalan J, Gath D, Anastasiades P, Bond A, Day A, Hall L. Evaluation of a brief psychological treatment for emotional disorders in primary care. Psychol Med 1991; 21:1013-8. 3. Boot D, Gillies P, Fenelon J, Reubin R, Wilkins M, Gray P. Evaluation of the short-term impact of counseling in general practice. Patient Educ Couns 1994;24:79-89 4. Hemmings A. Counselling in primary care: a randomised controlled trial. Patient Educ Couns 1997;32:219-30. 5. Harvey I, Nelson S, Lyons RA, Unwin C, Monaghan S, Peters TJ. A randomized controlled trial and economic evaluation of counselling in primary care. Br J Gen Pract 1998;48:1043-8. 6. Corney R. The effectiveness of attached social workers in the management of depressed female patients in general practice. Psychol Med 1984; (monograph suppl. 6):1-47. 7. Baker R, Allen H, Penn W, Daw P, Baker E. The Dorset primary care counselling service research evaluation. Bournemouth: University of Bournemouth, 1996. 8. Coe N, Ibbs A, O'Brien J. The cost effectiveness of introducing counselling into the primary care setting in Somerset. Taunton: Somerset Health Authority, 1996. 9. Hunter D, McCance C. Referrals to the psychiatric services by general practitioners in relation to the introduction of sessions by psychiatrists in health centres. Health Bull 1983;41:78-83. 10. Baker R, Allen H, Gibson S, Newth J, Baker E. Evaluation of a primary care counselling service in Dorset. Br J Gen Pract 1998;48:1049-53. 11. Walker F, McKerracher D, Johnson G. Taking mental health services to the people: the effects of referral to traditional psychiatric facilities. NZ Med J 1989;102:504-6. 12. Tarrier N, Woof K. Psychologists in primary care and their effects on GP referrals to psychiatry. Br J Clin Soc Psychiatry 1983;2:85-7.