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Working across primary and secondary care boundaries

David Harding-Price
RMN DipSp&C DADNcert
Forum for the Development of Mental Health Nursing
Royal College of Nursing
GP Liaison Nurse

As the NHS moves into the 21st century it aims to provide healthcare in an increasing number of new and innovative settings. As a result staff, in particular nurses, are increasingly working in new environments, for example walk-in centres, NHS Direct, GPs' surgeries, patients' hotels and local ­shopping centres. These are in addition to those places where community and district nurses have been working for many years, for example patients' homes, secondary clinics, homeless shelters and health centres. At the same time, with the reduction in the length of time people are spending in hospital, more specialist nurses are becoming required in primary care settings to provide pre- and post-hospital ­treatment.
Over the past 20 years I have been working with GPs and primary care teams in bringing mental health nursing direct to patients in the primary care setting. Until recently this has mainly taken place in the GP surgery; however, more recently it has included working with voluntary sector establishments, local coffee shops and even street corners. To achieve this required the development of different ways of working and thinking, including:

  • Building daily working links between primary care and community mental health teams.
  • Developing relationships beyond that of the recognised "CPN and social worker" or "CPN and the psychiatrist" to ones with workers in a wider range of fields inside and outside of healthcare, both in the statutory and nonstatutory sectors.
  • Providing a "first-aid" crisis mental health service in the primary care setting.
  • Being willing to meet the patient where they want rather than where the "trust" designates.
  • Looking for, and in some cases developing, ­alternative systems to try and avoid ­hospitalisation.
  • Supporting primary care staff in working with those who have mental health problems to enable care to be provided in a single location as much as possible.

Much of this is now becoming the bedrock of the modern CPN. However, there is a need to take this further to encompass staff from outside the mental health field. CPNs that are placed directly into primary care, while supporting other staff, are also able to partake in clinical work - this has to be a requirement in a modern health service because it has a number of benefits. These fall into three categories: the patient (for patient also read client), the carer or relative, and the service.
From the patient's point of view the benefits of having a CPN in their surgery is that they:

  • Speed up links with the mental health services, which are often secondary care providers.
  • Cut down waiting times for assessment.
  • Allow for early intervention.
  • Reduce the need for secondary care.
  • Can reduce the need for admission.
  • Reduce the stigma of mental illness.

For relatives and carers the advantages are that they:

  • Can access a mental health professional at the same place as they access other care for their ­relative.
  • Have a feeling of inclusion on a daily basis with the decision-making process.
  • Can easily talk with a mental health professional during times when the person with the mental ­illness is not accessing mental health services.

While from the primary care professional's viewpoint it allows for:

  • Access to a mental health professional on a ­regular basis, often daily.
  • Faster access to consultants, talking therapies and the multifaceted mental health teams, be that at secondary or tertiary level.
  • Support in clinical decisions.
  • Better all round healthcare for their patients.
  • Enhancement of the practice budget with monies being spent in a more targeted way (it can lead to an increase if funding comes from the Primary Care Trust to cover the cost of the CPN post).

However, there is one almost overriding benefit from the patient's point of view. Having a CPN at their GP practice supports their right to have a key say in their care. Many practices with mental health staff are working towards directly involving the user and their carers at the point of delivery, be that by having user groups to look at how the surgery approaches care of the mentally ill, or providing inhouse support groups for carers. This is particularly important from the perspective that it is the carers who are with the person 24 hours a day, 7 days a week and not the NHS or social service staff. At the same time it brings another area of primary care into line with government strategy.(1)

How far we've come
As mental health moves into the 21st century the provision of care moves to include a wider audience. Before the 1800s care for the mentally ill was provided within the village or neighbourhood. At that time local communities often tolerated the behaviour of most people with mental illness, assuming them to be possessed and turning to the Church for treatment - unfortunately this led to some being seen as witches and attended to accordingly.
In the 1800s the large Victorian asylums were built on the outskirts of most towns and cities and people with mental illness were "locked away" to be treated by doctors and cared for by attendants (see Figure). By the 1960s the policy was shifting towards the provision of community care and the inclusion in the care process of other professionals. Consequently by the 1980s and 1990s, most of the asylums were closed and their land sold, hence the birth of the community mental health team. Most teams were managed by nurses and consisted of nurses, doctors and occasionally social workers and occupational therapists. Today these teams are commonplace and have expanded to include many other disciplines.
The 21st century sees not only mental health nurses, but also practice-based nurses and other primary care nurses working cooperatively with a much wider range of professions. These range from the local voluntary sector provider/s, primary care teams, social services, accident and emergency departments and hospital wards, to education departments, local businesses, ­benefit agencies and criminal justice workers.
Having a CPN based in the GP practice appears to work. In the past 4 years referrals from the practice I work in to the community mental health team have dropped from around 140 per annum,(2) to under 25 per annum.(3) This is in part due to the provision of clinical mental healthcare in the practice, and support to the other members of the primary care team. Patients report that they prefer to be seen in the practice with some actively refusing to be seen at the local mental health unit.
The treatment programme is planned at the first or second session when the number of sessions before the next review is agreed. Some patients go on to make long-term care arrangements while others have brief interventions lasting only a couple of months. For some a single or a couple of sessions is all that is required.
All my patients are offered a small business card, which carries my name, surgery contact details and the trust name and telephone number. Some accept it and then carry it so that they can show it to people if they are in a crisis, allowing the person dealing with them to contact me in the knowledge I will have some current information about the person. In the past police, community mental health teams, accident and emergency departments, probation services, university tutors and prison officers from both inside and outside London have contacted me about my patients.
As a nurse, by linking in with organisations and agencies that your patient may have daily contact with, you are working with the patient towards normalising their life. For some patients discussing their mental health problems with their employer or social worker is something that they fear because of the consequences, perceived or real. For others their fear is telling hospital staff about their mental health problem when they go in for an operation. Equally a patient may present at accident and emergency, but may not be well enough to explain what they need in the way of help.
As budgets become tighter with increased demands to provide acute care, there is a need for as many services to be provided at the first point of contact so that costly secondary or tertiary services can be possibly avoided. Money apart this also provides for a better quality of care for the patients.
For the person with mental health problems links with the voluntary sector are becoming increasingly important. The voluntary sector's asset is time. Often they can provide services that the local social service or NHS teams cannot because of the pressure of work caused by the acute sector. As a result they can spend time working with patients, carers and relatives, looking at for example daily living needs. However, for the voluntary sector to be able to do this requires the support of a CPN with good clinical knowledge of the patient.
Modern health and social services are measured by their outcomes. It is argued that better services for patients and the community as a whole are provided if the set outcomes are achieved, although it has to be asked who sets these outcomes? If the outcome is cost then the provision of a CPN in the GP's surgery has been shown to save money by reducing referrals and admissions. If the outcome is set as being patient satisfaction then again this has been shown both anecdotally and in audit.(4)
However, there are other outcomes that can be used which are arguably more important to modern mental health. One is the reduction in stress for other clinical staff. They feel supported and are able to cope with mental health issues (even if only in the early stages) presented to them in their primary care setting. Having the CPN "at hand" allows them to work with people who otherwise would be sent direct to the secondary service - the mental health team.
For the patient the fact that they can see their CPN in the surgery can allow them to continue to hold down a job or in some cases get their first job. The stigma is reduced while services can be built around surgery hours, making them more accessible and safer for the staff member.

It has been said that every organisation needs mavericks, "the people who think outside the box and come up with the zany ideas that just might work".(5) While some may still argue that putting a CPN in a GP surgery is an expensive luxury, the benefits to the patient, the service and society as a whole far outweigh the pump priming and revenue costs.
If the only success is that patients keep their appointments then it has been a success. Once the patient is in front of the clinician then the opportunity for a caring dialogue is presented and this can lead to an improvement of the patient's quality of life. This is the ultimate outcome that everyone within the caring profession aims to achieve.


  1. Department of Health. Modern ­standards and service models - Mental Health National Service Framework. London:?The Stationery Office; 1999.
  2. Marriott S, Emmanuel J, White T. Primary care project. London: North West London Mental Health Trust; 1998.
  3. Harding-Price D. Annual report 2002. London: Central and North West London Mental Health NHS Trust; 2003 (in press).
  4. Harding-Price D. Annual report 1998. London: North West London Mental Health NHS Trust; 1999.
  5. Finn W. Managing mavericks. Live Wire (GNER Magazine) 2002;Oct/Nov:20-4.