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The graduate mental health worker - a new role

Roger Rowlands
BSc(Hons) CPNDip RMN RGN
DipCounselling
Senior Lecturer in Mental Health Nursing
University of Central Lancashire
E:rrowlands1@uclan.ac.uk

The last decade has witnessed prominent policy developments and initiatives in mental health awareness, as evidence shows that 90% of mental health problems are treated in primary care and 25% of routine GP consultations are for patients with mental health problems.(1) With mental illness booming towards epidemic levels, there is evidence to suggest a global increase in the rates of depression. The World Health Organization predicts that by 2020 depression will be the second highest cause of injury and disease.(2)
From the author's extensive clinical experience, this group of patients are often patronisingly branded "the worried well". More often than not they represent "the worried bloody sick", with potentially debilitating conditions causing serious family, social and occupational disruption. Bowers found that this patient group also posed a high suicide risk,(3) which is further evidenced by the author in a paper presented at this year's European Mental Health RCN Conference,(4) which showed that 10% of patients presenting with "common mental health problems" had serious suicidal ideation. These people often have little knowledge of their "illness" or treatment information.
However, the latest new force within the NHS armoury to fight depression and associated disorders is just around the corner.
 
The "graduate mental health worker" (GMHW)
Certain questions may be asked about the role of GMHWs - what are their objectives? How can these health professionals best sit within existing mental health teams and primary care services? How can they reach their most effective potential? Can they really make a difference to primary mental healthcare? There have been concerns regarding the need for yet another discipline in mental health primary care. Equally, there is apprehension and confusion about what they will do that isn't already being done. Why the choice of name "worker"? This does appear an amorphous term to use, but it probably encompasses the very nature of what appears, at the present time, to be an indeterminate role with varying dimensions of the actual "work" involved.
Optimistically, the GMHW could represent the beginning of a more robust primary care treatment package for the majority of mental health patients in the UK, leading to the development of a national template for the management of depression and anxiety, and providing consistency and integration of screening tools and effective treatments. Equally, it could run the risk of complicating an already complex service delivery with the "tribes" of therapeutic-based disciplines already out there.
The NSF for Mental Health places great emphasis and expectation on the primary care team to provide assessment and treatment of patients suffering "common" mental health problems.(5) The practice of primary mental healthcare has developed over time in an unsystematic, reactive way, leading to fragmented services and much confusion. Appropriate training is not currently widely available to the majority of primary care staff.
It is only recently that consideration has been given to the potential role that primary care nurses can play in relation to common mental health problems. Many patients see practice nurses as user-friendly sources of psychological support at times of emotional distress and illness. Yet in a national survey of practice nurses, Gray et al found that only 3% possessed the RMN qualification.(6) The GMHW is ideally placed to provide support for these often underacknowledged staff.
Recent research carried out by the Depression Care Training Centre found that 86% of respondents from a variety of community nursing disciplines felt the need for mental health training courses.(7) This mirrors past research by Thomas and Corney,(8) where 91% of practice nurses wanted more training in this field, the most significant reason being the deficit in educational knowledge and practical skills in meeting the needs of the patient group.
This new initiative proposes to meet the needs of the general practice population by training the GMHWs in the detection, assessment and treatment of mental illness in the primary care environment. It will address the issues emerging from key policy developments. Richardson suggested an increase in the number of skilled and ­effective primary care staff to deliver four of the seven standards that make up the core of the NSF:(9)

  • Standard 1 - mental health promotion.
  • Standards 2 and 3 - primary care and access to services.
  • Standard 7 - preventing suicide.

This led to the idea of developing a training programme with both clinical and theoretical components, which has the flexibility needed for the potentially politically turbulent times ahead in primary care. Within the northwest of England the successful collaborative bid involved the University of Central Lancashire and Liverpool John Moores University, with Manchester University taking the lead role in providing the training. The one-year programme will be available to 1,000 graduates holding first degrees in health-, psychology- or social science-related subjects. Despite the complexities that exist with respect to funding and placements, detailed liaison with Strategic Health Authorities and Workforce Confederations will provide a clearer idea of the number of workers intended for each PCT.
The training and education of the GMHW will cover the broad topics of policy, service structure, mental health and illness, therapeutic engagement and interventions.
To survive, this new group will need a pragmatic understanding of the culture and processes of primary care. This is essential to maximise the graduates' effectiveness in this complex and often "referral-bombarded" and policy-driven environment. Familiarisation with the wider organisation, both the statutory and voluntary sector, is crucial to provide essential information to support the posts.
Key aspects of the role will emerge, such as face-to-face contact with patients suffering "common" mental health problems such as depression and anxiety. Assessment and effective communication skills will be essential. Fundamental components of the training will focus on low-intensity psychological treatments, for example problem-solving and brief therapy. These may use some of the components of cognitive behavioural therapy (CBT) due to the efficacy of this approach.(10) Facilitated self-management of mental health problems, which has a strong evidence base,(11) will run parallel to this (eg, computer-based CBT, self-help information material and mental health promotion). The GMHW will not manage complex and severe cases, nor work in isolation.
Providing the expectations are realistic, the GMHWs may be instrumental in the active management of practice-based mental health disease registers; in addition, they could develop local databases of services available for patients and carers. Supporting GPs in follow-up appointments regarding medication compliance may well turn out to be a useful role. Skills in audit and possibly research could also prove of value, although that may be somewhat optimistic at this stage.
One question raised is whether more "verbal Prozac" can actually make a real difference, or is this a token gesture to address past imbalances of funding for the largest group of mental health users. Overall, the author's perspective is that mental health in the community cannot realistically hope to improve by the addition of more specialist mental health services. Only by expanding the capacity in primary care, with partnerships in education, can real advances be made in the quality and quantity of the provision of mental healthcare for the population. Collectively this represents a new challenge for centres of education and training, existing clinical staff and PCTs.

Conclusion
The NSF appears to offer many new developments and opportunities for both service users and providers. To achieve these positive objectives there are a number of critical challenges ahead. It is to be hoped the main ambitious foundations are now in place. Potentially a great deal has to be achieved to meet the government standards to pragmatically make a difference to the mental health of the nation. The Department of Health has set targets for all 1,000 workers to be in post by December 2004. The question that still needs answering by the Department of Health is around the issue of career structure and progression for the students postqualification. In the present climate, mental health has received a huge amount of national attention; the general public's expectations have equally gathered momentum. The media has become more active, playing the part of mental health promoter and executor. The primary care services need to improve their standards or risk an increasing assault by both media and patients alike. The outcomes as yet remain elusive.

References

  1. DoH. The NHS Plan. London: HMSO; 2000.
  2. WHO. The world health report 1999. Geneva: WHO; 1999.
  3. Bowers L. Community psychiatric nurse caseloads and the "worried well": misspent time or vital work. J Adv Nurs 1997;26:930-6.
  4. Rowlands R. A 5-year audit of an ­independent primary care mental health/counselling service. Presented at the 8th European Mental Health Nursing Conference, London; 2003.
  5. DoH. National service framework for mental health. London: HMSO; 1999.
  6. Gray R, et al. A national survey of practice nurse involvement in mental health interventions. J Adv Nurs 1999;30:901-6.
  7. Maloney S, et al. Development of new courses for primary care nurses. J Prim Care Mental Health 2001;5(2):28-30.
  8. Thomas R, Corney R. Working with community mental health professionals: a survey of general practitioners. Br J Gen Pract 1993;22:417-20.
  9. Richardson A. Graduate primary care workers. The content and process of one year, full time training. Draft Discussion Paper; 2002.
  10. Richards D, Lovell K. Multiple access points and levels of entry (MAPLE): ensuring choice, accessibility and equity for CBT services. Behav Cognitive Psychother 2000;28:379-91.
  11. Bower P, et al. The clinical and cost-effectiveness of self-help treatments for anxiety and ­depressive disorders in primary care: a systematic review. Br J Gen Pract 2001;51:838-45.

Resources
Fast-forwarding primary care mental health Publication from the Department of Health and National Institute for Clinical Excellence
Available from W:www.doh.gov.uk/mentalhealth/fastforwardguidancejan03.pdf

Sainsbury Centre for Mental Health
W:www.scmhonline.org.uk/wbm23.ns4/weblaunch/launchme