Short Life Working Group for Mental Health in Primary Care: report

Introduction

1. The Scottish Government Mobilisation and Recovery Group (MRG) was established to support our ‘Remobilise, Recover, Redesign Framework for Scotland’. Its aim is to ensure key expert, stakeholder and system-wide input into decisions on resuming and supporting healthcare service provision, in the context of the COVID-19 pandemic. The MRG sub group on Primary and Community Care highlighted the provision of mental health support as a key issue for primary and community services, supporting the parity of esteem between mental and physical health, as we emerge from the Covid-19 pandemic.

2. In response to this, the Short Life Working Group (SLWG) for Mental Health in Primary Care was commissioned and Terms of Reference can be found in Annex A. Its purpose was to consider “what good might look like” in terms of provision of mental health support within Primary and Community care settings.

3. Membership of the SLWG drew on a variety of geographical areas and specialisms and can be found in Annex A. At the outset of the group, a statement of intent (Annex B) was agreed between the Scottish Government, Royal College of General Practitioners and Royal College of Psychiatrists in Scotland, with input from the Royal College of Nursing. This described the ambition of the group – to agree principles and consider clinical models to deliver improved mental health capacity in Primary and Community care.

4. The Group agreed the following principles which should underpin service delivery for mental health in Primary and Community Care:

• All parts of the system should enable support and care that is person centred, looking to access the most appropriate information, intervention and support in partnership with the individual through shared decision making. Trauma Informed Practice will be the norm. Wherever a person is in touch with the system they will be listened to and helped to reach the most appropriate place for them - there is no wrong door.
• Primary Care mental health services should have no age or condition/care group boundaries, and meet the needs of all equalities groups.
• Local systems will positively seek to address health inequalities, proactively engaging those that are less likely to access support.
• Digital approaches to self and supported management of distress and mental health conditions will be an integral part of the service with the caveat that those who are digitally excluded need to be engaged positively in different ways.
• Where support can be accessed to help an individual within the Primary Care setting in their own local area this should be the default. If referral to specialist services is required, then this should be straightforward and timely.
• People presenting in the Out of Hours period should have access to the full range of options available in hours, accepting some options may not be available immediately.
• The Primary Care Mental Health Services (PCMHSs) linked to a group of practices or a locality to serve a population needs to be developed and resourced to provide appropriate levels of mental health assessment, treatment and support within that Primary Care setting.
• Staffing levels within PCMHSs will be subject to, and compliant with, safe staffing legislation.
• Evidence based psychological therapies need to be offered, with appropriate supervision and stepping up seamlessly to secondary care mental health services where appropriate.
• The use of screening and clinical measures pre and post intervention is encouraged, as this can indicate efficacy of intervention as well as assist with triage to ensure people are seen in the right service as quickly as possible.

5. The group collated examples of Mental Health models that are in place across various board areas in Scotland, which demonstrate good practice – the evidence paper alongside this report. This gave the group an understanding of current mental health service provision in Primary Care settings, highlighted potential gaps and helped to inform recommendations setting out how services can be improved.

6. The group met four times between September and December 2020 and this report reflects its discussions.

7. In the context of this report “Primary and Community care” is defined as all services that provide healthcare in a local area. These are services that are usually the first points of access for people in the community who are seeking advice or help with a health concern. “Primary and Community care” is linked closely to the wider services and assets within the community such as social care and support, education, community groups, leisure opportunities, workplaces etc. All of which may have roles to play in supporting the wellbeing of the local population.

8. “Mental Health in Primary Care” or “Primary Care Mental Health” (PCMH) in this report refers to a community based response to the following issues:

• stress and distress, including the outcome of socioeconomic pressures and the consequences of complex trauma and adversity;
• emotional and relational difficulties;
• anxiety and depression;
• wellbeing; and
• mental illness.

9. Presentation with such issues is often multifactorial and frequently requires a biopsychosocial formulation and can include the following three factors:

• A stressor (commonly relational, financial, or social difficulties) which the patient cannot manage within their usual resources.
• A background history of exposure to adversity and trauma, often in childhood.
• Limited availability of immediate, confiding social support.

10. Responding to these issues require a multifactorial approach, with the person at the centre. Early intervention especially with first line depression and anxiety can prevent difficulties escalating.

11. There is a considerable evidence base for psychological therapy in relation to presenting issues in mental health.