VOL: 97, ISSUE: 20, PAGE NO: 39
Wally Barr, PhD, BSc, MA, RMN, CQSW, is a research fellow at the Health and Community Care Research Unit, University of LiverpoolThree years ago the NHS Executive commissioned a three-year study on the effect of mental health registers in general practices across an English health district (Barr and Cotterill, 1998). This was one aspect of a broader drive to improve the targeting of services at people with severe and enduring mental illness.
Three years ago the NHS Executive commissioned a three-year study on the effect of mental health registers in general practices across an English health district (Barr and Cotterill, 1998). This was one aspect of a broader drive to improve the targeting of services at people with severe and enduring mental illness.
The need to prioritise this patient group has been stressed by various governments since the 1980s, and in the light of recent government reports it is clear that the issue remains high on the health agenda in England and Wales (Department of Health, 2000; National Assembly for Wales, 2000). In fact, the National Service Framework for Mental Health (DoH, 1999) notes that in many areas the first priority is to address shortfalls in current services for people with severe and enduring mental illness.
New government plans once again call for rapid and radical change in mental health services, but also offer the promise of a well-staffed NHS. But the findings of the NHSE study suggest that staffing issues lie at the heart of the implementation of health reforms (Barr, 2000).
The registers, held in each of six general practices in the district studied, were introduced in 1997 to help bring patients with severe mental health problems to the attention of GPs and CPNs, but the results of the study indicated that they had been of no measurable value in improving service-targeting for this patient group. For example, the study hypothesised that the CPNs would focus more attention on patients with severe mental health problems identified by the registers and that their contact with these patients would increase as a result. In fact, CPN contact with the 274 patients on the mental health registers of the six sample practices fell in the years that followed their introduction (Fig 1).
Unmet needs in registered patients were expected to diminish as the registers should have helped to identify patients in need who had previously fallen through the net of care. But this was not the case: evaluations using the Camberwell Assessment of Need (Dunn et al, 1995) showed that unmet needs in a sub-sample of 40 patients had barely changed a year after the registers were introduced (Fig 2).
Why did the registers fail?
So what lies behind this lamentable failure of the registers? The qualitative side of the study suggested that the answer might be more to do with the difficulties of implementing reform in an ever-changing health service than with severe mental illness registers. Many of the CPNs and GPs interviewed for the study alluded to a highly pressurised work environment as a result of CPN shortages. There was a significant turnover of CPNs in the district during the three-year study. Three of the six practices changed their CPN once during the course of the study and a further two changed their CPN twice.
In the second half of 1999, only two of the six practices could consistently offer the primary care team the service of a CPN. It seems reasonable to conclude that this situation would have placed a strain not only on patients but also on the workload and morale of the remaining CPNs and members of the primary care teams. There was considerable evidence of this strain in interviews held with CPNs and GPs in the summer of 1999.
The study suggests that these staffing difficulties have been a crucial factor in the failure of the registers to bring about measurable change. The NHS Plan states that in order to tackle inequality, primary care trusts should maintain registers of those who are at greatest risk of serious illness (DoH, 2000). If mental health and other register-based initiatives are to be effective, they must be implemented by staff members who have sufficient time and energy to do so. Mental health registers, for example, need to be computerised, regularly updated and used proactively in the management of patient health care. Ideally, they should be available on the consulting room computers of each GP and be easy to use.
The National Service Framework for Mental Health (DoH, 1999) states that a research priority will be the investigation of ways to enhance staff morale, retention, recruitment and performance, thereby improving service engagement and outcomes for patients. This point has been reinforced by the health select committee, which recently concluded that the national service framework was unlikely to achieve its aims unless mental health staff shortages were addressed (Health Select Committee, 2000).
The NHS Executive study (Barr, 2000) offers a small but significant example of staff shortages playing an important role in the failure of an initiative to improve service provision.
In spite of this there are theoretical grounds on which to introduce severe mental health registers into general practices nationwide. They can be said to represent a forward-thinking and progressive initiative in the service-targeting agenda.
However, the fate of these registers underlines the principal message of the health select committee - that building the infrastructure of primary and secondary care is both the foundation of reform and a prerequisite for the implementation of mental health policies. The NHS Plan offers crucial support to this infrastructure through a significant increase in staff that will be welcomed wholeheartedly.