The Primary and Secondary Care Interface in Adult Mental Health

The Primary and Secondary Care Interface in Adult Mental Health

The Primary and Secondary Care Interface in Adult Mental Health





August 2007



1 – 5communication and 4


6 – 10assessment and 5


11 – 16treatment and5-6


17 – 19care planning, monitoring7


20 – 22discharge and7-8

transferring care

23 – 24raising concerns 8


This document sets out the minimum standards for communication and practice between primary care and secondary mental health services including issues described as shared care.

The Haringey Primary Care LIT Committee following wide consultation and agreement has written it. This committee will have responsibility for auditing the use of this document and any future review.

Shared care within mental health practice has been defined as a process of collaboration between the General Practitioner and the psychiatrist that enables the responsibilities of care to be apportioned according to the treatment needs of the patient at different points in time in the course of a mental health problem and the respective skills of the GP and psychiatrist (1).

This paper takes the position that when a patient is receiving secondary service interventions, there is always shared care between general practice and secondary services. What requires clarity in these situations is who is taking the lead for what, who is responsible for what interventions, how and when the GP and psychiatric team communicate with each other and who and how clinicians take responsibility for ensuring the highest quality of care.

It should be noted that however clear and effective these standards are, they cannot replace the need for clinicians talking to each other within and across the interface. Whilst this document aims to support and encourage these communications, each clinician has a responsibility to foster good inter and intra professional and agency relationships.

This document clarifies who should be doing what where when and how. It has been written in the context of the significant improvements and changes being made to specialist community mental health services. These agreed standards will form the baseline for future audits of interface practice. Expected outputs from implementing these standards will be clearer plans in place for service users, with improved health outcomes.

1. Kates N, Craven C, Bishop J, Clinton T, Kraftcheck D, LeClair K, and others. Shared mental health care in Canada. Ottawa (ON): Canadian Psychiatric Association (CPA) and The College of Family Physicians of Canada; October 1997.

Service Issue / Primary Care Responsibilities / Secondary Care Responsibilities
1-Communication & Information / The PCT Primary Care Performance team to provide secondary care Mental Health services with information about GP practices in each locality; including details of GPs, practice nurses, practice managers, contact numbers and opening times - updated at least once a year. / Secondary care services to provide GP Practices with up to date information about their services & teams, including key contact numbers in the START service, Support and Recovery Teams (SRT), Crisis and Home Treatment teams; and to provide the mental health lead for each PBC collaborative with details of AMH link workers and their corresponding surgery – updated at least once a year.
2-Communication & Information / Each PBC collaborative to have a named Mental Health GP Lead, and each practice to have a named surgery contact to take on coordinating role for the practice in relation to mental health. / SRTs to have a named Link-Worker for each GP practice, who will help arrange and coordinate liaison meetings with practice and be contact person for queries about MHT working/ policies and help facilitate clinical interface issues
(NB.coordinators & linkworkers will not work clinically with all practice patients)
3-Communication & Information / Practices to have regular (e.g. quarterly) face-to-face mental health meetings with clinicians from the MHT, and other mental health professionals working with the practice (counsellors, primary care psychologists, etc.). These meetings should help with case management issues and consultation of surgery case issues.
Precise arrangements should be negotiated between the practice and mental health team. / START and SRTs to ensure availability of senior clinical staff to attend liaison meetings (this could be senior psychiatrist, Team Manager or other senior clinician).
Meetings should occur once a year as a minimum, with arrangements flexibly negotiated
4-Communication & Information / GPs to use MHT generated patient list to formally cross reference with their practice information including SMI register / Teams to provide list of patients from each practice on CPA for liaison meetings.
Local arrangements to be made to facilitate flexible phone/email contact with MHT as appropriate.
5-Communication & Information / Practices to have a mechanism in place to ensure that SMI register is reviewed at least once a year and is up to date. The review will examine care plan, consider if mental and physical health needs are being met, and adjust the care plan accordingly. / SRTs to ensure that patient/CPA list is kept up to date
6- Assessment & Referral / GPs should be familiar with steps one and two of the stepped care model and will demonstrate assessment and interventions at these levels in referrals to secondary care services
All acute referrals (other than those requiring an emergency police, ambulance or A&E response) will be made to the START service on 020 8442 6714 / Link workers should be available to help liase and consult with GPs on issues of service threshold and appropriate referrals
The START Service to be available by telephone to GPs to help and advise re threshold issues.
The START service will ensure that they are available to consider any acute referral at any time.
7- Assessment & Referral / GP should use standard assessment tool (i.e. HADS or PHQ9) to assess patients with possible depressive and anxiety illness as per clinical standards
The PCT are responsible for ensuring that clear care pathway for accessing primary care (step 2) psychological and talking therapies are provided. / Secondary care services to provide primary care with information on:
  • How to access START Service
  • Role of:
- Crisis Response Teams
- SRTs
- Psychiatric assessment and
- Psychology assessment and
8- Assessment & Referral / When making a referral to the START Service GPs will provide adequate information including; the urgency of the referral, what’s changed since previous contact with members of the mental health team, presenting problems, physical condition and family details.
The GP perceived need for specialist intervention must be clear / If further information is required from the GP in order to process the referral, START will contact the GP.
START will inform GP of proposed response to referral at least within 5 working days
MHT will offer patients an appointment within agreed time frames following referral. Details of appointments offered will be communicated to GP within 2 weeks of decision.
9- Assessment & Referral / GPs should be familiar with the core functions and eligibility criteria for secondary care mental health services in order to make appropriate referrals. / Following an assessment, services will send GPs initial brief written communication within 10 working days, with details of the assessed need, proposed care plan and name of care co-ordinator/ key contact person.
10- Assessment & Referral / If unsure where/ if to refer, the GP will phone START on 020 8442 6714 for advice
11- Treatments and interventions / GPs and practices will be up to-date with treatments and interventions, offering interventions at step 1, 2 and 3 of the care pathway, including pharmacological and talking interventions / Primary care talking therapies and psychological interventions based on best evidence will be available to GPs for their clients, provided by the PCT, BEHMHT and voluntary sector.
12- Treatments and interventions / GPs will ensure that evidence of treatments provided within primary care are communicated to specialist services when referred / Referrals to specialist mental health services via the START Service will be triaged on the day of receipt, with speed of direct assessment dependant on perception of need.
13- Treatments and interventions / GPs will ensure that pro-active physical health checks and health promotion activities are undertaken and recorded on SMI register and patient record at least once per year.
14- Treatments and interventions – drug prescribing / Referral of the patient to the GP by the psychiatrist for continuing psychiatric medicine management will be subject to the GP’s agreement
However, practices are expected to provide medicine management including anti psychotic depot and lithium medication where the patients needs warrant sole primary care management.
Specific drug shared care agreements will be followed.
(see lithium shared care protocol) / Prescribing responsibility will only be transferred when the Consultant psychiatrist and the patient’s GP consider the patient’s condition to be stable or predictable. Transferred care will be documented on care programme and crisis planning documentation
15- Treatments and interventions - Physical care / GPs hold key responsibility for the physical care of their patients
The GP will ensure that any patient on the practice SMI register will be actively offered a yearly physical health review.
The GP will ensure that universal health promotion activities are targeted to patients on their SMI register.
GP practices will ensure that the whole staff team, particularly the practice nurse, have the necessary skills to work with the physical health needs of patients on the SMI / Specialist mental health teams will ensure that the CPA process formally considers the physical health needs of the patient, including issues such as smoking, eating, exercise and access to wider health agencies such as dentists and optometrists.
16- Treatments and interventions- Physical care / GP practices will ensure that they have a system in place to assess the emotional needs of their patients with known long-term physical health conditions.
17- Care Planning, Monitoring, CPA and SMI / GPs to contribute information to CPA reviews via liaison with Care Coordinators (e.g. using proforma or by attending meeting).
If other primary care staff (e.g. Practice Nurses) are involved in providing care, they should also contribute to CPA reviews.
Contribution should include issues of emotional and physical health / Care Coordinators to keep GPs fully informed through the CPA
process. CPA’s should highlight any specific interface issues, as well as clear crisis and contingency plans
Care Coordinators to invite all GPs to participate in CPA reviews, either by verbal/written report (eg proforma) or by invitation to attend. (This may involve holding CPA review at the GP practice at a mutually convenient time).
Care Coordinators to inform GPs about any significant changes in the care plan – including changes in medication, change of Care- Coordinator, discharge from care; or significant events (e.g. violent incidents).
18- Care Planning, Monitoring, CPA and SMI / Practices will update SMI registers within 5 working days following being made aware of changes to CPA plans. Practices will ensure that the SMI clearly references the users crisis and contingency plan
GPs to keep the Care Coordinator informed of any significant changes to psychiatric medication and any significant events / Care Coordinators to send GPs a copy of the Care Plan following reviews (within 5 working days).
19- Care Planning, Monitoring, CPA and SMI / GPs to take responsibility for managing physical healthcare issues – inform Care Coordinator of relevant significant changes (within boundaries of patient confidentiality).This should happen at least once a year, and be recorded on the SMI register. / Care Coordinators to inform GPs of any concern about physical health problems and actively support and encourage patients to access primary care and health improvement services.
20- Discharge and transfers of care / GP should inform MHT if there is reason to remove one of MHT patients from their list. Management of such patients should be discussed in mental health liaison meeting if possible. / Inpatient units will contact GPs by telephone prior to discharging patients from hospital. Units will contact GPs by telephone on the same working day if a patient self-discharges.
21- Discharge and transfers of care / SRTs, crisis and home treatment teams will discuss and agree discharges of patients from their service with the GP prior to discharge. Agreement to the discharge by the GP will be dependant upon the completion of a comprehensive crisis and contingency care plan.
22- Discharge and transfers of care / GP practices will ensure that they have informed the relevant MH team of newly registered patients who are being added to the practice’s SMI register. Within 10 working days / START Service will ensure that the GP has a record of completed care within five working days of a patient’s discharge.
22 – Discharge and transfers of care *Patients who do not attend or who seem lost to follow up / If a GP/practice are unable to contact a patient (including non attendances - DNAs), they will discuss matter with the MHT (for patients who are under the care of MHT)
When a patient with significant mental health difficulties repeatedly DNAs practice appointments (3 consecutive times or more) a plan must be put in place to attempt to actively engage them before removal from the list can be considered. Patients should never be removed from a practice list when non attendance is due to the impact of active symptoms. When a patient is under the sole care of primary care, and the surgery is unable to contact them, the matter should be discussed in practice meetings, and a plan agreed on how to proceed
The PBC mental health lead and PCT clinical specialist are available for consultation in these matters / When a patient know to MHT is not contactable the MHT must discuss the matter with the GP.
For DNAs, the MHT will follow their current policy. Assertive and proactive attempts to make contact should be made.
If a patient does not attend a first appointment, this must be discussed with the referrer and communicated to the GP, so that further primary care management can be considered.
23- Raising concerns about interface communication / GP and their teams will agree to raise any issues of difficulty and concerns with interface or communication with the mental health worker directly in the first instance. / MH team will agree to raise any issues of difficulty and concerns with interface or communication with the GP practice directly in the first instance.
24- Raising concerns about interface communication / If issues are not resolved, the GP practice will cascade the issue to the mental health GP lead for the PBC collaborative, and/or the PCT clinical lead for primary care mental health
Issues of concerns will be managed by primary care clinical specialist in collaboration with BEHMHT AD. Matters will be formally reported to the joint primary care LIT committee. / If issues are not resolved, the Manager of the MH team will cascade the issue of concern to the inpatient or community assistant director for BEHMHT.
Issues of concerns will be managed by primary care clinical specialist in collaboration with BEHMHT AD. Matters will be formally reported to the joint primary care LIT committee.


Haringey primary/secondary mental health communication agreement. 1st edition august 2007