How to navigate your way through the British mental health services
by Dr Andy Montgomery
A bit about me: I’m a psychiatrist having worked in the NHS since 1991. I was a consultant psychiatrist between 2005 and 2012. As such I have a particular perspective on the way the system works (or doesn’t work). It’s very likely that other people may take a different view, for example general practitioners, service users or other psychiatrists.
The key components of NHS mental health services are the same in other branches of medicine, i.e. primary care (or general practitioner) services and secondary or specialist services. I will talk about each service in turn, and give some tips on how to get the best out of the services that you use.
Primary care services
The core person for you, as a potential user of mental health services in the UK, is your general practitioner (GP). The GP acts as the hub in the network of your care. This means they have the best chance of being properly informed about what is going on both in terms of your progress, and in terms of what is available for you in the local area.
In many cases this works very well, with patients forming long-lasting and trusting relationships with their GPs. They have a huge advantage over other practitioners in that they may have known patients for a long period of time, potentially before they developed difficulties, meaning that they are able to understand the patients difficulties in a very long-term and “holistic” sense.
Unfortunately the ideal scenario described above doesn’t always occur. Different GPs have different levels of interest in getting involved with people with mental health problems: some rightly regard it as part of their “core business” but others are uncomfortable and feel unskilled when working with people with mental health problems.
It’s also a general fact of life that we don’t all get on with everybody, and problems can occur in a relationship between patient and their GP as it can in other relationships.
Given the importance of your relationship with your general practitioner, if you feel things aren’t working out, it’s important to be upfront and try to address the issue with them. A discussion about why things aren’t working may lead to an improvement in the situation.
However, if you find that you cannot work effectively with your GP, or you feel that they are not doing the right thing for you, then you have every right to change your GP. You can do this by writing to the GP practice and explain you want to change your GP. You don’t need to give reasons, but constructive criticism may be helpful for the GP in their work with other patients in future.
How to ensure that you get the best outcome from your appointments with your general practitioner
There’s a lot that you can do to improve the chances that you will get what you want from your GP. If you have a complicated problem (as mental health problems often are) it may be worthwhile trying to book a double appointment so the GP is less rushed than usual. Some people find it helpful to write a list of the difficulties they are experiencing as it can be difficult to remember things you wanted to say in the rush of an appointment. It is often useful to go with a friend or relative who knows you well, so that they can help you ensure that the story you want to tell gets told.
Depending on the nature and severity of the problems that you are experiencing a number of different outcomes are possible after meeting with your GP. You may both agree that no further action is required; you may arrange to meet with the GP again in a week or two to see how things are going, perhaps after trying some simple strategies, such as advice about diet, exercise, sleep or use of alcohol. Alternatively the GP may feel they need to get some advice from a specialist service about how best to proceed, in which case they will write to the appropriate specialist service asking them to get in touch with you.
Different forms of specialist mental health service are described below.
Specialist mental health services
There are 2 main components to specialist mental health services which GPs are able to refer patients to: the “improving access to psychological therapies” (IAPT) services and community mental health teams (CMHT).
IAPT services are generally aimed towards people with “common mental health disorders” i.e. depression, anxiety, phobias and stress. Depending on the nature of your difficulties your GP may feel that referral to this service would be appropriate, particularly if you express an inclination towards talking therapies rather than medicines.
CMHTs tend to work with people more serious problems whose mental health problems may result in a risk to themselves (through suicide or self-harm) or risk to others. They also work with people with psychotic illnesses (i.e. illnesses associated with unusual ideas or hearing voices).
IAPT is a central government initiative which aims to make psychological therapies much more widely available than was previously the case. At the time of writing, IAPT services are at different levels of development across the UK, with some areas having very developed and comprehensive services, and other areas still at a relatively rudimentary stage. IAPT services have many different names across the country and are provided by a variety of different organizations, some NHS, some charities, and some independent organizations.
IAPT services offer a variety of psychological interventions, some conducted one-to-one, some in groups. Generally people start at the simpler types of intervention and proceed to more complex interventions, such as longer term therapy, if necessary.
Community mental health teams (CMHT)
If a GP is concerned about a patient he or she will often refer to the local CMHT for advice. The people working in CMHTs come from broad variety of professional backgrounds including mental health nursing, occupational therapy, social work, psychology and psychiatry.
After a referral from the GP you will be asked to attend an appointment with one or two workers from the team who will carry out an assessment of your current mental health needs. The appointment may be at the local base of the CMHT or in your own home. This assessment should include a detailed account of your current difficulties, and a review of different aspects of your life such as your childhood, education, the sorts of work you have done, your relationships and your use of substances such as alcohol.
At this assessment a number of decisions have to be made: firstly are your mental health needs likely to be met most appropriately by the community mental health team? If the answer to this question is “yes” then further appointments will be arranged with other members of the team such as psychologist or psychiatrist depending upon the sort of problem you have been experiencing.
If the assessing team feel that you don’t have the sort of mental health needs which would be best met by the community mental health team they will write back to your GP explaining their decision. They may refer you to a service they believe is appropriate for you. They should also provide you with relevant information and a copy of their assessment.
From your perspective the things you can do to make the most of this appointment are the same as the advice given earlier for how to get the best out of a GP appointment i.e. make a list; take a friend; think in advance about what question it is that you want answered.
Other specialist mental health teams/services
The other teams tend to have more specialist role. For example first episode psychosis teams, as the name would suggest, work with people who have symptoms of psychosis for the first time. Assertive outreach services work with people who have more established and severe mental illnesses, often complicated by substance use, and often with quite high levels of risk. Home treatment team or crisis teams work with people who are “at risk” of a hospital admission. This will often involve intensive work in the patient’s own home to help them recover from a crisis without hospital. Inpatient units come in a variety of different forms, some focus on providing care in hospital for a short period (days a week) whereas some provide care for people who are likely to need to be in hospital for longer periods.
This article was provided by Dr Andy Montgomery, MbBChir, PhD, MRCP, MRCPsych of PSYCHIATRY-UK. His registrations numbers are: General Medical Council: 3616932 Royal College of Psychiatrists: 13163. Last reviewed by the Mental Health Forum Web Team on March 20, 2019. We welcome let us know on our information resources.