Historical Event – Mental Health in Primary Care

Mental Health in Primary Care

The Event

Last year, Implemental had the opportunity to organise and support a historical event on the history of mental health in primary care in England.

The project was funded by the Psychiatry Research Trust through a grant provided by Chairman Tom Craig.

The event was run in the form of a witness seminar, this is a specialised form of oral history allowing us to capture aspects of lived experience from those involved. This was run with the intention of creating a collaborative resource to inform historians, policy makers and those working in primary care.

The resource has taken the form of a discursive transcript which is publicly accessible on the Royal College of Psychiatry online library.

Project Leads

The project was led by three GPs, two of whom were working in primary care in the 1980s:

André Tylee, MD, FRCGP, MRCPsych (Hon), FRCPsych

Emeritus Professor of Primary Care Mental Health in the Health Services and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London and the NIHR South London ARC, UK.

Alan Cohen, FRCGP

Retired GP and Board Member, Oxfordshire Mind, Oxford, UK.

Lydia Thurston, MRCPsych

Psychiatrist, Part of The Community Learning Disability Team, South Oxfordshire, Oxford Health NHS Foundation Trust, UK.

Memorable Quotes

After a background study of historical literature, the leading team outlined three stages of development which were driven by national policy and culture:

Delivering Primary Care by Relationships: The Balint Era (1960 – 1989)

“In clear and memorable language, Balint articulated a new and much expanded role for GPs, which went far beyond patients’ physical health to include their emotional and psychological wellbeing as well. His ideas were highly influential and strongly permeated the early architecture of General Practice.” – Andrew Elder, GP

“I can only say that, as someone who’s been a patient myself, I have absolutely no doubt that relationships are key. And for me, continuity of care was absolutely key. And that continuity is something that we don’t have now, that we did then.” – Linda Gask

“I think one of the problems we have increasingly devised systems where the relationships are unimportant, that no one knows anyone anymore. So GPs now, not only do they not know their patients, they don’t know their receptionists, the receptionist they don’t know them. They certainly don’t know their colleagues. All these things were untrue when I first joined.” – David Zigmond

Delivering Primary Care by Money: GP Fundholding and the Purchaser-Provider Split (1989-2995)

“First of all, fundholding was about relationships. And I think it was almost a leadership incubator for the next 10 or 20 years through fundholding I met Alan Cohen, Geraldine Strathy, and so on. And then tremendous influence on the whole landscape of mental health over the years because of that, it was the first time for a long time that stakeholders, patients and GPs and others were actually listened to and had some ability to change things.” – John Hague

“I think for me the broader issue is how do you commission and/or provide services for populations with needs, whether their populations with mental health needs or populations with comorbidities, or frailty, or wherever? And I think fundholding was an experiment, which, as we said, did have lots of problems, but also maybe arguably some benefits.” – Nav Chana

“All sorts of terrible things about fund holding. Absolutely. And all the things that you know, Tony said, were absolutely right. But there was still an opportunity that if you wanted to improve the care of your patients, you had to grasp and we were faced with a terrible decision we could have not grasped and not improved service for our patients or do we swallow our morals and ethics and do something about trying to improve our practice?” – Alan Cohen

Delivering Primary Care by Guidelines: IAPT (2005-2019)

“And if you had a good idea, and you could sway your local agency, there was autonomy and those innovations without constraints. And I think this concept of regulatory culture is again quite a useful thing to get our head around the whole tension between quite proper improvement of clinical practice, but also allowing autonomy and clinical practice.” – John Hall

“Some IAPT services are considerably better. And we really, really ought to try and learn the lessons from those really good ones, and push them on to the services that aren’t good enough because some are up to 70%+ recovery in many cases, and that’s an achievement.” – John Hague

“I’m also a little bit uneasy about that we’ve really overlooked older people’s mental health, in particular, the dementias today. And I think in terms of protocols and guidelines, I just wonder how much, when the acetylcholinesterase inhibitors were introduced, how much that de-skilled GPs from the dementia slide because they’ve had to be prescribed through secondary care.” – Clare Hilton

Further details of the project can be found in this editorial written by the project leads.

A note from the team

Implemental would like to thank Tom Craig and the GP event leads for commissioning this historical event.

Implemental would also like to thank all of the attending speakers and guests for their enthusiasm and invaluable contributions to the project.

Finally, Implemental would like to thank the Royal Society of Medicine, the Royal College of General Practitioners and the Royal College of Psychiatry for archiving the event transcript.