- Email: [email protected]
The role of the general practitioner in severe mental illness
THE BROADER PICTURE
The role of the general practitioner in severe mental illness
– mean that these patients are at increased risk of developing chronic bronchitis, hypertension and angina (Kendrick, 1996). Mortality rates from cardiovascular and respiratory diseases are more than doubled in schizophrenia.
Tony Kendrick
General practice is essentially reactive: GPs and practice nurses wait for patients to come and see them or request a home visit. However, a significant proportion of patients with SEMI need to be sought out for review. GPs and practice nurses need to be aware of those who do not attend for review, in order to alert the CMHT to find out if the patient is experiencing difficulties. This involves reversing the usual assumption in primary care that if a patient does not return it means they are well. To be aware of who is and is not attending for care, the practice ideally needs a register of patients with SEMI. The NSF recommends that agreements should be reached between primary care and specialist mental health services to target care management resources for people with SEMI, and that practices should produce a register of such patients, to ensure that regular reviews are carried out (to include both mental and physical health problems).
The need for a register of patients with SEMI
Primary care teams and the care of severe mental illness The UK National Service Framework (NSF) for Mental Health (1999) urged mental health teams to stay in contact with all people with severe and enduring mental illnesses (SEMI), but in reality a significant proportion (25–30% of patients) will lose contact with psychiatric services and be looked after entirely in general practice (Kendrick et al., 1994). Even when patients are in contact with specialist services they still need the help of their GP as well, if only for repeat prescriptions and sickness certificates. Also, a significant number of people with chronic psychoses receive their regular depot neuroleptic injections from general practice nurses rather than community mental health nurses. It is very important, therefore, that GPs, practice nurses and other members of the primary care team have an understanding of the problems of their patients with SEMI, and know where to seek help when necessary. GPs do have a number of advantages to help them remain involved in the care of their SEMI patients. They have often known their patients as children or young people before the illness developed, and many people who will not attend psychiatric clinics are still happy to go to their own doctor’s surgery for care. Many community mental health teams (CMHTs; see pages 11–14) do not offer 24-hour care and the practice is often the first port of call for patients’ relatives when problems develop out of hours.
Drawing up a register of patients with severe and enduring mental illnesses Patients can be identified from the following sources: Practice data • Computerized prescriptions for patients on: • Antipsychotic drugs (oral and depot) • Anticholinergics • Antidepressants • Anxiolytics • Computerized diagnostic records or disease register, where appropriate • Patients being seen for depot injections by the practice nurse, where appropriate • Appointment lists of patients seen in surgery or on home visits in the previous 3 months (as a reminder of patients who are not on medication or seeing the nurse)
Physical and preventative care GPs and practice nurses have an important role to play in the physical care of patients with SEMI. High rates of smoking and obesity – in part due to the side-effects of psychotropic drugs
Mental health services data • Patients of the community psychiatric nurse • Consultant psychiatrists’ case-registers and out-patient records • Day-hospital patients
Tony Kendrick is a General Practitioner and Professor of Primary Medical Care at the University of Southampton School of Medicine, Southampton, UK. His doctoral thesis was a study of improving the care of people with long-term mental illness in general practice. He has written more than 60 papers, 20 book chapters and 4 books on mental health problems in primary care, including depression, eating disorders, bereavement and carers’ health, as well as schizophrenia and other severe and enduring mental illnesses.
PSYCHIATRY 3:9
Social services data • Social workers’ caseloads (From Kendrick et al., 1994)
1
26
© 2004 The Medicine Publishing Company Ltd
THE BROADER PICTURE
Drawing up a register of patients with SEMI Over 90% of patients with SEMI can be quickly identified, especially now that most practices are computerized, by listing all those already known to the primary care team and CMHT, combined with searching repeat prescription systems for psychotropic drugs (Kendrick et al., 1994). Figure 1 lists sources of information that might help in the construction of a register. Having identified the patients, the GP should check their records for current contact with psychiatric services; the GP should have been informed of all patients in receipt of the Care Programme Approach (CPA). Patients who are out of contact may benefit from referral back to secondary care, although a proportion of patients will decline referral, preferring to see their GP for continuing care.
lengthy, comprehensive psychiatric and social assessment of the kind performed in specialist out-patient clinics. Traditionally, GPs have been taught that the most efficient consulting style is to start with an open question and encourage the patient to set the agenda. This ensures that the patient’s concerns are quickly identified and can be addressed in the time available. However, this approach may be inappropriate for many people with SEMI. Those with negative symptoms (including apathy, inactivity, a poor self-image, self-neglect and indifference to discomfort) are unlikely to bring problems to their GP’s attention. A number of problems can build up which could lead to a crisis in care if not detected. What is needed, therefore, is a repertoire of specific closed questions to ensure that problems are not missed. Figure 2 shows a special record card designed for general practice Lloyd George-size record envelopes. On one side is important summary information which might be needed in an emergency – such as being called to see a partner’s patient on a Friday evening when everyone else has gone home – and on the other is a structured record focusing on important areas of mental and physical health and social functioning. There are now computer templates for paperless practices to use for their structured assessments of their SEMI patients. EMIS, probably the commonest system used in general practice, has a bespoke template.
The need for structured patient assessments Patient contacts in primary care are relatively short: an average of 8 minutes per consultation in the GP’s surgery, perhaps longer on home visits; practice nurse appointments may last only 5 minutes for a depot injection. Therefore GPs and practice nurses need a strategy to identify important problems or changes in their patients with SEMI quickly and efficiently. There is not time to carry out
General practice structured review card for patients with severe and enduring mental illnesses Side 1
Side 2
Name
DoB
Date
First diagnosed
Hospital no.
Medication Anxiety
Hospital admissions
Depression Hallucinations Relatives/other carers
Delusions
GP
Community psychiatric nurse
Consultant
Social worker
Psychologist
Occupational therapist
Appearance Behaviour Preventive Physical
Pattern of relapse Housing Important notes
Finance Daily activities
2
PSYCHIATRY 3:9
27
© 2004 The Medicine Publishing Company Ltd
THE BROADER PICTURE
by the nurses were not always dealt with by their GPs. It was concluded that joint GP and nurse assessments would be best, in special clinic sessions.
The evidence base A randomized controlled trial of setting up registers of the longterm mentally ill and teaching GPs to carry out structured assessments of these patients was carried out in 16 group practices in the south of England (Kendrick et al., 1995). The assessments were associated with clear changes in the process of patient care over a 2-year period. Changes in psychotropic medication, particularly neuroleptic drugs, and referrals for psychosocial problems, particularly to community mental health nurses, were significantly more frequent in the intervention group. However, most of the GPs in the study, who were self-selected for their interest in mental health, considered that there was not enough time in routine consultations to carry out the structured assessments. It seemed unlikely, therefore, that most GPs would be willing to do it. An alternative approach involved setting up special clinic sessions in practices to assess patients with SEMI, similar to those for asthma and diabetes that are already widespread in general practice. Nazareth and colleagues (1996) carried out a controlled trial of such an approach in four inner-London practices and found it to be generally feasible, and to lead to small but measurable improvements in symptoms on the Present State Examination and functioning on the Global Assessment Scale. A third approach was a randomized controlled trial of teaching practice nurses who give depot neuroleptic injections to carry out brief structured assessments during injection appointments and to bring any problems to their GP’s attention (Burns et al., 1998). The trial found that the practice nurses were generally unsure and anxious about the problems of people with chronic psychosis and keen to learn more about them. However, the impact of training nurses in structured assessments on patient care could not be demonstrated. This seemed to be because problems uncovered
Targeted payments in general practice Initiatives aimed at increasing the quantity and quality of reviews of patients with SEMI in general practice have the potential to change the process and outcome of care. Setting up registers and special review sessions is time-consuming, however, and competes with numerous other obligations in general practice. These initiatives therefore need to be promoted through targeted remuneration. Burns and Cohen (1998) showed that more practices in southwest London would set up joint GP/practice nurse assessments in response to the introduction of trial item-of-service payments for the initiative. The new General Medical Services contract for GPs in the UK, agreed in 2003, allows practices to earn more money if they adopt two quality indicators related to SEMI. Practices can earn seven points for producing a register of people with SEMI who require and have agreed to regular follow-up, and up to 23 further points related to the percentage of patients on the register with a review recorded in the preceding 15 months, which includes a check on the accuracy of prescribed medication, a review of physical health, and a review of coordination arrangements with secondary care. Figure 3 shows the recommended elements of the regular review for which practices can earn extra income under the new contract.
Conclusion People with severe and enduring mental illnesses are among the most vulnerable members of society. Motivating and rewarding primary care teams for focusing more of their efforts on this group has the potential to make a huge difference to their future health and life expectancy.
Recommended elements for the regular review of SEMI patients REFERENCES Burns T, Cohen A. Item-of-service payments for general practitioner care of severely mentally ill persons: does the money matter? Br J Gen Practt 1998; 48: 1415–16. Burns T, Millar E, Garland C et al. Randomized controlled trial of teaching practice nurses to carry out structured assessments of patients receiving depot antipsychotic injections. Br J Gen Pract 1998; 48: 1845–8. Kendrick T. Cardiovascular and respiratory risk factors and symptoms among general practice patients with long-term mental illness. Br J Psychiatryy 1996; 169: 733–9. Kendrick T, Burns T, Freeling P. Randomised controlled trial of teaching general practitioners to carry out structured assessments of their long-term mentally ill patients. BMJ 1995; 311: 93–8. Kendrick T, Burns T, Freeling P et al. Provision of care to general practice patients with disabling long-term mental illnesses: a survey in 16 practices. Br J Gen Practt 1994; 44: 301–5. Nazareth I, King M, See Tai S. Monitoring psychosis in general practice: a controlled trial. Br J Psychiatryy 1996; 169: 482.
Physical care • Regular preventative care, e.g. cervical cytology • Issues relating to alcohol or drug use • Smoking and heart disease (including history suggestive of arrhythmias) • Risk of diabetes from olanzapine and risperidone Medication • Accuracy of medication which the GP is prescribing Coordination of services • Community mental health nurse involvement • Inclusion of patient in Care Programme Approach • What services are actually being received (From NHS Confederation/BMA, 2003)
3
PSYCHIATRY 3:9
28
© 2004 The Medicine Publishing Company Ltd
THE BROADER PICTURE
FURTHER READING Burns T, Kendrick T. The primary care of patients with schizophrenia: a search for good practice. Br J Gen Practt 1997; 47: 515–20. (Practical, evidence-based guidelines developed by an expert consensus group.) Department of Health. National Service Framework for Mental Health. London: Department of Health, 1999. (Includes recommendations for primary and secondary care, and good practice examples.) Gask L et al. A Practical Guide to the National Service Framework for Mental Health, 30–31. Manchester: National Primary Care Research and Development Centre (wwwnpcrdc.man.ac.uk). (Includes practical guidance on setting up registers and implementing regular review.) New GMS Contract 2003. Investing in General Practice. London: NHS Confederation/BMA, 2003. (Includes a separate book of supporting documentation.)
The role of social care Craig Morgan
Social care is a generic term embracing all those services provided to ‘adults who require assistance with aspects of daily living as a result of disability, illness or ageing’ (Barton, 2000). All forms of mental illness have an impact – to a greater or lesser degree – on daily living, often impairing the capacity of sufferers to attend to domestic chores, sustain employment and develop and maintain supportive relationships. As the locus of mental health care has moved from long-stay institutions to the community (see pages 5–7), the importance of social care services in providing practical and emotional support to enable people with mental health problems to function successfully in community settings has grown. This contribution describes the range of social care services available relating to mental health, discusses the value of socialcare services in this field and considers the often problematic relationship between health care (psychiatry) and social care.
The range of social care services Agencies and activities Social care workers are employed by a range of agencies, both voluntary and statutory, and in a variety of settings, including: • hostels • day-care centres • community mental health teams (CMHTs) • patients’ own homes or localities. A wide assortment of tasks are undertaken, ranging from those that are relatively structured, such as welfare and housing advice and advocacy, to those that are more nebulous and unstructured, such as support, counselling and befriending. There is some overlap with health care professionals such as community psychiatric nurses, who often provide informal support and counselling. The diversity of tasks is reflected in the many job titles under which social care workers are employed: support worker, project worker, residential social worker, day-care assistant and so on. Within this broad group there are considerable variations in levels of training and responsibility, and many work part-time or on a voluntary basis. The majority are unqualified or have basic qualifications in social care, and only a minority are professionally qualified social workers.
Practice points
Social work Qualified mental health social workers are almost invariably employed by local authorities and attached to multidisciplinary
• People with SEMI often do not present for regular review in primary care • Practices can easily set up registers, using repeat prescribing data • Regular structured assessments can improve the process and outcome of care • Practices can now earn extra income for reviewing their SEMI patients
PSYCHIATRY 3:9
Craig Morgan is MRC Special Research Fellow in Health Services Research at the Institute of Psychiatry, London, UK. His research interests include ethnic variations in the use of mental health services, and social influences on the onset and course of severe mental illness.
29
© 2004 The Medicine Publishing Company Ltd
The role of the general practitioner in severe mental illness
– mean that these patients are at increased risk of developing chronic bronchitis, hypertension and angina (Kendrick, 1996). Mortality rates from cardiovascular and respiratory diseases are more than doubled in schizophrenia.
Tony Kendrick
General practice is essentially reactive: GPs and practice nurses wait for patients to come and see them or request a home visit. However, a significant proportion of patients with SEMI need to be sought out for review. GPs and practice nurses need to be aware of those who do not attend for review, in order to alert the CMHT to find out if the patient is experiencing difficulties. This involves reversing the usual assumption in primary care that if a patient does not return it means they are well. To be aware of who is and is not attending for care, the practice ideally needs a register of patients with SEMI. The NSF recommends that agreements should be reached between primary care and specialist mental health services to target care management resources for people with SEMI, and that practices should produce a register of such patients, to ensure that regular reviews are carried out (to include both mental and physical health problems).
The need for a register of patients with SEMI
Primary care teams and the care of severe mental illness The UK National Service Framework (NSF) for Mental Health (1999) urged mental health teams to stay in contact with all people with severe and enduring mental illnesses (SEMI), but in reality a significant proportion (25–30% of patients) will lose contact with psychiatric services and be looked after entirely in general practice (Kendrick et al., 1994). Even when patients are in contact with specialist services they still need the help of their GP as well, if only for repeat prescriptions and sickness certificates. Also, a significant number of people with chronic psychoses receive their regular depot neuroleptic injections from general practice nurses rather than community mental health nurses. It is very important, therefore, that GPs, practice nurses and other members of the primary care team have an understanding of the problems of their patients with SEMI, and know where to seek help when necessary. GPs do have a number of advantages to help them remain involved in the care of their SEMI patients. They have often known their patients as children or young people before the illness developed, and many people who will not attend psychiatric clinics are still happy to go to their own doctor’s surgery for care. Many community mental health teams (CMHTs; see pages 11–14) do not offer 24-hour care and the practice is often the first port of call for patients’ relatives when problems develop out of hours.
Drawing up a register of patients with severe and enduring mental illnesses Patients can be identified from the following sources: Practice data • Computerized prescriptions for patients on: • Antipsychotic drugs (oral and depot) • Anticholinergics • Antidepressants • Anxiolytics • Computerized diagnostic records or disease register, where appropriate • Patients being seen for depot injections by the practice nurse, where appropriate • Appointment lists of patients seen in surgery or on home visits in the previous 3 months (as a reminder of patients who are not on medication or seeing the nurse)
Physical and preventative care GPs and practice nurses have an important role to play in the physical care of patients with SEMI. High rates of smoking and obesity – in part due to the side-effects of psychotropic drugs
Mental health services data • Patients of the community psychiatric nurse • Consultant psychiatrists’ case-registers and out-patient records • Day-hospital patients
Tony Kendrick is a General Practitioner and Professor of Primary Medical Care at the University of Southampton School of Medicine, Southampton, UK. His doctoral thesis was a study of improving the care of people with long-term mental illness in general practice. He has written more than 60 papers, 20 book chapters and 4 books on mental health problems in primary care, including depression, eating disorders, bereavement and carers’ health, as well as schizophrenia and other severe and enduring mental illnesses.
PSYCHIATRY 3:9
Social services data • Social workers’ caseloads (From Kendrick et al., 1994)
1
26
© 2004 The Medicine Publishing Company Ltd
THE BROADER PICTURE
Drawing up a register of patients with SEMI Over 90% of patients with SEMI can be quickly identified, especially now that most practices are computerized, by listing all those already known to the primary care team and CMHT, combined with searching repeat prescription systems for psychotropic drugs (Kendrick et al., 1994). Figure 1 lists sources of information that might help in the construction of a register. Having identified the patients, the GP should check their records for current contact with psychiatric services; the GP should have been informed of all patients in receipt of the Care Programme Approach (CPA). Patients who are out of contact may benefit from referral back to secondary care, although a proportion of patients will decline referral, preferring to see their GP for continuing care.
lengthy, comprehensive psychiatric and social assessment of the kind performed in specialist out-patient clinics. Traditionally, GPs have been taught that the most efficient consulting style is to start with an open question and encourage the patient to set the agenda. This ensures that the patient’s concerns are quickly identified and can be addressed in the time available. However, this approach may be inappropriate for many people with SEMI. Those with negative symptoms (including apathy, inactivity, a poor self-image, self-neglect and indifference to discomfort) are unlikely to bring problems to their GP’s attention. A number of problems can build up which could lead to a crisis in care if not detected. What is needed, therefore, is a repertoire of specific closed questions to ensure that problems are not missed. Figure 2 shows a special record card designed for general practice Lloyd George-size record envelopes. On one side is important summary information which might be needed in an emergency – such as being called to see a partner’s patient on a Friday evening when everyone else has gone home – and on the other is a structured record focusing on important areas of mental and physical health and social functioning. There are now computer templates for paperless practices to use for their structured assessments of their SEMI patients. EMIS, probably the commonest system used in general practice, has a bespoke template.
The need for structured patient assessments Patient contacts in primary care are relatively short: an average of 8 minutes per consultation in the GP’s surgery, perhaps longer on home visits; practice nurse appointments may last only 5 minutes for a depot injection. Therefore GPs and practice nurses need a strategy to identify important problems or changes in their patients with SEMI quickly and efficiently. There is not time to carry out
General practice structured review card for patients with severe and enduring mental illnesses Side 1
Side 2
Name
DoB
Date
First diagnosed
Hospital no.
Medication Anxiety
Hospital admissions
Depression Hallucinations Relatives/other carers
Delusions
GP
Community psychiatric nurse
Consultant
Social worker
Psychologist
Occupational therapist
Appearance Behaviour Preventive Physical
Pattern of relapse Housing Important notes
Finance Daily activities
2
PSYCHIATRY 3:9
27
© 2004 The Medicine Publishing Company Ltd
THE BROADER PICTURE
by the nurses were not always dealt with by their GPs. It was concluded that joint GP and nurse assessments would be best, in special clinic sessions.
The evidence base A randomized controlled trial of setting up registers of the longterm mentally ill and teaching GPs to carry out structured assessments of these patients was carried out in 16 group practices in the south of England (Kendrick et al., 1995). The assessments were associated with clear changes in the process of patient care over a 2-year period. Changes in psychotropic medication, particularly neuroleptic drugs, and referrals for psychosocial problems, particularly to community mental health nurses, were significantly more frequent in the intervention group. However, most of the GPs in the study, who were self-selected for their interest in mental health, considered that there was not enough time in routine consultations to carry out the structured assessments. It seemed unlikely, therefore, that most GPs would be willing to do it. An alternative approach involved setting up special clinic sessions in practices to assess patients with SEMI, similar to those for asthma and diabetes that are already widespread in general practice. Nazareth and colleagues (1996) carried out a controlled trial of such an approach in four inner-London practices and found it to be generally feasible, and to lead to small but measurable improvements in symptoms on the Present State Examination and functioning on the Global Assessment Scale. A third approach was a randomized controlled trial of teaching practice nurses who give depot neuroleptic injections to carry out brief structured assessments during injection appointments and to bring any problems to their GP’s attention (Burns et al., 1998). The trial found that the practice nurses were generally unsure and anxious about the problems of people with chronic psychosis and keen to learn more about them. However, the impact of training nurses in structured assessments on patient care could not be demonstrated. This seemed to be because problems uncovered
Targeted payments in general practice Initiatives aimed at increasing the quantity and quality of reviews of patients with SEMI in general practice have the potential to change the process and outcome of care. Setting up registers and special review sessions is time-consuming, however, and competes with numerous other obligations in general practice. These initiatives therefore need to be promoted through targeted remuneration. Burns and Cohen (1998) showed that more practices in southwest London would set up joint GP/practice nurse assessments in response to the introduction of trial item-of-service payments for the initiative. The new General Medical Services contract for GPs in the UK, agreed in 2003, allows practices to earn more money if they adopt two quality indicators related to SEMI. Practices can earn seven points for producing a register of people with SEMI who require and have agreed to regular follow-up, and up to 23 further points related to the percentage of patients on the register with a review recorded in the preceding 15 months, which includes a check on the accuracy of prescribed medication, a review of physical health, and a review of coordination arrangements with secondary care. Figure 3 shows the recommended elements of the regular review for which practices can earn extra income under the new contract.
Conclusion People with severe and enduring mental illnesses are among the most vulnerable members of society. Motivating and rewarding primary care teams for focusing more of their efforts on this group has the potential to make a huge difference to their future health and life expectancy.
Recommended elements for the regular review of SEMI patients REFERENCES Burns T, Cohen A. Item-of-service payments for general practitioner care of severely mentally ill persons: does the money matter? Br J Gen Practt 1998; 48: 1415–16. Burns T, Millar E, Garland C et al. Randomized controlled trial of teaching practice nurses to carry out structured assessments of patients receiving depot antipsychotic injections. Br J Gen Pract 1998; 48: 1845–8. Kendrick T. Cardiovascular and respiratory risk factors and symptoms among general practice patients with long-term mental illness. Br J Psychiatryy 1996; 169: 733–9. Kendrick T, Burns T, Freeling P. Randomised controlled trial of teaching general practitioners to carry out structured assessments of their long-term mentally ill patients. BMJ 1995; 311: 93–8. Kendrick T, Burns T, Freeling P et al. Provision of care to general practice patients with disabling long-term mental illnesses: a survey in 16 practices. Br J Gen Practt 1994; 44: 301–5. Nazareth I, King M, See Tai S. Monitoring psychosis in general practice: a controlled trial. Br J Psychiatryy 1996; 169: 482.
Physical care • Regular preventative care, e.g. cervical cytology • Issues relating to alcohol or drug use • Smoking and heart disease (including history suggestive of arrhythmias) • Risk of diabetes from olanzapine and risperidone Medication • Accuracy of medication which the GP is prescribing Coordination of services • Community mental health nurse involvement • Inclusion of patient in Care Programme Approach • What services are actually being received (From NHS Confederation/BMA, 2003)
3
PSYCHIATRY 3:9
28
© 2004 The Medicine Publishing Company Ltd
THE BROADER PICTURE
FURTHER READING Burns T, Kendrick T. The primary care of patients with schizophrenia: a search for good practice. Br J Gen Practt 1997; 47: 515–20. (Practical, evidence-based guidelines developed by an expert consensus group.) Department of Health. National Service Framework for Mental Health. London: Department of Health, 1999. (Includes recommendations for primary and secondary care, and good practice examples.) Gask L et al. A Practical Guide to the National Service Framework for Mental Health, 30–31. Manchester: National Primary Care Research and Development Centre (wwwnpcrdc.man.ac.uk). (Includes practical guidance on setting up registers and implementing regular review.) New GMS Contract 2003. Investing in General Practice. London: NHS Confederation/BMA, 2003. (Includes a separate book of supporting documentation.)
The role of social care Craig Morgan
Social care is a generic term embracing all those services provided to ‘adults who require assistance with aspects of daily living as a result of disability, illness or ageing’ (Barton, 2000). All forms of mental illness have an impact – to a greater or lesser degree – on daily living, often impairing the capacity of sufferers to attend to domestic chores, sustain employment and develop and maintain supportive relationships. As the locus of mental health care has moved from long-stay institutions to the community (see pages 5–7), the importance of social care services in providing practical and emotional support to enable people with mental health problems to function successfully in community settings has grown. This contribution describes the range of social care services available relating to mental health, discusses the value of socialcare services in this field and considers the often problematic relationship between health care (psychiatry) and social care.
The range of social care services Agencies and activities Social care workers are employed by a range of agencies, both voluntary and statutory, and in a variety of settings, including: • hostels • day-care centres • community mental health teams (CMHTs) • patients’ own homes or localities. A wide assortment of tasks are undertaken, ranging from those that are relatively structured, such as welfare and housing advice and advocacy, to those that are more nebulous and unstructured, such as support, counselling and befriending. There is some overlap with health care professionals such as community psychiatric nurses, who often provide informal support and counselling. The diversity of tasks is reflected in the many job titles under which social care workers are employed: support worker, project worker, residential social worker, day-care assistant and so on. Within this broad group there are considerable variations in levels of training and responsibility, and many work part-time or on a voluntary basis. The majority are unqualified or have basic qualifications in social care, and only a minority are professionally qualified social workers.
Practice points
Social work Qualified mental health social workers are almost invariably employed by local authorities and attached to multidisciplinary
• People with SEMI often do not present for regular review in primary care • Practices can easily set up registers, using repeat prescribing data • Regular structured assessments can improve the process and outcome of care • Practices can now earn extra income for reviewing their SEMI patients
PSYCHIATRY 3:9
Craig Morgan is MRC Special Research Fellow in Health Services Research at the Institute of Psychiatry, London, UK. His research interests include ethnic variations in the use of mental health services, and social influences on the onset and course of severe mental illness.
29
© 2004 The Medicine Publishing Company Ltd