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Bridging the gap in mental health.

The past 15 years in mental health services throughout the country have seen significant changes. The interface between primary and secondary care has been one area that has suffered from seemingly constant flux and transition. Services have become more specialised but consequently more fragmented, making access at times difficult and confusing for patients and their GPs. This interface is pivotal in ensuring patients' acute and ongoing care is managed throughout their treatment, which in mental health can be years. Primary care must also feel it can easily and readily call on specialty services for advice and consultation. Recognising the need for a more collaborative approach to deliver "best care and good outcomes for mental, health consumers," mental health services (MHS) within Canterbury District Hearth Board (CDHB), and Pegasus Health, the trust comprising most GPs in Christchurch, formed a joint venture known as Access Canterbury. This is an attempt to bridge the gaps and facilitate better collaboration and co-operation between primary and secondary care.

Access Canterbury has developed a number of projects, the MHS/GP liaison position (my role) being the most recent, beginning in February this year. The pilot project is working with five general practices with a total of 14 GPs, in north west urban Christchurch. There is a budget, jointly funded by Pegasus and CDHB, to encourage the practices to spend more time in assessment and management of patients with mental, health problems. The pilot covers those with mild depression or anxiety to those who are seriously mentally ill. There are around 100 such patients in the five practices. My role is to assist the practices manage mental, illness, to provide education and to be a link between all services in their management of mental illness. When I first heard this position was being developed I was immediately attracted to the concept of working so closely with primary care. In my previous role as a "frontline" nurse at the psychiatric emergency service, I often had to deal with GPs who were often anxious, sometimes angry, frustrated with the strict criteria we had before we would do an urgent psychiatric assessment. As one of the GPs now on the pilot programme put it, the patient" had to be ready to jump off a bridge" before we would readily offer an appointment. We just didn't have the resources to offer an assessment in the time frame the GP was wanting. I saw my new role as being able to assist the GPs, quickly, in the patients' and GPs' environment.

From my previous experience in community-based secondary care, I sensed GPs' knowledge and skill in mental, health assessment and treatment was somewhat Limited and their threshold for referral to secondary services relatively low, often resulting in "soft" referrals. After six months in this position I have been pleasantly surprised to the contrary. Generally, most GPs I work with manage people with some very complex mental health problems with a good skill and knowledge. The threshold for referral is also much higher than I previously thought. Often they don't do things the way we in mental health services do them, but none the less, they generally do them well and with great care and compassion.

Working in primary care has been a huge culture shock for me, having worked in MHS for 30 plus years. Probably the most striking aspect bas been the number of patients seen each day in the practices and the need for economy of time to assess, treat and manage them. Documentation is refreshingly succinct, as is discussion about cases.

Another area which took some adjustment was the role of nurses within the primary care "team". In MHS, nurses are more actively involved in assessment and treatment and are an integral part of the case management of patients. Although clearly an integral part of the practice team, practice nurses by the very nature of most general practices, tend to be more task orientated and generally they don't see themselves--nor do the GPs see them--as equal players in the treatment process. Practice nurses also John significantly underestimate how much mental health care they deliver in their daily practice. Although some still minimise their importance in mental health care delivery, most thankfully have embraced the project and have increasingly sought me out for more education and advice on mental health issues. One nurse, with support from the GPs in the practice, is regularly doing phone and one-on one follow-up sessions with depressed patients. The feedback from all concerned has been very positive.

Recent statistics on the poor physical health and mortality rates of patients with serious mental disorders are alarming. (1) One of the reasons identified was the Lack of clear Lines of responsibility in their physical care. Currently we are using the pilot project to target this group and ensure they get the full benefit of primary care and practice nurses will be fully involved in this ongoing process of assessment, treatment and monitoring.

Mostly, this has been a very positive experience. My respect for my colleagues in primary and secondary health has been immensely enhanced and I am grateful for this unique insight into primary care.

And the future? Given that at Least 20 percent of patients presenting to their GP will have some degree of mental disorder, it is imperative we all work together to deliver the best outcome to patients. Initiatives such as this pilot will be part of that, but all clinicians have a duty to ensure they liaise with any health professional involved in the care of their patients. I look forward with great optimism to being part of this continuing collaboration.


1) Handiside A. (2004) "Our Physical Health ... Who Cares?" Mental Health Commission Occasional Paper, No 5. Wellington: Mental Health Commission.

John Halligan, RPN, is the mental health services/GP liaison nurse for a joint venture between Canterbury District Health Board and Pegasus Health in Christchurch.
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Title Annotation:Editorial
Author:Halligan, John
Publication:Kai Tiaki: Nursing New Zealand
Geographic Code:8NEWZ
Date:Sep 1, 2004
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Next Article:The dangers of diminishing the EN role.

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