The Role of Primary Care

The Role of Primary Care Helen Lester , University of Birmingham February 2012

What I’m going to cover • Physical health problems in primary care • Primary Care’s attitudes • Primary Care’s business

Physical health • People with psychosis die on average 16-25 years sooner than the general population (Parks J et al. 2006. Morbidity and Mortality in People with Serious Mental Illness.13th technical report. Alexandria. Virginia) • They have higher rates of respiratory, cardiovascular and infectious disease and of obesity, abnormal lipids and diabetes (De Hert M et al. 2009. www.easd.org/easdwebfiles/statements/EPA.pdf) • Drug side effects include weight gain of 5-6kg in 2 months (Foley D, Morley L. Arch Gen Psychiatry. 2011;68(6):609-616). • They are less likely to be offered mainstream screening programmes (Roberts et al. Fam Pract 2007;24(1):34-40.)

Smoking • People with schizophrenia are more likely to smoke and to smoke more heavily than the general population (McDonald C. Br J Psychiatr 2000;176:596–7) • The point prevalence of smoking for people with schizophrenia has been estimated to be between 58% and 90% (McCreadie R, Kelly C. Br J Psychiatr 2000;176:109) • Smokers with SMI are more nicotine-dependent; more likely to become medically ill; and less likely to receive help in quitting, compared with the general population (Phelan M et al. BMJ 2001;322:443-44)

Disease prestige hierarchies? Myocardial infarction 1 Asthma 12 CKD 19 Depression 34 Schizophrenia 35 (Album D, Westin S. Soc Sci Med 2008; 66: 182-188)

“Good enough” primary care “I mean, the GP has to have some understanding of mental health, but I don’t expect a GP, you know, to know all the issues to do with my illness. I would though expect him to refer me through to a specialist person. The important thing is that somebody is looking after you, so it’s not just you on your own.” P1, F, Birmingham (Lester et al. BMJ 2005; 330:1122-1128)

“Good enough” primary care “But what I want is for him just to tell me - ‘Yes, Mrs F, I understand what depression is, you know, and if you book up may be next week then we’ll talk about it’ - and you’d feel that would calm you down, because you’d feel at least somebody wanted to listen to your madness” P3, F, Birmingham.

Hope for the future “When I approached my GP, he never gave me any hope that things could change. I remember being told that I’d never be able to work again, I’d never have an education, never have relationships, never have anything in my life.” P9, M, Cannock “Write him off!” P10, F, Cannock “That’s what they done. But the thing is, people do recover. And they’re never told there are people who do recover, so it’s not a life sentence.” P9, M, Cannock

GP views on care “Well, some people don’t come when they’re well and some don’t come when they’re sick and to be honest it’s a bit of a relief because I can catch up on being late.” GP4, F, Worcester “They are notoriously bad at keeping appointments…they turn up when you’re not there.” GP8, F, Birmingham “I know that I cannot look after people with severe and enduring mental health problems. I do not have the skills or the knowledge. I couldn’t do it well.” GP 10, M, Worcester

Primary care’s business? • 31% of patients were managed solely in primary care • 47% were seen once or twice a year only in secondary care • 69% had a LTC as well as their serious mental health problem • Patients have 1.6 LTCs for every 1.0 LTC in patients without SMI

Use of Primary Care (2008/9)

Interpersonal continuity of care • 2-4 GP contacts in a year, 14.0% had poor continuity • 5+ GP contacts in a year, 19.9% had poor continuity • Continuity in primary care was the same regardless of whether you had secondary care follow up

So what do we know so far? • Group with significant health and social needs • 31% were seen only by primary care • 73% seen mostly by primary care • Under use of practice nurses in primary care • Under use of preventive care • Room for improvement in interpersonal continuity of care • Evidence of GP reluctance but... IT IS PRIMARY CARE’S BUSINESS

So what is the role of primary care? • To provide holistic care • To take particular responsibility for physical health care from the start • To be the point of contact for the patient and their family • To advocate for the patient and their family within the wider health and social care system • To be holders of hope

The Role of Primary Care