In 2021, there were 4.3 million referrals to mental health services (Iacobucci, 2022). This prompted the Royal College of Psychiatrists (RCP) to urge the government to establish a recovery plan by 2024, in addition to the policy that already aims to improve a broad range of mental health services in the community (RCP, 2023).
It is important that community nurses (CNs) know what help is available for patients. It is not always obvious that there are as many acute and community services available, despite the NHS being under such pressure. The CN must get a referral in progress. Primarily, this starts by having a conversation with the GP. The patient may already be known to mental health services, but would have been deemed stable. Yet, if the CN notices a deterioration, they may be able to directly contact the mental health team and quickly reengage the patient with all the necessary services they are linked to.
Some individuals may not be known to or under mental health services, and may have limited access to their GP (e.g. it is difficult to get an appointment, and often the appointment may be over the phone). In such instances, the CN may inadvertently become the only point of contact for the patient. It is crucial that the CN has open conversations with the individual and makes observations of any changes in their behaviour, alongside any expressions of certain symptoms (i.e. low mood, feeling that life is pointless, fatigue or instability). The CN should identify any risk factors that would lead to a much earlier diagnosis and less severe outcome, with timely support and greater efficacy of support provided. Sometimes, it may take longer to get an appointment, but the CN can liaise with the GP to communicate with the service required to try and speed up the process, and find other services that can be provided it in the interim.
The standard services available include: GP-referred counselling, or self-referred Improving Access to Psychological Therapies (IAPT) counselling. Specialist services exist in every part of the country. The specialist community mental health teams available are: home treatment services; crisis intervention; early onset psychosis; first episode psychosis; assessment and brief treatment (ABT); continuing care; rehabilitation; assertive outreach; and forensic services. Services such as home treatment and crisis intervention are acute services, but based in the community. For crisis intervention, you can help the patient by providing the crisis team number. For example, if they feel suicidal, it is integral that they do not wait for a GP appointment or referral, but that they call the number immediately. The team will then speak to the individual and assess the situation. They will sometimes visit the individual right away. This is an acute service that can quickly help someone survive a severe depressive or psychotic episode. If necessary, the patient may be sectioned by this team and two assessing psychiatrists, but this is rare. Sometimes, teams such as these may offer the patient to come and stay in the mental health hospital for treatment, but this would be deemed an ‘informal stay’. An agreement would be made as to how long this would need to be. Other patients may receive follow up from the home intervention service after the crisis team assesses them, perhaps needing daily visits or calls. Other patients deemed non-acute or not in crisis, would fall under a GP referral to a specialist non-acute community service. There are a range of other teams that provide longer-term community support for personality disorders, eating disorders and addictions. These are complex problems requiring longer-term support and can trigger crises, although they are not under the realm of services for psychotic illnesses as these are different types of problems that do not usually involve loss of insight. For example, if your patient has disclosed that they self-harm, this of course needs to be explored by the crisis or home treatment team and GP as appropriate, but may be related to a personality disorder (as an impulsive coping mechanism) where the patient still maintains full insight. If you are unsure about insight, speak to the patient's GP about these issues and they can be the judge of what happens next regarding referral; it is likely the GP will visit the patient to determine what is required. If the GP is unsure, then the mental health specialists may intervene. However, knowledge and assertiveness are extremely useful in the CN's role.
Trenoweth and Warren (2022) wrote about mental health practice for adult nursing students, noting that a separation of services resulted in a separation in training. This resulted in a gap of knowledge on both sides of the nursing spectrum, which can negatively impact on patients. They noted the importance of consent when referring a patient or providing mental health treatment, and a focus on the whole-person ‘recovery approach’, which focuses on holistic care. There has been a dualistic approach in medicine and in nursing through the division of training. This approach separates the mind and body and each is aimed to be ‘treated’ when a problem arises. For example, chronic pain is a well known contributing risk factor for depression. Treatment efficacy cannot be achieved if pain is not considered when treating depression. People with physical disability often experience isolation and social exclusion due to their limited ability to do every day activities. This also causes depression. Therefore, it is important to consider the social aspect—isolation, exclusion and also other barriers such as those from marginalised communities, where mental health may be stigmatised, or where language may present a barrier to treatment. It is also important to understand the biopsychosocial perspective as it helps us identify others needs better. This, in turn, is what helps the community adult nurse meet the needs of a patient with mental health problems.
Trenoweth and Warren (2022) explained that the very role of a nurse—regardless of whether they have specialised in physical or mental illness—must be ‘inextricably linked with meeting the individual needs of their patients, clients and service users.’ They also stressed the importance of having a strong sense of emotional stability and resilience while being reliable to the patient and knowledgeable, informing the patient of their legal rights, for example (Trenoweth and Warren, 2022; Mind, 2023).
Mental health care may not be initiated, even after a health check identifies mental health concerns. Geyti et al (2020) noted that poor mental health is a significant public health concern; yet, mental illness often goes unnoticed. The researchers noted that providing feedback to the GP about the mental health of their patient may help to improve the detection of cases and therefore, improve access to mental healthcare for those who need it. To identify how access to mental healthcare can be improved, Geyti et al (2020) asked the GPs what factors might indicate poor mental health. The researchers also attempted to identify the factors linked to why a patient may not initiate treatment for their mental health. This was a prospective cohort study with a 1-year follow up. The feedback was in fact provided by an e-assessment tool, and the overall study showed the importance of feedback to the GP, even if it is through an e-assessment filled in by the patient.
The team carried out a population-based preventive public health initiative called ‘CheckYour Health’, which combined a mental and physical health check in a region of Denmark, between 2012 and 2015, in collaboration with local GPs. Overall, there were 350 participants between the ages of 30 and 49, with screen-detected poor mental health, but who had not received mental health care within the previous year. Their mental health was assessed by the mental component summary score of the 12-item Short-Form Health Survey. The team then focused on whether mental healthcare was started after this assessment. This included psychometric testing carried out by the patient's GP, talk therapy provided by their GP, contact with a psychologist, contact with a psychiatrist, and psychotropic medication.
The team found that within a year, of those detected with poor mental health (from the e-assessment), 22% initiated mental healthcare. The team found that some people did not start their treatment due to not being significantly unwell, with milder symptoms of mental ill health. Geyti et al (2020) did not find that socioeconomic factors were related to initiating mental healthcare, although these factors could act as a barrier to the initial assessment of the patient, which this study does not cover. The study highlights the usefulness of a systematic provision of mental health test results gathered electronically, for improving access to appropriate care, although there are some barriers requiring further research. Geyti et al (2020) noted that there was a significant concern among those with detected symptoms—with a larger number of men not initiating mental healthcare. This area in particular, the researchers suggested, requires further investigation.
The Mental Health Implementation Plan
In terms of policy, the Mental Health Implementation Plan was set up in 2019, with objectives for reaching numerous outcomes by 2024 (NHS England, 2019). It is important to be aware of what the future of service provision looks like and through this awareness, one can be cognisant of what is lacking now. It also helps to highlight more areas of mental health, in addition to what has already been covered in this article.
To improve the joining up of physical and mental health services, 390000 people with severe mental illness will be provided a physical health check and 55000 people a year will have access to individual placement and support services. In terms of crisis care, the new plan aims for there to be 100% coverage of 24/7 age-appropriate crisis care through NHS 111 by 2024. A variety of complementary and alternative crisis services to A&E and admission will be introduced, while ambulance provision will be improved for crisis care; appropriate training will be given to ambulance staff, and an integrated team with nurses and other professionals will be part of the new integrated care clinical assessment service (NHS England, 2019.) The plan also indicates that waiting times for services will be improved upon.
IAPT will also improve provision under the new policy to include a total of 1.9 million adults and older adults in its services. Alongside improvements for common mental illnesses, adults with severe mental illness in the community will also see improvements, with new models of integrated primary and community care for adults and older adults, and care incorporated for people with eating disorders, addressing rehabilitation needs and for those with complex mental health problems under the spectrum of the ‘personality disorder’ diagnosis, built around primary care networks (NHS England, 2019).
In the past, older people were overlooked by the system in place. People are living longer and the demand for mental health services in older age is increasing. The outcomes mentioned earlier, if met, will automatically also improve the older adult mental health service provision. Suicide bereavement support will increase significantly.
Among the many aims of the NHS Mental Health Implementation Plan (NHS England, 2019), is its goal to help at least 66000 women suffering perinatal mental health issues by 2023/2024. They will be provided access to specialist care in the community from pre-conception up to 24 months after birth, and access to evidence-based psychological therapies will be increased. Mental health assessment for partners will also be provided, with appropriate signposting for their own needs, which are currently neglected by the system in place.
Digitally-enabled mental health care by 2023/24
Building on an effective digital mental health leadership and strategy across each sustainability and transformation plans, and the partnerships/integrated care systems by 2021/22, 100% of mental health providers are to be fully digitised and integrated with other parts of the health and care system by 2024. Additionally, NHS England and NHS Improvement will continue to support the development of apps, digitally-enabled models of therapy and online resources to support good mental health and enable recovery.
Moving with the times and rightfully so, digitally-enabled mental health care will be improved upon. As the study by Trenoworth and Warren (2022) has shown, digital tools can help someone access care for their mental health without having to arrange an appointment to be assessed. These tools and online therapies can be very useful to many. NHS England will therefore be developing apps and models of therapy and resources that support good mental health and enable people to recover. These may fill the voids of long waiting lists or treat someone with mild symptoms, thus, avoiding the need to ‘go through the system’, as it can be arduous for many, and at times can seem institutionalised and tiring. Proactive healthcare, rather than reactive healthcare, is absolutely essential for mental health.
Conclusion
Hopefully, this two-part series has helped the reader understand mental health in more depth, with regards to different diagnoses, their prevalence and symptoms, as well as services, barriers to treatment, and policy. This can inform your practice and help you assess the patient, before the GP conducts their own assessment. By understanding some of the complexities around mental ill health from a holistic person-centred view, we can then begin to think about what may be required according to need, severity of need, and service provision.