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References and Abstracts
Objectives: To collect information on current working arrangements between general practitioners (GPs) and mental health professionals and to assess GPs attitudes towards developing closer working practices with psychiatrists in the primary care setting. Method: Six hundred and three GPs from South Australia were surveyed with questionnaires. Main outcome measures included information about existing primary care links between GPs and mental health professionals, GPs preferred working arrangements with psychiatrists in the primary care setting and their attitude towards developing these practices, including perceived obstacles, advantages and disadvantages. Results: One hundred and eighty-one completed questionnaires were returned. One in 11 GPs returning the questionnaire (RGPs) had established primary care links with a psychiatrist, 1 in 6 with clinical psychologists and 1 in 17 with psychiatric nurses and social workers. RGPs held positive attitudes towards developing closer links at their work settings with psychiatrists when it leads to improved collaboration and access to psychiatrists. Reservations were expressed about the public weakening of the GPs primary care role. Conclusions: The joint needs of clinical care and GPs further training in psychiatry could be addressed by further development of schemes to attract psychiatrists to work in primary care settings. This is mostly viewed very positively by GPs, although the percentage of GPs responding make these conclusions tentative. It is more likely to occur with changes to current funding of both private psychiatric care and GP remuneration, with a recognition of time spent in liaison.
Bindman J, Johnson S, Wright S, and others Integration between primary and secondary services in the care of the severely mentally ill: patients and general practitioners views Br J Psychiatry 1997;171:169-74.
Background: Communication between secondary and primary care is an important aspect of continuity of care. We investigated communication between general practitioners (GPs) and psychiatric teams about a representative group of patients with severe mental illness (SMI). We also sought views on GP involvement in care from the patients and their GPs. Methods: One hundred patients with SMI were randomly selected from those under the care of two psychiatric sector teams in inner London. The patients and their GPs were interviewed. Results: GPs knowledge about the care their patients received was limited. Most GPs perceived their role as providing physical care and prescribing. Few patients consulted GPs for mental health care. GPs perceived themselves as less involved in the care of Black Caribbean or Black African patients. Conclusions: Considerable discontinuities of care between secondary and primary care were identified. GP involvement in the care of patients with SMI appears limited. Better communication is necessary if care is to be shared.
Blaney D, Pullen I. Communication between psychiatrists and general practitioners: what style of letters do psychiatrists prefer? J R Coll Gen Pract 1989;39(319):67.
This study investigated the style of referral letter that psychiatrists would like to receive from general practitioners. Ninety psychiatrists in Edinburgh were asked to answer a brief questionnaire about their preferences and select one of six sample letters presented to them. The most popular letter was one page in length and contained two or three headings.
Brown LM, Tower JE. Psychiatrists in primary care: would general practitioners welcome them? Br J Gen Pract 1990;40(338):369-71.
During the spring of 1988 a postal questionnaire was sent to all general practitioners in one health district, enquiring about their present links with psychiatrists and asking for their views on the desirability of psychiatrists visiting their surgeries regularly. At present only a minority of general practitioners have a regular link of this kind but a substantial majority would welcome such an arrangement. The type of link most commonly desired is one in which the general practitioner shares actively in the assessment and treatment of the patient. A degree of ambivalence about the role of other mental health professionals was detected.
Cornwall PL. Communication between general practitioners and child psychiatrists BMJ 1993;306(6879):692-3.
Coulter A, Noone A, Goldacre M. General practitioners referrals to specialist outpatient clinics. I. Why general practitioners refer patients to specialist outpatient clinics. BMJ 1989;299(6694):304-6.
There has been much concern about the wide variations in general practitioners referral rates and the consequent implications for cost and quality of care. This has led to a call to evaluate the appropriateness and effectiveness of referrals. A collaborative audit of referrals to outpatient clinics was conducted by 127 general practitioners in 33 practices in the Oxford region. Records were kept of 18,754 referrals, which included data on diagnoses and reasons for referral. Overall, 6553 (35.4%) of the referrals were for particular treatments or operations and a further 6475 (34.9%) were for specific investigation or diagnosis. Advice on management was the main reason for referral in 2656 (14.3%) cases, and in 1719 (9.3%) cases the general practitioners wanted the consultants to take over managing their patients. Reassurance of either the general practitioner or the patient was recorded as the main reason in only 762 (4.1%) referrals. There seems to be scope for rationalising the referral process. A programme with three stages for evaluating referrals to outpatient clinics is recommended.
Craven MA, Cohen M, Campbell D, Kates N, Williams JI. Mental health practices of Ontario family physicians: a study using qualitative Methodology. North York, Ontario: Institute for Clinical Evaluative Sciences in Ontario, 1996.
Craven MA, Goodman S. Summary of the Family Medicine/Psychiatry Focus Group Project. Report of a supplementary project of the Hamilton-Wentworth District Health Council. Hamilton Ontario, March 1993.
Falloon IR, Ng B, Bensemann C, Kydd RR. The role of general practitioners in mental health care: a survey of needs and problems. N Z Med J 1996;109(1015):34-6.
Objective: To assess the attitudes of general practitioners to central Auckland mental health service provision, and their perceived role and educational needs for clinical management of patients with mental disorders. Method: A postal questionnaire survey of all general practitioners within the Auckland Healthcare (Central Auckland CHE) area. Results: 140 (49%) valid responses were returned from 287 sampled. 94% supported a shared care role with mental health services; 57% considered their role as main case manager to be important. 79% of the general practitioners considered they had insufficient time to manage patients with mental disorders. 69% of respondents reported difficulties receiving information about changes to treatment; 65% were unsure whether patients had a case manager, and 64% reported general difficulties with liaison with the mental health services. Education about a range of mental health issues was sought by three quarters of the group. Conclusion: This survey suggested that liaison between general practice and specialist mental health services in central Auckland is poor, but that general practitioners are eager to seek ways to improve the care of people suffering mental disorders.
Goldberg D, Mann A, Pilgrim D, and others. Developing a strategy for a primary care focus for the mental health services. London, England. Institute of Psychiatry and the Department of General Practice UMDS. 1993.
Kendrick T, Sibbald B, Burns T, Freeling P. Role of general practitioners in care of long-term mentally ill patients BMJ 1991;302(6775):50810.
Objective: To assess general practitioners involvement with long-term mentally ill patients and attitudes towards their care. Design: Postal questionnaire survey. Setting: General practices in South West Thames region. Subjects: 507 general practitioners, 369 (73%) of whom returned the questionnaire. Main Outcome Measures: The number of adult long-term mentally ill patients whom general practitioners estimate they have on their lists and general practitioners willingness to take responsibility for them. Results: 110 respondents had noticed an effect of the discharge of adult long-term mentally ill patients on their practices. Most (225) respondents estimated that they had 10 or fewer such patients each on their lists. Having higher numbers was significantly associated with practising in Greater London or within three miles of a large mental hospital and having contact with a psychiatrist visiting the practice. 333 general practitioners would agree to share the care of long-term mentally ill patients with the psychiatrist by taking responsibility for the patients physical problems. Only 59 would agree to act as a key worker, 308 preferring the community psychiatric nurse to do it. Only nine had specific practice policies for looking after long-term mentally ill patients and 287 agreed that such patients often come to their general practitioners attention only when there is a crisis. Conclusions: The uneven distribution of long-term mentally ill patients suggests that community pyschiatric resources might be better targeted at those practices with higher numbers of such patients. Most general practitioners seem to be receptive to a shared care plan when the consultant takes responsibility for monitoring psychiatric health with the community nurse as key worker. The lack of practice policies for reviewing the care of long-term mentally ill patients must limit general practitioners ability to prevent crises developing in their care.
Kendrick T, Burns T, Freeling P. Randomised controlled trial of teaching general practitioners to carry out structured assessments of their long-term mentally ill patients. BMJ 1995;311(6997):93-8.
Objective: To assess the impact of teaching general practitioners to carry out structured assessments of their long-term mentally ill patients. Design: Randomised controlled trial. Setting: Sixteen group general practices in South Thames (west) region. Subjects: 440 adults disabled by long-term mental illness. Interventions: Patients were identified by using practice data with help from local psychiatric and social services. In eight practices the practitioners were taught a structured assessment schedule to use with patients every six months for two years. Main Outcome Measures: Changes in drug treatments, referrals, consultation rates, and recording of preventive health data in the two years after intervention. Results: Follow up data were available on 373 patients (84.7%). At least one structured assessment was recorded for 127 patients in the intervention group but only 29 had four assessments recorded. Participating practitioners considered the structured assessment to be time consuming and reported that it did not often lead directly to changes in treatment or referrals. Changes in treatment with neuroleptic drugs and referrals to community psychiatric nurses, however, were significantly more frequent in the intervention group (differences for intervention group minus control group adjusted for activity in two years before intervention were 14.3% (95% confidence interval 4.3% to 24.33%; P < 0.01) for neuroleptic drugs and 13.3% (2.0% to 24.6%; P < 0.05) for referrals). There were no significant differences in psychiatric admissions, use of the Mental Health Act, drug overdoses, prescriptions, referrals or admissions for physical problems, consultation rates, continuity of care, or recording of preventive data. Conclusions: Teaching general practitioners about the problems of long-term mentally ill patients may increase their involvement in patients psychiatric care. Regular structured assessments do not seem feasible in routine surgery appointments. More training for general practitioners and increased resources such as more nurse time may be necessary if improvements in care of long-term mentally ill patients in general practice are to be generalized.
Kentish R, Jenkins P, Lask B. Study of written communication between general practitioners and departments of child psychiatry. J R Coll Gen Pract 1987;37(297):162-3.
King M, Nazareth I. Community care of patients with schizophrenia: the role of the primary health care team. Br J Gen Pract 1996;46(405):231-7.
Schizophrenia is a severe, chronic mental disorder that usually begins in early adulthood. Recurrent relapse leading to long-term psychological and social disability means that patients may require intensive community support. Despite a recent fall in the overall numbers of patients consulting their general practitioner with mental disorders, presentations by those suffering from severe mental disorders have risen. This review encompasses the role of general practitioner in the management of schizophrenia, considering in turn drug and psychological therapies, family interventions, innovations in care, the effects of community care developments, and the liaison between primary health care and mental health professionals. There is a need for further research in the area of family-practice-based interventions involving general practitioners and the practice team.
Lang FH, Johnstone EC, Murray GD. Service provision for people with schizophrenia. II. Role of the general practitioner Br J Psychiatry 1997; 171:165-8.
Background: This second report of a study of service provision for patients with schizophrenia describes patients contact with general practice and general practitioners (GPs) views of the mental health services. Method: A postal questionnaire was sent to the GPs, and patients primary care records were examined. Results: Data were collected on 131 subjects. The majority of patients (96) (73%) were in regular contact with their GP and were consulting for many different reasons; 27 (21%) were posing particular difficulties for the primary care team. GPs reported that 27 (21%) patients required additional support and that the care arrangements for 50 (38%) patients could be improved if alterations were made to the roles of the professionals already involved. Conclusions: GPs are central to service provision for patients with schizophrenia. Both additional resources and changes in working practices are required to improve patient care. The service implications of these findings are discussed.
Lesage AD, Goering P, Lin E. Family physicians and the mental health system. Report from the Mental Health Supplement to the Ontario Health Survey. Can Fam Physician 1997;43:251-6.
Objective: To determine family physicians role in the mental health care system. Design: The Mental Health Supplement to the Ontario Health Survey is an epidemiologic, retrospective, home-interview survey. Results reported here are based on responses of a weighted sample of patients aged 15 to 64. Setting: Ontario, 1990 to 1991. Participants: Random sample of 9953 household residents. Main Outcome Measures: Standardized assessment of mental disorders, associated risk factors and disability, and patterns of use of mental health services. Results: More people seek mental health services from their family physicians (FPs) than from psychiatrists, social workers, or psychologists. Among patients who consulted for mental health purposes, more than 35.4% saw FPs only, 24.7% saw FPs and other mental health care providers (psychiatrists, psychologists, social workers, others), and 40% saw other mental health care providers only. There were few sociodemographic, diagnostic, or clinical severity differences between the FP-only group and the other two groups. Some evidence suggested FPs saw more recent onset cases, but they were also involved in joint care for more complex or disabled cases. More than 57% of those seeing FPs received medication; 43% received other forms of care. Those seeing FPs only made four visits yearly; those who consulted other mental health professionals made 14 to 20. Conclusions: Our study confirms FPs important role in the current mental health care system.
Lipkin M. Pulling together or falling apart. Primary Psychiatry 1997(January):22-31.
Maguire N, Cullen C, OSullivan M, OGrady-Walshe A. What do Dublin GPs expect from a psychiatric referral? Ir Med J 1995;88(6):215-6.
The advent of community psychiatry has tended to blur the interface between primary and secondary psychiatric care. We used a postal questionnaire to investigate each new referral from general practice to the public outpatient clinics of three West Dublin Psychiatric Sectors. 70 referrals, from 35 general practitioners, over a four month period in 1991 were analysed, regarding reason for referral and prior management in general practice. On average patients had seen their GP six times over a period of ten months. Mixed anxiety/depression was the most common diagnosis (23%). Medication had been prescribed for 61% of patients and 67% had counselling before referral. Common reasons for referral were: Access to therapies not available directly to the GP (30%); Failure of treatment (20%); To share the burden of chronic care (14%). In only 13% of referrals did the GP wish the psychiatrist to take over care. We conclude that the GPs surveyed undertake extensive pre-referral management of patients with psychological illness. They have well defined expectations of referral and are keen to follow up patients themselves. Future plans for community psychiatric services should take account of this pattern of care.
Maoz B. Psychiatry and primary medicine. Isr J Psychiatry Relat Sci 1992;29(4):245-50.
Psychiatry and primary medicine are related to one another for theoretical and practical reasons. The development of this relationship in Israel in recent years is described. Many patients with mental problems are seen by the primary physician only. The most serious cases are usually detected and referred. The main problem is that people with modest mental disturbances are often neither detected nor referred and treated. The development of various forms of communication between psychiatry and primary medicine, such as consultation-liaison programs, Balint groups and other methods of training, are described and discussed.
Maoz B, Stern J. Psychiatry and primary care practice in Israel and other countries. Israel J of Psychiatry Relat Sci 1985;22(4):233-244.
As managed care achieves greater penetration in the marketplace, increasing attention is being devoted to models of integration and coordination of behavioral health with general medical care. In considering strategies and models, attention must be given to the heterogeneity of patient populations and the fact that successful approaches with some patient populations may not be suitable for others. Six approaches are reviewed: mainstreaming, the liaison psychiatry/collaboration model, new practitioner models, independent carveouts, functionally integrated carveouts, and extended care models. Each offers potentials and limitations, but little outcome data are available. Managed care models are diverse and changing rapidly. Much depends on the commitments of managers and professionals to the collaborative process and the extent to which incentives are consistent with clinical goals. Despite the uncertain and changing environment, it is clear that primary care physicians will remain significant providers of mental health services if for no other reason than many patients will resist referral to specialty mental health providers.
Mechanic D. Integrating mental health into a general health care system. Hosp Community Psychiatry 1994;45(9):893-7.
To implement the proposed Clinton mental health benefit for the year 2001 requires a capacity to manage a flexible, comprehensive benefit. If fragmentation of services and discontinuity of care are to be reduced, mechanisms must be developed to coordinate services among domainsbetween acute and chronic care, and among public and private providers. Evidence exists that basic mental health services generally can be managed in health maintenance organizations (HMOs) with considerable cost savings and without detrimental effects on health, but it is less clear whether this is true of services for persons with severe and persistent mental illness. Effective services for persons with severe disorders require a capacity to organize and manage services across broad medical and social areas, but anticipated costs encourage providers to narrow the scope of care they offer and to select low-risk patients. Much will depend on developing Methodologies that allow providers to be reimbursed accurately in relation to risk and that protect small providers from the potential cost of acquiring too many high-risk patients.
Morgan D. Psychiatric cases: an ethnography of the referral process. Psychol Med 1989;19(3):743-53.
Investigation into the referral histories of a consecutive series of new patients attending two psychiatric out-patient clinics questioned the assumption that only the more severe and problematic cases are selected by general practitioners for specialist referral. In 40% of cases, clinical indications only became decisive in relation to emergent difficulties in managing the case, while 38% of patients or their relatives requested referral. The implications of these observations are considered in relation to alternative models of psychiatric intervention in the management of psychosocial disorders in primary care.
Naik PC, Lee AS. Communication between GPs and psychiatrists. BMJ 1993;306(6884):1070.
Nazareth ID, King MB. Controlled evaluation of management of schizophrenia in one general practice: a pilot study. Fam Pract 1992; 9:171-2.
The study reports on a controlled evaluation of services offered to patients with a diagnosis of schizophrenia in comparison to diabetic patients and matched attenders with no chronic illness. Data were collected from one inner city London group practice, by a retrospective analysis of patients notes over a period of 6 years. Although patients with schizophrenia attended significantly more often than other patients, clinical assessments in the surgery were rarely undertaken. Communications with hospital consultant services were rare for both chronic groups of patients but in the case of those with schizophrenia the doctor received on average only one letter every 2 years. The findings support other recommendations for a more structured approach to the care of schizophrenia in general practice with regular attention to mental state assessment and monitoring of drug treatment.
Nazareth I, King M, Davies S. Care of schizophrenia in general practice: the general practitioner and the patient. Br J Gen Pract 1995;45(396):343-7.
Background: The transfer of patients with chronic schizophrenia from large mental hospitals into the community has had an impact on the role of the general practitioner in the effective delivery of primary care services to these patients. Aim: A study was undertaken to assess the care available in general practice for patients with schizophrenia, the attitudes of general practitioners and patients to the care provided and the factors influencing patients use of services. Method: Eighty three patients with a diagnosis of schizophrenia and 26 doctors in 13 London practices registered on the VAMP research bank took part in a series of structured and semi-structured interviews. This was followed by a systematic examination of the patients case notes. Results: Only 14 patients (17%) had no active symptoms according to the present state examination interview and 52 (63%) were currently taking antipsychotic medication. Fifty three patients were in contact with a psychiatrist. Approximately one quarter of patients were visited by a community psychiatric nurse; in 18 of these 19 cases, the main reason for contact was reported to be for administration of medication by depot injection. In all but one case, patients seeing a community psychiatric nurse were also being seen by a psychiatrist. Sixteen doctors reported having had a consultation in the previous month with a patients relative, friend or member of hostel staff. There were considerable differences between patients and their doctors in their attitudes to the use of services. Of the 26 general practitioners, 23 were enthusiastic about the possibility of introducing shared care records. Of the 54 patients in contact with a mental health professional, only 18 favoured the use of shared care records. Most of the doctors (19, 73%) reported they would welcome a psychiatric liaison service in their practice; 40% of 53 patients said they would not. Patients receiving antipsychotic drugs and patients registered with inner city practices attended their general practitioners more frequently than those not taking antipsychotic medication and those registered with suburban practices. Use of antipsychotic medication (adjusted odds ratio (OR) 8.2, 95% confidence interval (CI) 2.2 to 30.7, P < 0.01), male sex (OR 5.8, 95%CI, 1.5 to 22.1, P < 0.01) and active symptoms on the present state examination (OR 4.1, 95%CI, 1.0 to 17.5, P = 0.06) were all predictive of current contact with mental health professionals. Conclusion: Family doctors were closely involved with the care of patients with schizophrenia and their relatives and were eager for increased liaison with secondary care services. Although patients were more resistant than doctors to management innovations this may reflect lack of familiarity with changes in community services. Greater input is needed by mental health professionals, particularly community psychiatric nurses, and some consideration of the burden of care in inner city practices is necessary in health service planning.
Orleans CT, George LK, Houpt JL, Brodie HK. How primary care physicians treat psychiatric disorders: a national survey of family practitioners. Am J Psychiatry 1985;142(1):52-7.
A survey of 350 family practice physicians nationwide showed that 22.6% of their patients had significant psychiatric disorders. Physicians reported treating most psychiatric problems themselves, usually through a combination of psychotropic drugs, advice, and reassurance. The results suggest that anxiolytics are more conservatively used and referrals for mental health care more often made than past studies indicate. Physicians cited patient resistance and time limitations as the most important barriers to primary care mental health treatment, followed by limited third-party payment for mental health services, poor coordination between the primary care and mental health care sectors, and insufficient training to treat psychiatric disorders.
Parker G, Wright M, Robertson S, Sengoz A. To whom do you refer? A referrer satisfaction study. Aust N Z J Psychiatry 1996;30(3):337-42.
Objective: To report the development of a referrer satisfaction measure. Method: Urban and rural general practitioners, physicians, neurologists, as well as obstetricians and gynaecologists rated 36 items in terms of their judged importance to the respondents satisfaction with a psychiatric service. Responses of the whole sample and component practitioner sub-groups were ranked. Results: We established a high level of agreement across the several subgroups suggesting that we had identified general rather than idiosyncratic variables contributing to referrer satisfaction. Referrers prioritized as most important the immediacy of initial appointment, the psychiatrist reporting at the beginning and end of any treatment course, and ready verbal communication between the referrer and the psychiatrist. Items accorded low priority were the psychiatrists billing arrangements, the psychiatrist being perfect (in either having a high cure rate or making a definitive diagnosis initially), or the psychiatrist taking complete responsibility for difficult patients. A principal components analysis identified four factors underpinning the item set, and we again established that scores on these factors were not influenced by the particular referrer sub-group. Conclusions: Such findings suggest that only minor modifications would need to be made to the item set in developing a referrer satisfaction measure for quality assurance activities.
Poynton A, Higgins P. Role of general practitioners in care of long-term mentally ill patients. Br J Psychiatry 1991;159:703-6.
Objective: To assess general practitioners involvement with long-term mentally ill patients and attitudes towards their care. Design: Postal questionnaire survey. Setting: General practices in South West Thames region. Subjects: 507 general practitioners, 369 (73%) of whom returned the questionnaire. Main Outcome Measures: The number of adult long-term mentally ill patients whom general practitioners estimate they have on their lists and general practitioners willingness to take responsibility for them. Results: 110 respondents had noticed an effect of the discharge of adult long-term mentally ill patients on their practices. Most (225) respondents estimated that they had 10 or fewer such patients each on their lists. Having higher numbers was significantly associated with practising in Greater London or within three miles of a large mental hospital and having contact with a psychiatrist visiting the practice. 333 general practitioners would agree to share the care of long-term mentally ill patients with the psychiatrist by taking responsibility for the patients physical problems. Only 59 would agree to act as a key worker, 308 preferring the community psychiatric nurse to do it. Only nine had specific practice policies for looking after long-term mentally ill patients and 287 agreed that such patients often come to their general practitioners attention only when there is a crisis. Conclusions: The uneven distribution of long-term mentally ill patients suggests that community psychiatric resources might be better targeted at those practices with higher numbers of such patients. Most general practitioners seem to be receptive to a shared care plan where the consultant takes responsibility for monitoring psychiatric health with the community nurse as key worker. The lack of practice policies for reviewing the care of long-term mentally ill patients must limit general practitioners ability to prevent crises developing in their care.
Pullen IM, Yellowless AJ. Is communication improving between general practitioners and psychiatrists? Br Med J (Clin Res Ed) 1985;290(6461):31-3.
General practitioners and psychiatrists communicate mainly by letter. To ascertain the most important items of information that should be included in these letters (key items) questionnaires were sent to 80 general practitioners and 80 psychiatrists. A total of 120 referral letters sent to psychiatric clinics in 1973 and 1983 were studied, together with the psychiatrists replies, and these were rated for the inclusion of key items. General practitioners letters contain less information about the family but more about psychiatric history than they did a decade ago. Overall, psychiatrists letters have not changed. Registrars, however, now include noticeably more key items than they did 10 years ago, but their letters remain twice the length of those written by consultants. It is suggested that letter writing skills are vital to good patient management and should be taught to postgraduate trainees in general practice and psychiatry.
Shepherd M. Primary care psychiatry: the case for action. Br J Gen Pract 1991; 41:252-5.
Since the introduction of the National Health Service a number of epidemiological enquiries have established the importance of mental disorders in the field of primary care. Examples are provided from the work of the General Practice Research Unit at the Institute of Psychiatry in London. The results furnish a rational basis for collaborative action between research workers, general practitioners and policy makers.
Stansfeld SA, Leek CA, Travers W, Turner T. Attitudes to community psychiatry among urban and rural general practitioners. Br J Gen Pract 1992;42(361):322-5.
General practitioners requirements for community psychiatric services may differ according to the area in which they practise. A questionnaire survey of general practitioners attitudes to community psychiatric services is reported from three contrasting areas: an inner city urban area, a new town and a rural area. General practitioners in all areas wanted more consultation with psychiatrists, and 53-68% wanted regular psychiatric outpatient clinics in their surgeries. There was enthusiasm for community psychiatric nurses and for help with psychotherapy. In the rural area general practitioners favoured surgery based psychiatric outpatient clinics and arranging emergency hospital admissions themselves; in urban areas domiciliary visits from psychiatrists to help with emergencies were favoured. These results appear to reflect the greater geographical distance between primary and hospital based secondary care in rural as opposed to urban areas. Overall, general practitioners wanted more support from community psychiatric services in carrying out their primary therapeutic role especially in rural areas far from hospital-based psychiatric services.
Three models of interaction between primary care and psychiatry in the British National Health Service are presented. Although the first two are traditional and well recognized, the third, the liaison-attachment model, is an innovation of the last decade. Two studies are described that outline the extent and nature of this form of working collaboration between specialists and generalists. Clinical, service, and educational implications are discussed in the context of the British primary care structure.
Strathdee G. Psychiatrists in primary care: the general practitioner viewpoint. Fam Pract 1988;5(2):111-5.
Within the past few decades, a growing number of psychiatrists in the UK have moved their outpatient clinics out of their hospital bases and have established liaison-attachment clinics in primary care settings within their catchment areas. This study reports the views of the senior general practitioners who have access to such clinics in their practices. The majority described a significant alteration in the nature of their relationships with the specialists. This, together with the opportunity for general practitioners to become involved in integrated management approaches, is believed to significantly improve continuity of patient care.
Tanielian TL, Pincus HA, Dietrich AJ, and others. Referrals to psychiatrists. Assessing the communication interface between psychiatry and primary care. Psychosomatics 2000;41(3):245-52.
The Study of Outpatient Referral Patterns was conducted in 1998 to examine the nature of the communication relationship between psychiatrists and primary care physicians regarding outpatient referrals. Nationally representative psychiatrists were surveyed (N = 542) regarding their aggregate experience with outpatient referrals from non-psychiatric physicians in the previous 60 days. Data regarding frequency and type of information and mode of communication were gathered. Results indicate that primary care physicians represent a significant source of referrals to psychiatrists and that psychiatrists are generally satisfied with the communication interface with the referring physicians. Psychiatrists level of satisfaction was related to the quantity and quality of information provided by referring physicians.
Tobin M, Norris G. Mental health and general practice: improving linkages using a total quality management approach. Aust Health Rev 1998;21(2):100-10.
This paper reports on a project to implement total quality management strategies to improve the linkages between general practitioners and specialist mental health services. The project implemented a process of change and Objectively assessed the success of the process. The project involved all mental health staff (n = 100) in the St George Division of Psychiatry and Mental Health. General practitioners registered with the St George Division of General Practice were invited to participate in the change process. The project showed that the attempts to engage general practitioners in the ongoing care of patients with chronic mental illness is unlikely to be successful until mental health services promote general practitioner linkages as an ongoing service goal, relevant at all levels of delivery.
Toews J, Lockyer J, Addington D, and others. Improving the management of patients with schizophrenia in primary care: assessing learning needs as a first step. Can J Psychiatry 1996; 41:617-22.
Objective: To assess family physician learning needs related to the care of patients with schizophrenia. Methods: Questionnaires were mailed to all family physicians and general practitioners practising in southern Alberta. Physicians were asked to indicate the number of patients with schizophrenia cared for, their interest in improving the care they provided, their preferred learning methods, and the content they wished to learn. Results: A total of 539 surveys were returned for a return rate of 43.8%. Over half of the physicians (53.5%) indicated that they saw 1 to 2 patients with schizophrenia each month. Almost half (48.5%) indicated they were somewhat or very interested in increasing the care provided. Primary learning needs included increasing their knowledge of psychopharmacologic agents and monitoring and adjusting medications. Lectures and half-day workshops were the preferred learning methods. Conclusion: Our study was helpful in identifying the types of education that physicians wanted as well as the duration of the programming prior to the development of teaching interventions.
Watters L, Gannon M, Murphy D. Attitudes of general practitioners to the psychiatric services. Irish J of Psychological Medicine 1994; 11:44 - 46.
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