Psychiatric care in general practice: an experiment in collaboration

Liaison psychiatry in rural general practice

The recent government health strategy document described the integration between primary and secondary care in Ireland as often poor and outlined plans to redress this deficit. In mental health care, the gradual shift away from institutions over the past four decades has resulted in the GP becoming the most frequent professional contact for people with mental disorders. However, access to specialist opinion is usually available only for the fraction of psychiatric presentations which are formally referred to the psychiatric service.

On-site psychiatric liaison to primary care is commonly practised in other countries but not in Ireland. Research in the area suggests possible advantages for approaches which aim to enhance GPs' psychiatric skills while selectively encouraging referral of more serious disorders. This model has been adopted by GPs and psychiatrists in east Cavan and may be relevant to other similar settings, especially in the context of forthcoming changes in the organisation of primary care services.

Specialist outreach clinics in primary care and rural hospital settings

BACKGROUND

Specialist medical practitioners have conducted clinics in primary care and rural hospital settings for a variety of reasons in many different countries. Such clinics have been regarded as an important policy option for increasing the accessibility and effectiveness of specialist services and their integration with primary care services.

OBJECTIVES

To undertake a descriptive overview of studies of specialist outreach clinics and to assess the effectiveness of specialist outreach clinics on access, quality, health outcomes, patient satisfaction, use of services, and costs.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) specialised register (March 2002), the Cochrane Controlled Trials Register (CCTR) (Cochrane Library Issue 1, 2002), MEDLINE (including HealthStar) (1966 to May 2002), EMBASE (1988 to March 2002), CINAHL (1982 to March 2002), the Primary-Secondary Care Database previously maintained by the Centre for Primary Care Research in the Department of General Practice at the University of Manchester, a collection of studies from the UK collated in "Specialist Outreach Clinics in General Practice" (Roland 1998), and the reference lists of all retrieved articles.

SELECTION CRITERIA

Randomised trials, controlled before and after studies and interrupted time series analyses of visiting specialist outreach clinics in primary care or rural hospital settings, either providing simple consultations or as part of complex multifaceted interventions. The participants were patients, specialists, and primary care providers. The outcomes included objective measures of access, quality, health outcomes, satisfaction, service use, and cost.

DATA COLLECTION AND ANALYSIS

Four reviewers working in pairs independently extracted data and assessed study quality.

MAIN RESULTS

73 outreach interventions were identified covering many specialties, countries and settings. Nine studies met the inclusion criteria. Most comparative studies came from urban non-disadvantaged populations in developed countries. Simple 'shifted outpatients' styles of specialist outreach were shown to improve access, but there was no evidence of impact on health outcomes. Specialist outreach as part of more complex multifaceted interventions involving collaboration with primary care, education or other services was associated with improved health outcomes, more efficient and guideline-consistent care, and less use of inpatient services. The additional costs of outreach may be balanced by improved health outcomes.

REVIEWER'S CONCLUSIONS

This review supports the hypothesis that specialist outreach can improve access, outcomes and service use, especially when delivered as part of a multifaceted intervention. The benefits of simple outreach models in urban non-disadvantaged settings seem small. There is a need for good comparative studies of outreach in rural and disadvantaged settings where outreach may confer most benefit to access and health outcomes.

Psychiatric liaison to family medicine. Patient with delusional disorder

The liaison model of consultation shows how including a psychiatrist on a medical team can enhance patient care. A case history of a patient with a delusion about her eyes and her need for ophthalmologic surgery is used to illustrate diagnosis and management of patients who misinterpret or deny signs of disease.

Liaison psychiatry in general practice: the comprehensive collaborative model

A model of liaison psychiatry in general practice is described and its impact assessed using data from the Nottingham psychiatric case register. The model incorporates a comprehensive network of general practice psychiatric clinics for both psychiatrists and other mental health professionals, associated with mainly informal liaison with general practitioners and others in the primary care team, and a reduction in psychiatric outpatient clinics. Following the introduction of this model, the proportion of new and referred patients seen in primary care settings rose from 1% to 18% in Nottingham over an 8-year period. Over this period admission rates significantly fell in Nottingham compared with the rest of England and evidence is given that the growth of primary care psychiatry contributed significantly to this reduction.

Psychiatric clinics in general practice. Do they reduce admissions?

General-practice-based psychiatric clinics have increased substantially in recent years. We investigated the influence on psychiatric admissions of this style of practice in England over an 18-year period. We utilised data from a previous survey concerned with this type of work (Strathdee & Williams, 1984) and compared them with figures on psychiatric admissions. Parts of the country in which there has been greater development of general-practice-based psychiatric clinics were also those in which there has been a steeper decrease in psychiatric admissions. Further analysis showed this to be due primarily to an effect on admission of non-psychotic patients.

Scottish psychiatrists in primary health-care settings. A silent majority

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.

Working with general practitioners

Psychiatrists and general practitioners have found new ways of working together in the last ten years, but there have also been separate activities which could develop into rivalry. These opportunities and dangers are the central theme of this paper. Ways are considered in which the psychiatry of general practice differs from the experience of psychiatrists. Forms of help are suggested which general practitioners need from psychiatrists, whether in clinical practice or education.

A comparison of referrals to primary-care and hospital out-patient clinics

All referrals from two general practices to psychiatrists in hospital and primary-care out-patient clinics were examined. Women in all diagnostic groups were preferentially referred to the primary-care clinics, which provided especially for psychotic and chronic illnesses, and at which attendance rates on first and subsequent appointments were substantially higher than at the hospital clinics. The hospital crisis-intervention clinic dealt particularly with acute psychosis and personality disorder. Patients referred to the traditional hospital out-patient service were those with the less common neuroses and personality disorder. These results are reviewed in the context of the criticism that psychiatric clinics in primary care serve only the "worried well".

Psychiatrists in primary health care settings

An increasing number of psychiatrists are now working partly in primary care settings. This paper describes how the movement began and how both psychiatrists and other members of the specialist psychiatric treatment team have explored ways of working with family doctors in the diagnosis and management of psychiatric disorders. Various styles of collaborative work, the declared advantages of such attachment schemes, the reservations being expressed about their further extension, and their research and educational potential are explored. If such enterprises, designed to help the family doctor identify psychiatric morbidity in the practice and to extend his skills in managing such patients and their relatives, are to be commanded, they must be carefully monitored so that the cost-benefit balance can be established.

The psychiatric patient, the general practitioner, and the outpatient clinic: an operational study and a review

A sample of general practitioner referrals to a Psychiatric teaching centre was investigated by means of standard interviews, first with the practitioners and subsequently with the patients. Hospital treatment and disposal were examined in the light of the doctors' reasons for referral, and of the expectations which they and the patients had held of the hospital service. The findings are related to previous work in this field, and the implications for service planning discussed.