Hi All

I'm doing some work at the moment looking at the different roles in a (fictional) local system of a consultant psychiatrist and a specialist GP. I'm wondering where people draw the lines (if any) between the two roles. Its already been suggested that dual diagnosis is one area that the GP would 'step aside' for the consultant, but I wonder what other issues might be better dealt with by a Consultant Psychiatrist working within a Mental Health Trust. Pregnancy was suggested to me as one - however its clear that GPs deal with a whole heap more pregnant women than psychiatrists ever do. Another area was where patients are more chaotic - but then I was told that actually people with more complex needs can actually find it easier to engage with primary care because of the flexibility and availability of a good GP service. Similarly I am interested in understanding more about areas in which the GP - with their focus on undifferentiated need - can deliver more appropriate responses.

I know that there are some very strong and positive partnerships between GPs and MHTs across the country - and I have been wondering what characterises them. I am also interested in what happens when this relationship breaks down - and what impact this has on the whole treatment system.

Really interested in all comments

Sara McGrail
www.saramcgrail.co.uk
sara.mcgrail@btinternet.com

Hi Sara
This also fascinates me and I could go an at considerable length. I completely agree about pregnancy by the way. I won't go on at lenth, though, as its late, but I just wanted to check if you are aware of the Roles and Responsiblities paper which does provide some useful demarcation, and also New Ways of Working which describes psychiatirsts working with other members of multidisc team such as GPs in what amounts to something like a Managed Clinical Network. Both should be google-able

Hi Susi -

Yes, I've the Roles and Responsibilities documents and I'll look out the new ways of working doc.

But its more how it actually works that I'm trying to get to.

In the latest (summer) edition of SCANbites, theres a highly spirited defense of the role of the Specialist Psychiatrist in the face of what they describe as bad commissioning involving disinvestment from specialist psychiatric services. While I would agree that specialist MHT services can be useful, I guess I may find myself in disagreement with some about what proportion of a local treatment system's capacity they should be delivering. Some DATs I know are striving for greater plurality across tier three and four with the majority of interventions provided as close to the patients regular experience of healthcare as possible. I think this is an interesting approach. My particular concern is that entry to the treatment system should be into a primary care led service - with referral to secondary care only if risk and complexity require it. I worry about the current top down approach in some places where people are held in highly specialist MHT services until its agreed they are "stable enough" to move to primary care led services. I wonder if in working this way people are missing out on some of the skills of the primary care team to manage highly complex cases.

Sara

This message has been edited. Last edited by: Sara McGrail,

I do agree with you Sara - and it's really good to hear you are doing this piece of work. Primary care is such a good place to manage complexity, in practices who are motivated and well resourced to do so. The flexibility which primary care is able to offer is all important.
One area of primary care with a proven record of working with complexity is in homelessness. In my previous experience as a GP in a homeless service we had built up working practices which kept people in treatment who had struggled to cope with secondary care services in the past - this included those needing help with addictions as well as a range of mental health problems.
I like your phrase "undifferentiated need", its very neat and accurate. Good luck with this piece of work - I'd love to know more about it.

Hi Sara
Fantastic reading your post.
I too have been looking at this very subject recently, well not really by choice but still fascinating.
I did read in some psych journal (????) about a certain area where this relationship you talk of and one we would surely want to see work is or has been breaking down.
With all the diplomacy i can muster i find it hard to find a case that cannot be dealt with in primary care.
I have a great respect for consultants and good secondary services, afteral it was a secondary service that finally took me into treatment five years ago after waiting 15months, my GP merely monitoring my demise as far as i could see.
Since though i have discovered and met people in primary care that could deal with anything you could throw at them.
It is however bad practice to force your competency levels, areas of interest and experience on colleagues who may not be in the same place as you (a complex area i now understand better).
So it would be great to hear how you get on with this work Sara....good luck.
Just to add in my role as advocate i have found recently a good few people in primary care who want to treat the drug dependent but the 'big fat consultant cat' in the area(s) will not allow it, it beggars belief when we are looking at waiting lists again and SIRs of three week wait plus becoming the norm again (in some areas) that we do not use ALL the resources at our disposal, especially when they are willing to roll up their sleeves and get their hands dirty in the world of drug treatment. These consultants need to learn to share.
My best
TonyB

Clearly, there is a place for the specialist skills and knowledge (and sometimes prescribing licences) that specialist services can bring to drug treatment whether that be specialist psychiatrists dealing with dual diagnosis or specialist maternity services dealing with pregnancy. However, in most other fields of treatment only the minority of the most complex and intractable cases are dealt with by specialist services while the majority are managed in primary care sometimes following assessment or with some support by specialist services. The specialist/primary care proportions are often reversed in drug treatment. As I approach retirement I am struck by the familiarity of the arguments I come across against locating hepatitis C treatment in primary care – they are almost identical to those I encountered twenty years ago when drug use was overwhelming specialist services’ capacity to offer accessible and effective treatment.

What an interesting thread, I will attach a copy of the SCAN'nip' that Sara mentioned when I figure out how too!! I have worked in the sector for a fair while, and in two areas where there is no Cons Psychiatry in Substance Misuse input at all. Remarkable as this may seem, mainstream psychiatry picked up the the mental health needs, substance services picked up the substance misuse issues, and we delivered a coherent package of care.

quote:

Originally posted by Scooby:
I will attach a copy of the SCAN'nip' that Sara mentioned when I figure out how too!!

I have the pdf copy of the relevant issue of SCANbites - but I can't work out if I can post an attachment either! Could one of the administrators let me know if thats possible if you're reading this?

Thanks to all for your comments. I'll let you know how the work goes on. I think from a DATs point of view there are many feeling that shifting the balance in local commissioning away from specialist psych to specialist primary care lead can result in a better treatment system - though obviously as in most things, its generally about personalities and relationships (which is why IMO centrally mandated systems can be problematic!).

Sara

It seems to me the way forward is towards a managed clinical network, where the psychs are the repository of expertise, exp wrt mental health and psychologies and provide excellent training, supervision, clinical governance etc, whilst primary care strengths include physcial healthcare, perinatal care, multi-organisational working, flexibility and a 'can-do' approach, local knowledge of families and communities etc etc. I believe both can learn alot from each other, and both can contribute more than the sum of their parts to a healthy treatment system.
I lead a drugs team in an area such as is described above, where we have no psychiatrist. I have RCGP parts one and 2 and I'm even now a part 2 tutor but I do a much better job as a result of ad-hoc supervision which 2 or 3 experienced psychiatrists have kindly allowed me to access when needed over the years.
There are areas in the UK where the two disciplines seem to work well together, I think that's what we should be aspiring to for all. Of course its not quite that simple, I haven't seen the article but from your description, it seems to be confirm that many psychs feel undervalued by the shifts in balance in commissioning which have happened so far. It would be natural to take a defensive position in that situation, and even to try and exclude primary care from the system. That isn't v helpful as then primary care feels undervalued! When I was at NTA I observed at several intercollegiate meetings, hosted by SCAN, which did some scoping work for a conference where doctors of all varieties cd get together, describe what we saw as our own and each others strengths to each other, and look at what an ideal, balanced treatment system might look like. I was sorry it never happened, and the meetings seem to have stopped (temporarily, I hope). Still, you can't put a good idealist down! I have a dream.......

quote:

Originally posted by susi:
When I was at NTA I observed at several intercollegiate meetings, hosted by SCAN, which did some scoping work for a conference where doctors of all varieties cd get together, describe what we saw as our own and each others strengths to each other, and look at what an ideal, balanced treatment system might look like. I was sorry it never happened, and the meetings seem to have stopped (temporarily, I hope). Still, you can't put a good idealist down! I have a dream.......

Hi Susie, Thanks again for your reply. SCAN and SMMGP are having their conferences on the same day ..... just 350 miles apart!!!! Theirs is called Specialism/Professionalism in addiction treatment and its at the Radisson Hotel Manchester on the 25th and 26th September - the same day SMMGP's in Bristol....


I think in an ideal situation, the managed clinical network is a great set up. Then as Sally suggests the patient can start out in primary care (or in a primary care managed service)and move to secondary care if there are issues that can't be managed in primary care. I'm really interestsed to try and identify what those issues are, obviously dual diagnosis is the first tha springs to mind, but then I kind of dry up. Would forensic issues be another? Or Personality disorder? - Or is the retention of a specialist service a matter of additional experience? If so in time might we expect as more and more GPs undertake parts one and two, that more clinical supervision would be provided within primary care structures rather than ending up in psychiatry? Or is psychiatry still the "senior service" and therefore most appropriate place to provide clinical supervision? Certainly the SCAN piece identifies Management of Shared Care Schemes as a key role of the consultant psychiatrist.

Sorry to keep prodding away, its just at the heart of so many system design and commissioning decisions and the modelling work we're planning will need to be based on a strong understanding of the different roles, not just now but in the future.

Sara

I think i may be about to say something contraversial here, but I do see the role of a consultant psychiatrist as fairly pivotal to a clinical network. I guess its in terms of that 2 year training they all go on about - they do learn some stuff, about management of teams, teaching, supervision, research, audit and clinical governance, which GPs only skate over really (keep my head down as I say this...).

Yes to all the mental health stuff, and also somebody fairly central, (not necessarily a psych, could be a primary care specialist) needs to have a sufficient concentration of the more unusual drugs cases to garner the experience to do it well, I'm thinking of amphetamine, injectable heroin and methadone, unlicenced and newly licenced medications and so on. And to do research as well.
Management of shared care schemes is a funny one though, its an awful lot about commissioning, and I think that's more a strength in primary care, both historically with their role of running a business (the practice), and even more nowadys with the PCT role, Practice based commissioning and so on.
hope this helps, and also that people feel free to challenge me!

quote:

Certainly the SCAN piece identifies Management of Shared Care Schemes as a key role of the consultant psychiatrist.

Hi Sara

Obviously it all depends on the local arrangements. I have not read the SCAN piece but put like that, it is quite a bald and bold statement.

I can think of localities in which the key players of the PCT and their GPwSI constituents would consider that an unecessary and bitter pill to swallow. And I can see how the SCAN proposition could be interpreted as perhaps patronising.

After all, if the maturity and capability exists in primary care itself, why should it need to be 'managed' by secondary care?

Cheers
Simon

The almst complete absence of psychiatrist input to very many drug services has not affected the quality of service for 95% of clients. The role of 'consultant' should be exactly that, someone brought in for consultation for the times when their specialist knowledge is needed.

Locally the link required for dual-diagnosis clients is managed by a nurse, psychiatrists are very much in the background, (and mostly not too interested either).

I fear some 'turf-war' breaking out over this issue. Substance misuse is now clearly seen as a multi-factorial, multi agency, multi disciplinary issue. Primary care has been managing this type of need very well for decades.

quote:

Originally posted by Simon Morton (quoting me):
[QUOTE]Certainly the SCAN piece identifies Management of Shared Care Schemes as a key role of the consultant psychiatrist.

Hi - just in the interests of accuracy I need to correct myself a little here. The actual quote from the SCANbites issue says:

1 Addictions psychiatrists make unique and valuable contributions to substance misuse services:
a. Addictions psychiatrists provide a safe and secure treatment setting that supports the functioning of other services by:
• taking difficult cases from primary care
• providing services in areas not covered by primary care
• seeing patients in a range of settings - general hospitals, psychiatric wards, community bases, at home, in GP surgeries
• offering comprehensive telephone support and advice to GPs, substance misuse workers, pharmacists etc
• providing a range of specialist services for individuals with alcohol problems
• being the final repository for “insoluble” problems
b. Addictions psychiatrists provide high level skills for:
• dual diagnosis and other severe complex needs
• support to the Courts with child care cases, offending related to dependence etc
• teaching/training:
i GP trainees, psychiatric trainees
ii GPs, general medical colleagues
iii MRCPsych, MRCGP, MRCP, MSc
course contributions
• treatment and care of sick doctors on behalf of the GMC
• leading on clinical governance
• supporting service developments
• developing innovative practice
• conducting research
• contributing to Royal College work – support for national policy development
Addictions psychiatrists bring high quality standards to routine clinical care of individuals with alcohol and drug problems:
• through clinical leadership
• by establishing/running Shared Care Monitoring Groups
• through detailed knowledge of NICE guidelines/Clinical guidelines
• by identifying and addressing poor practice"

Establishing and running Shared Care Monitoring Groups is a bit different to my somewhat hurried summation (above). I do however still wonder if this is a role for a consultant psychaitrists per see or for an experienced specialist in substance use services - who could be a psychiatrists but just as easily could be a GP. I also wonder which otehr of the roles identified above cannot be provided by a Specialist GP and absolutely must be provided by a consultant psychiatrist. I'd be interested in your views.

I too am concerned about turf wars - and not just between primary and secondary care, but also the statutory and voluntary sector, the small local community groups and the large third sectors monoliths, bewteen local and national commissioning. Maybe these are however in some ways a predictable result of "trough shrinkage". We've had so much money for so long that there's been less need for professional groups and organisations to corner off their own particular turf. As the amount of money reduces, people start to worry more about "competition".

On the other hand this particular debate may be a result of the maturity of the primary care substance misuse field and the fact that there are senior practitioners who are providing commissioners with genuine alternatives to psychiatry led provision. I agree with Jim about the potential breadth of the GP role. I guess as the drug treatment system becomes more sophisticated about how and to what end we are providing treatment (cf: the 'recovery'agenda and mainstreaming) we may need a different set of skills for clinical oversight of treatment services and a different orientation for those services themselves. The trick will be in not losing the indepth knowledge around dual diagnosis that psychiatry can bring. If anyone would like the copy of SCANbites that had this piece in, please email me on sara1967@fastmail.co.uk and I'll send you the electronic copy.

I think Simon's point about it being down to local areas and individuals probably brings us nicely back down to earth. Those who took part in the NTA's Opening Doors Initiative all those years ago will remember the focus on outcomes for real patients - and that fit between the care pathways and the patient journey. As long as commissioners can make the case that they are establishing the most appropriate treatment system given available clinical and other resources that they can and that people's rights to effective treatment as identified in the NICE guidelines, through accepted good clinical practice and with regard to patient choice and public health, it maybe doesn't matter if its a specialist psychiatrist or a specialist GP who leads the service ...?

This message has been edited. Last edited by: Sara McGrail,

quote:

by establishing/running Shared Care Monitoring Groups

Thanks for this Sara.

Mmm. As someone who has 'sat in' on on more Shared Care Monitoring Groups than most perhaps (when I toured as an SMMGP advisor), I can't say that I ever saw one that was either established by or run by a Consultant Psychiatrist.

Which isn't to say that they weren't round the table, or weren't positively contributing stakeholders.

Simon

Sara thank you so much for sending me SCANbites. I can now see the context of the section you pasted, in a big article by Colin Drummond (who ran the SCAN meetings into collaborative work) and Keron Fletcher (who attended, as RCPsych addictions faculty chair) and I am very sad to see how undervalued they are feeling. I feel more strongly than ever that the time has come for that conference, so the primary care and psychiatry disciplines can start looking at how we work together and value each others' roles. How did it ever happen that SCAN and SMMGP are having their conferences on the same days in different locations?

I have been asked for advice by a commissioner who is trying to design a primary care-led specialist service, specifically what the functions would be. The SCAN article was somewhat helpful, but I have added a good deal more. This is my first draft and i am worried I have still missed things out - I would be grateful for any contribution from the field to assist me, and perhaps it will also help with future conversations with secondary care?

Here it is:



a. Provide high level clinical skills for:

Patients with complex needs eg:

Pregnancy
Significant co-dependencies of two or more depressant drugs (esp heroin and/or alcohol and/or benzodiazepines)
Acute liver problems or liver failure
Chronic pain

Patients requiring specialist drug misuse treatment (as specified in DH Drug Misuse and dependence; guidelines on Clinical management) eg

Injectable opiate substitution therapy
Long term benzodiazepine prescribing
(?Amphetamine prescribing)
Substitution for dependence on prescription medicines
Initiation of naltrexone
Initiation of prescribing outside of national guidance or licencing
Treatment and care of sick healthcare professionals on behalf of the GMC or other registration bodies

Patients in drug treatment modalities requiring intensive review eg

Titration
Stabilisation
Transfer of therapies, especially methadone to buprenorphine
Detoxification

b. Support drug misuse management in other services by:

Active participation in recruitment and development of primary care-based drug treatment
Taking cases from primary care where the practitioner does not feel competent or confident to manage or where relationship with primary healthcare team has broken down
Providing services for patients in areas not covered by primary care
Providing support to hospital inpatients (especially perioperative, acute medical and gastroenterology patients)
Providing support to hospital outpatients (especially pain management patients)
Offering comprehensive telephone support and advice to GPs, substance misuse workers, pharmacists, and hospital specialist teams
Being the final repository for cases which are proving difficult to manage

c) Provide non-clinical patient services at specialist level

Support to the Courts with child care cases, offending related to dependence etc
Medical reports to DVLA on request
Medical reports to professional body regulatory authorities

d) Quality assurance and quality improvement for the treatment system as a whole

Teaching/training of generic caring professionals: GP registrars, A&E staff, primary healthcare teams, pharmacists, and other caring professions
Clinical supervision and appraisal of shared care GPs/NMPs
Clinical leadership and policy development
Active participation in systemic clinical governance activities, through TSRG and CTMG
Quality assuring treatment system through advisory role and active participation in systematic clinical governance review and clinical audit
Leading cross-organisational significant clinical event reviews (especially for Drug-related deaths)
Supporting service developments
Developing innovative practice
Conducting research
Identifying and addressing poor practice and underperformance

e) Support to local partners

Clinical advice to Partnership
Advice and liaison with PCT pharmaceutical advisors, Professional Executive Committee and PCT clinical governance

Can’t think what else, but I bet there’s something I’ve missed!

I have stuck very much to the medical/prescribing role, I think a decent specialist service should also provide the NICE-validated formal psychosocial interventions, eg contingency management, CBT, Behavioural couples therapy, family therapy etc
Thanks in advance

Susi

This message has been edited. Last edited by: susi,

this has been a long and at times emotional discussion in the field of drug misuse. The NTA and both RCPsych and RCGP brought out a very helpful consensus document a number of years ago on this issue. It acknowleged that within the field of general practice there is a variety of skills from those working at generalist level to those working at specialist level. Similarly it acknowledged a continuum for psychiatrists. It acknowledged that individuals from either discipline could take on a clinical lead role - it's possessing the competencies that is important. In New Zealand I believe there is now a faculty for drug misuse treatment comprising psychiatrists,GPs and general physicians who are working at a "specialist" level with drug users. This could be a model that eventually evolves in the UK?

Interesting to consider whether there is any significant difference in the ancillary staff assisting variously GP's or consultants provide services. Other than the old chesnut around qualifications, are there any other differences?

I can only speak for our local Health Board, but there are advantages of being a GP over a psychiatrist.

First - our budget is not ring fenced, there is no limit ( except time/numbers ) that can be prescribed - unlike the local services who 'run out of funds' ( as shocking as that may seem ).

Second - you're not bound by formularies and protocol, e.g. if someone does well on a dihydrocodeine script,then I'm at liberty outside of it's licence at my discretion ( and my own neck on the block ).

Third - we're more accesable - just walk in for same day appointment -if things are going wrong ( even in clients who are deemed 'too difficult' for primary care ), it'll be us they come to first.

Fourth and to answer Perseverences question - all the other complications and services we can access.
e.g. Today had to send someone for a scan for a suspected DVT,last week the same person was admitted confused, prior week to that we had to ring around pharmacies to try and get a script delivered to him as they had fractured their hip.
In all of this, the surgeons hadn't considered doing a DXA scan to check for osteoporosis ( in view of history of heavy drinking ), or the medis considering doing a CT scan to see if there is any sign of Wernickes - these are the things a GP can check out.
All the above ( if had gone through secondary care would have been referred back to primary to organise ).

Personally I find the role of the consultant psychiatrist of one of access to inpatient beds,dual diagnosis ( the local psyches don't want to know if drugs are mentioned ), support and advice.Like all things, if you don't know - ask.