Embedding clinical psychology within general practice: Nuts and bolts of collaborative care

Problem

General Practice (GP) has a leading role in the diagnosis and management of people with long-term physical health conditions (LTCs). Physical and mental ill health commonly overlap; nearly half of patients with COPD and diabetes suffer from mental health problems, and models based on psychological wellbeing practitioners may fail to improve physical outcomes or even be harmful to patients. Annual care planning has been introduced to manage LTCs in GP. It is understood as a nurse-led collaborative process that offers the opportunity to engage patients in decisions about their care and support their LTC self-management, acknowledging both psychosocial and physical needs. Despite this, there remains a paucity of vocational mental health training for practice nurses, and practitioners report continued difficulties in addressing emotional distress within their consultation. Missed opportunities for interventions to improve mental health outcomes can lead to further deterioration in quality of life, exacerbate physical illness, and drive up costs of care.

Approach

A feasibility pilot of collaborative care has been set up within two Tower Hamlets GP networks. Two clinical health psychologists (CHPs) work alongside practice staff focusing on COPD, and diabetes respectively. We aim to support patients living with poorest controlled diabetes and COPD using the following components: 1) education and training for GP staff to address potential mental ill health in consultations; 2) direct CHP care including individual assessment, intervention, and group workshops for patients; and 3) connecting relevant services for holistic care.

Findings

Firstly, CHPs introduced the pilot and potential of their role. This involved attending GP and multidisciplinary team meetings, observing care planning sessions, developing close working relationships with specialist and voluntary services, local Mosques, and pre-existing psychology services. A questionnaire was sent to GP staff as a baseline measure of skills and needs surrounding the management of people with LTCs. Patient feedback was also collected. Interim findings suggest that lack of training, perceived lack of time and resources, and patient perception of the role and remit of GP are some of the greatest barriers. The first-hand experience of each CHP thus far has been varied and informative. Patient involvement has revealed a constellation of causes for symptoms of depression and anxiety, requiring a holistic, combined care approach. CHPs are working to develop shared learning between GP and community organisations, as well as increase awareness and use of available services. CHPs apply systemic approaches to understand the complex needs of patients and unlock barriers to service delivery.

Consequences

Effective collaborative care of people with LTC demands an integrated approach going well beyond the symptomatic treatment of anxiety and depression to tackle root causes. A highly skilled psychologist brings the expertise needed for staff training, team building and better integration with relevant services.