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Filling the chasm: Reimagining primary mental health care

GPs and primary care are the first port of call for many people experiencing poor mental health. The vast majority of people with mental health conditions in England do not have contact with specialist mental health services. About two-thirds receive no support at all from the NHS, and most of those who do are in contact only with primary care services. This includes a growing number of people who are ‘stepped down’ from specialist services as well as those who are referred but do not meet local secondary care thresholds (which are variable across the country), including many with complex psycho-social situations implicated in either poor mental health or physical health problems, or both.

Because of its relative accessibility and universal coverage, primary care has a critical role to play in both treating mental health difficulties and preventing problems from occurring or escalating. However, GPs and their colleagues often find themselves without the time, resources or capacity to respond effectively and make the most of their potential. Thus, key opportunities to address poor mental health for individuals and their families, and to build the resilience of people living in their area, may be missed.

This challenge has not gone unrecognised and yet the role of primary care in mental health has rarely been the focus for policy development or attracted the same level of attention as specialist mental health services in England. As a consequence, individual practices and clinical commissioning groups (CCGs) have developed their own arrangements, and there has been a burgeoning of initiatives that seek to offer more effective support for people’s mental health needs in primary care (NHS

Clinical Commissioners, 2017a). The scoping of developments across London by the Healthy London Partnership, for example, highlighted a lack of confidence and capacity in primary care to respond effectively, a lack of clarity of roles between primary and secondary care, and concerns about the sustainability of initiatives that are being developed to address the need for support at a primary care level (NHS Clinical Commissioners, 2017a).

This means that the mental health support that people are offered in primary care will depend on local developments and the interest and commitment of local GPs and colleagues to strengthen the mental health offer. We therefore know very little about what constitutes good quality primary mental health care and how to improve access to effective support for those who currently do not get the help they need as well as fully realising primary care’s role in prevention. But there is a lot we can learn from the many different initiatives that are emerging in order to build a more solid evidence base and raise the profile of primary mental health care nationwide.

This briefing paper seeks to identify promising initiatives that could provide the basis for a framework or set of standards for primary mental health care to support commissioning and provision. It is a collaborative effort between GPs with an established track record in this area, in partnership with the Health Services Management Centre and Centre for Mental Health, who each bring expertise in mental health systems and service development. To create this report we have held meetings, undertaken a rapid appraisal of the literature informed by the review undertaken by the Healthy London Partnership (NHS Clinical Commissioners, 2017b), sought examples of good practice through a call on the Centre’s website and followed these up with telephone interviews or visits to eight local areas. We have also interviewed GPs who are leading developments in this area in their practices. The aim of these interviews has been to identify emerging positive practice, the challenges to developing capacity in primary mental health care, and how these may be overcome.