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References and Abstracts
Objectives: To establish the extent and nature of specialist outreach clinics in primary care and to describe specialists and general practitioners’ views on outreach clinics. Design: Telephone interviews with hospital managers. Postal questionnaire surveys of specialists and general practitioners. Setting: 50 hospitals in England and Wales. Subjects: 50 hospital managers, all of whom responded. 96 specialists and 88 general practitioners involved in outreach clinics in general practice, of whom 69 (72%) and 46 (52%) respectively completed questionnaires. 122 additional general practitioner fundholders, of whom 72 (59%) completed questionnaires. Main Outcome Measures: Number of specialist outreach clinics; organisation and referral mechanism; waiting times; perceived benefits and problems. Results: 28 of the hospitals had a total of 96 outreach clinics, and 32 fundholders identified a further 61 clinics. These clinics covered psychiatry (43), medical specialties (38), and surgical specialties (76). Patients were seen by the consultant in 96% (107) of clinics and general practitioners attended at only six clinics. 61 outreach clinics had shorter waiting times for first outpatient appointment than hospital clinics. The most commonly reported benefits for patients were ease of access and shorter waiting times. Conclusions: Specialist outreach clinics cover a wide range of specialties and are popular, especially in fundholding practices. These clinics do not seem to have increased the interaction between general practitioners and specialists.
Barber R, Williams AS. Psychiatrists working in primary care: a survey of general practitioners’ attitudes. Aust N Z J Psychiatry 1996;30(2):278-86.
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.
Brown LM, Tower JE. Psychiatrists in primary care: would general practitioners welcome them? Br J Gen Pract 1990; 40:369-71.
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.
Corney RH. Links between mental health care professionals and general practices in England and Wales: the impact of GP fundholding. Br J Gen Pract 1996;46(405):221-4.
Background: Fundholding general practitioners are able to determine the type of contracts they place with providers of mental health care, and are able to employ some categories of mental health care professionals directly. The impact of this on the care of the mental health of patients in non-fundholding practices is not yet fully known. Aim: A survey was undertaken of 100 fundholding general practices and 100 similarly sized non-fundholding practices in order to investigate the changes in mental health provision made by general practitioners. Methods: A sample of 100 fundholding general practices in England and Wales was randomly chosen from the list supplied by the Association of Fundholders and matched to a similarly randomly chosen sample of non-fundholding practices. Postal questionnaires were sent to the senior partner and to the practice manager in each practice. Results: The number of mental health care professionals who are either employed by or attached to general practices, or who visit the general practice on a regular basis appears to have increased substantially since 1991. This increase was particularly marked in fundholding practices. The results suggest that general practitioners with specific links to particular mental health care providers were more satisfied with the service provided by the mental health care team, and more likely to increase referrals to that service in the last 2 years, than general practitioners without such links. There was little evidence to suggest that increasing the number of mental health care professionals in primary care had brought about a major reduction in referrals to psychiatrists. Conclusion: General practitioners, particularly fundholders, are increasing their links with mental health professionals, and community psychiatric nurses, psychiatrists, psychologists and counsellors are spending more time either based in general practice or visiting regularly. While the shift of resources to primary care, particularly to fundholders, may increase the treatment options available to patients with less severe illnesses, this may have the effect of reducing the services available for the long-term and severely mentally ill.
Lambert D, Hartley D. Linking primary care and rural psychiatry: where have we been and where are we going? Psychiatr Serv 1998;49(7):965-7.
Linking primary care with psychiatric care has long been promoted as a way to improve access to rural mental health services. The authors describe a national survey that identified 53 successfully linked programs, ranging from small local efforts to sophisticated multicounty networks. Findings indicated that lessons from successful integrations are not easily reduced to a how-to list. Organizations cooperate with each other when it is in their interests to do so. Motivation to integrate cannot be mandated, nor is the availability of funding alone sufficient to provide motivation. The authors discuss ways that managed care may facilitate or hinder the link between rural primary care and rural psychiatry.
Pullen IM, Yellowlees AJ. Scottish psychiatrists in primary health-care settings. A silent majority. Br J Psychiatry 1988;153:663-6.
There has been a growing number of reports of psychiatrists moving out into primary-care settings. We report a survey of consultant psychiatrists to assess the extent of this practice in Scotland. Some time spent in the primary-care setting was reported by 56%, the figures being highest in rural areas. An equal number of non-consultant medical staff were involved. Most schemes were initiated by psychiatrists, over half of whom had had some postgraduate general-practice experience. A similar survey in England and Wales showed that only 19% of consultant psychiatrists spent time in primary-care settings, a smaller proportion of non-consultant staff being involved. The value of working in primary-care settings has yet to be assessed.
Sibbald B, Addington-Hall J, Brenneman D, Freeling P. Counsellors in English and Welsh general practices: their nature and distribution BMJ 1993; 306:29-33.
Objective:To establish the prevalence of counselling services in English and Welsh general practices and factors associated with their distribution; to describe qualifications, working arrangements, and case mix of “counsellors.” Design: Postal questionnaire and telephone interview survey of a sample of about one in 20 general practitioners in England and Wales. Setting: English and Welsh general practices. Subjects: 1880 general practitioners of whom 1542 (82%) completed questionnaires. Main Outcome Measures: Prevalence and distribution of practice counselling services; counsellors qualifications and funding; types of patients referred. Results: 586 counsellors were distributed among 484 of the 1542 practices. Three types of counsellor predominated: community psychiatric nurses (187); “practice counsellors” (145); and clinical psychologists (95). Practice characteristics which independently predicted the presence of a counsellor were for community psychiatric nurses four or more partners (odds = 1.72, 95% confidence interval 1.18 to 2.26); for practice counsellors stress clinic (odds = 2.22; 1.83 to 2.61), training practice (odds = 1.70; 1.24 to 2.16), and health region (chi 2 = 55.94; df = 14; P < 0.001); and for clinical psychologists list size of or = 10,500 (odds = 1.79; 1.09 to 2.49), training practice (odds = 1.78; 1.31 to 2.25), health region (chi 2 = 48.31; df = 14; P < 0.001). 197 counsellors had training in counselling. The qualifications of 85 were unknown to the general practitioner. The principal source of funding was the district health authority for community psychiatric nurses (150) and clinical psychologists (58) and the family health services authority for practice counsellors (76). All counsellors were referred a wide range of problems. Conclusions: Counselling services are wide- spread in general practice, but a high proportion of counsellors lack qualifications, and many may be referred problems outside their knowledge.
Thomas RV, Corney RH. A survey of links between mental health professionals and general practice in six district health authorities. Br J Gen Pract 1992;42(362):358-61.
The aim of this study was to obtain an estimate of the extent to which collaborative schemes exist between general practice and mental health professionals and to assess the influence of practice size and district on these schemes. A questionnaire asking about such links was sent to each general practice in six randomly selected health districts in England. The response rate was 75%. Half of the 261 responding practices had a link with a community psychiatric nurse, 21% with a social worker, 17% with a counsellor, 15% with a clinical psychologist and 16% with a psychiatrist. Practices with more general practitioners were significantly more likely to have a link with a counsellor, after allowing for marked differences between the sizes of practices in the different districts. There was a tendency for some practices to have many links, while others had few. This poses questions about the efficiency and equity of collaborative schemes in primary care. Further research is required to investigate the quality of these links and the extent to which they serve the interests of the patient.
Thomas RV, Corney RH. Working with community mental health professionals: a survey among general practitioners. Br J Gen Pract 1993; 43:417-21.
Links between general practitioners and mental health professionals, such as counsellors, psychiatrists, community psychiatric nurses, clinical psychologists and social workers, are increasing in number and type. The aim of this survey was to elicit general practitioners’ attitudes to these workers, comparing those with a link with a mental health worker and those without. General practitioners in two district health authorities were surveyed and a response rate of 70% was obtained. General practitioners linked to a mental health professional were more likely to have made a referral to that service in the previous three months and, on the whole, were more satisfied with that service. The commonest problem reported by respondents was the length of waiting lists. Regarding liaison with social workers, inadequate feedback and difficulty with contact were the problems mentioned most by doctors. A number of general practitioners expressed a desire for closer contact with all these mental health services. While caution is required in ascribing causality to these relationships, it is clear that a closer working relationship between general practitioners and mental health workers is productive and is valued by general practitioners. The challenge for policy makers is to structure mental health provision in such a way that more general practitioners are able to benefit than at present.
Valenstein M, Klinkman M, Becker S, and others Concurrent treatment of patients with depression in the community: provider practices, attitudes, and barriers to collaboration. J Fam Pract 1999; 48:180-7.
Background: In randomised controlled trials, patients with major depression who receive broad-based collaborative treatment by both primary care physicians (PCPs) and mental health providers (MHPs) have better outcomes than patients who receive usual care. However, little is known about the concurrent treatment of patients with depression in the community. This study describes the perceptions of PCPs of the frequency of concurrent treatment in community settings, the degree of collaboration between co-treating providers, and factors associated with greater interaction and collaboration. Methods: A survey was distributed to a stratified, random sample of 276 eligible family physicians in Michigan. Primary analyses were descriptive statistics (point estimation) of PCP practice patterns. Secondary analyses explored predictors of collaboration with multivariable regression. Results: A total of 162 eligible PCPs (59%) returned the survey. PCPs reported that they co-treated approximately 30% of their depressed patients with MHPs. They made contact with co-treating MHPs in approximately 50% of shared cases; however, provider contact seldom included joint treatment planning. PCPs perceived collaborative treatments to be more problematic when patients were enrolled in managed care programs. In multivariable regression, co-location of MHP and PCP practices (in the same building) was strongly associated with increased interaction and collaboration (P < 0.001). Conclusions: Concurrent treatment of depressed patients is common in the community, but these treatments are less interactive and collaborative than the treatment models proven effective in randomised controlled trails. If concurrent treatments are to become more collaborative—with regular contact and effective communication—co-location of practices appears important.
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