REVIEW ARTICLE 93

Community mental health care: primary team and specialist services Peter Brook, m.d., F.R.c.Psych. Psychiatrist, Warley Hospital, Brentwood, Essex Brian Cooper, m.d., M.R.c.Psych. Reader in Epidemiological Psychiatry, Institute of Psychiatry, London, S.E.5. Consultant

Service reorganisation of National THE generalist and specialist medical services, and health social service agencies. try

allows a fresh look at the tasks of at their co-ordination with other and We here to review the roles of primary care and specialist teams in the field of mental health, and to fit their contributions into an effective model of community psychiatry. No branch of specialist practice stands in more urgent need of reappraisal than psychiatry, whose problems of manpower and resources are now becoming acute. The impending crisis can be attributed partly to failures of professional recruitment10,76 and partly to the increasing demands beingmade onhospital psychiatric services. Paradoxically, these demands have arisen largely as a result of the trend towards community care for the mentally ill, which, while reducing the numbers of mental hospital beds, has at the same time created a need for greatly expanded outpatient, day-patient and domiciliary care. The burden on hospital psychiatry has become all the heavier because ofthe tardi¬ ness of local authorities in providing, and of central government in financing, residential and day-care places for patients with chronic disabilities.26 In many areas, the transfer of mental welfare responsibilities to the new social service departments has also created problems both in procedure for hospital admission and in aftercare.63,68,89 Questions of policy about the provision either of hospital beds or of community hostels and day-care units are outside the scope of this review. It is important, however, to consider the implications of community care for the general medical services. One result of latter-day trends is the appearance in the community of many patients with partially remitted symptoms and residual handicaps, who in tormer times would have remained in mental institutions.12'93 The ability of hospital-based psychiatrists and nurses to supervise this large group of patients is already in doubt, and will become more so as the number of hospital beds is further reduced.21,92 The run-down of mental hospital beds has not been the only, or even the principal, factor in drawing attention to the significance of psychiatry for primary medical care. During the past decade, there has been a growing awareness that, quite apart from any question of official policy or of new trends, most consultations for mental or emotional disorder take place in general practice. This fact has been repeatedly confirmed by population surveys. General practice and community surveys A substantial part ofthe case-load in general practice is made up of neuroses and related conditions. While estimates have differed widely, the more careful studies suggest that 10-20 per cent of registered patients in the NHS will present with psychiatric symptoms in any given year. A survey of London practices, for example, found a one-year pre¬ valence among adults of 14 per cent, with an inter-quartile range of 11-17 per cent.80 Only one in four major psychoses, and one in 20 of all psychiatric cases, were referred for Journal ofthe Royal College of General Practitioners, 1975, 25, 93.110 the

the

Health

94

Peter Brook, Brian Cooper

specialist treatment during the survey year. Similarly, an investigation of a rural part of Wales showed that two-fifths of psychoses, and 56 per cent of all psychiatric problems, were unknown except to the local practitioners.47 Comparable findings have been reported from other parts of Great Britain.57,87 The highest rates of severe mental disturbance occur among the elderly. Organic or functional psychoses were diagnosed in eight per cent of people over 65 in Newcastleupon-Tyne, mostly among those resident in the community.50 General medical care of the elderly infirm, and with it much of the psychiatry of old age, devolves largely upon the family doctor.67*91 At the other end of the age-scale, child guidance clinics can deal with only a fraction of all maladjusted children. Surveys in different areas of Great Britain have reported rates of maladjustment among school children varying from seven to 14 per cent, whereas the proportion under child guidance care is usually less than one per cent.14,51,77*81 Statistics of this kind can be used to build up a composite picture of psychiatric Table 1, abstracted from a report of the Royal morbidity in the national population. College of General Practitioners 74 is based on data from several sources. The figures refer to the registered patients of an average practitioner: multiplied by ten they could be applied to a health-centre population of 25,000; multiplied by 100 to a district population of 250,000. TABLE 1 Psychiatric disorders and social pathology m a hypothetical average population of 2,500

Royal College of General Practitioners (1973). Present state and future needs ofgeneral practice. Third edition.

Insofar as they are based on consulting patients, rather than on the total population, the illness rates shown in table 1 are almost certainly too low. The rate of social pathology is also an under estimate if, for example, poverty, social isolation, abortion, illegitimacy, divorce, and sexual deviation ought to be included under this heading. Survey statistics thus support the economic argument that specialist referral and treatment is bound to remain impracticable for the great majority of psychosocial problems. There are, in any case, grounds for arguing that such referral would be undesirable on clinical and social grounds. "

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Community mental health care: primary team and specialist services

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Modern trends in mental health care A high prevalence of minor disorders may point to the need for better primary care and social services, rather than for more specialists. One team studying child maladjustment concluded that "... most children with psychiatric disorder will need to be treated by people other than psychiatrists. Quite apart from the necessity of this, there are reasons for believing that even given unlimited resources this would still be the best approach for many children ".77 That it is equally preferable for most adults has been forcefully argued by Shepherd 79 and by a recent World Health Organisation report which lists the advantages of generalist care as: continuity; a holistic approach to illness; an avoidance of stigma or unnecessary labelling'; a capacity to bridge the specialties and so to prevent fragmen¬ tation of care, and an equally important capacity to view family morbidity in perspective.95 While the force of these arguments is now widely acknowledged, a number of diffi¬ culties must be overcome before the mentally-disturbed patient can be sure of satisfactory treatment at the primary care level. Some of these, relating to professional attitudes and training, will be discussed individually for doctors, nurses, and social workers. Others, however, are bound up with the structure and organisation of our health services. *

Sectorisation

Contemporary changes in the NHS may have a profound impact on mental health care community, and require careful assessment from this standpoint. The most immediately relevant is the trend towards sectorisation' of psychiatric services, which has its analogues in a number of European countries.63,68'89 In the United Kingdom, clinical facilities formerly provided in the big mental institutions are now being transferred to smaller units in district hospitals, designed to give a high-quality locally-based, comprehensive psychiatric service ". u One result will be to bring psychiatry and general practice into closer contact, especially where in the

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individual consultant's teams are allocated to defined areas. Of comparable, though less obvious, significance for community psychiatry is the growth of multi-disciplinary teamwork in primary care units. During the past 20 years, there has been a steady decline in the number of single-handed practitioners and a corresponding increase in group practices: a development owing less to planned policy than to changing urban conditions. More recently, however, official policy has encour¬ aged the formation of teams based on health centres: by 1972, over 300 such centres had been opened in Great Britain and many more were under construction.74

Community hospitals A related development, which is still at the experimental stage, has been the appearance ofthe community hospital.64,82 Staffed by doctors and nurses from primary care teams, this type of unit is intended to complement the large district hospital while remaining essentially part of local community resources. In the model designed by the Oxford Regional Board, there is provision for some psychiatric and geriatric beds as well as a day ward for the physically and mentally handicapped. It seems probable, indeed, that the community hospital will deal mainly with elderly and disabled patients.35 The con¬ tribution of such units to community psychiatry has yet to be evaluated. Social services In addition to these changes in health care there has been a drastic reorganisation of social services following the Seebohm Report78 and the Social Services Act of 1970. While the-short-term effects on medicosocial collaboration have given rise to some

96 Peter Brook, Brian Cooper

concern,71,86 there are grounds for hoping that the long-term prospects are brighter. Potentially advantageous for primary health care are the transfer of hospital social workers to local authorities and the formation of area fieldwork teams each serving a population of about 75,000.23,69 The change to generic training courses may also prove beneficial provided there is enough opportunity for further training in medical social work in the community.22 This rapid evolution of health and welfare services calls for a careful re-definition of professional roles, both between primary care and specialist agencies and within the primary care unit. In what follows, some.though by no means all.of these roles will be discussed briefly. Each professional worker may function most effectively within a multi-disciplinary team, and that in this sense the team may be greater than the sum of its parts.

Generalist care.the primary health team Teamwork offers distinct advantages for mental health care. Closer collaboration between doctors, health visitors, and nurses can bring many unknown cases to light, as well as improving the surveillance of known cases. A centre providing health care for a population of 20,000 or more can serve as a base for psychiatric and other specialist sessions, and also for social workers who can play a large part in the management of

psychosocial problems. Against these advantages must weigh the risks involved in any move away from personal medical care. In the words of the Harvard Davis Committee: There is an inherent risk in group practices of losing the invaluable relationship between doctor and patient, which single-handed practice permits, and of medical care becoming episodic and fragmented '\22 To create at the primary care level a style of impersonal, transient doctor-patient relationship would be to repeat the worst mistakes of hospital practice, and no class of patient would suffer more in consequence than the mentally ill. Most observers agree, however, that this risk can be successfully combated and the best features of singlehanded practice carried into the team situation, provided the issues are fully understood. It follows that the size of the primary care unit is a crucial factor for mental health care, and here the lack of agreement is worrying. The optimum size has been put by some writers as high as 50,000 patients, or 15 to 20 doctors, while others have advocated much smaller units.22,25,85 The model put forward by the Harvard Davis Committee, of a group of five or six doctors with adequate nursing and ancillary support, offers a suitable compromise. Such a unit could provide comprehensive cover, including specialist consultation, while avoiding the worst dangers of impersonal, fragmented care.22 There is more general agreement about the composition of the team, which should comprise general practitioners (primary physicians), health visitors, home nurses, prac¬ tice nurses, receptionists, secretaries and some part-time attached workers such as midwives.6,22,74 Many authorities now accept that a social worker should also be an integral member of the team. In the course of this short review, only those workers most directly concerned with mental health problems can be considered individually. (1) The general practitioner Normally the doctor of first contact under the NHS, the general practitioner is in a key position to monitor episodes of psychiatric illness and to refer appropriate cases to hospital.49 Specialist referral affects only a small minority of cases, most practitioners regarding the treatment of neurotic disorders as part of their own clinical function.80 Unfortunately, the treatment they provide is frequently sporadic and unsystematic, with too much emphasis on palliative prescribing and too little on the underlying personal, "

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family, and social problems.4,45,80 Certain types of disorder are grossly under-diagnosed or receive low priority in treatment; for example, chronic alcoholism62,66 and senile disorders.34,91 In the long-term, these deficiences can only be remedied by improved medical edu¬ cation. Changes recommended by the World Health Organisation 94 and the Todd Report,85 if implemented, would make the primary physician ofthe future better equipped to deal with mental illness. The Todd Report stressed the need for more undergraduate teaching in the behavioural sciences, as well as in clinical psychiatry. The proposal for a three-year postgraduate training has now been officially accepted and is due to be implemented in 1977. Eventually, 1,000 to 1,500 doctors annually will complete training schemes, many of which will include six months in psychiatry.41 Ambitious aims and objectives of training have been formulated by the Royal College of General Practitioners,73 and, in order to evolve a common policy, a joint workingparty of psychiatrists and general practitioners has been formed. More immediately, participation in teamwork should help to improve the general practitioner's care of his mentally sick patients. Closer liaison with psychiatric colleagues can increase his clinical knowledge and confidence in this field.39,54 At the same time, collaboration with home nurses and health visitors offers opportunities for early casedetection and diagnosis: in other words, for a preventive approach to mental health

problems.48 (2) The health visitor

The team member most closely associated with preventive care is the health visitor. Traditionally, her duties under the local health authority were restricted to prevention and health education. In recent years, however, the functions of health visitors have increased as a result of changes both in their training and in their deployment. The training course was extended in 1966, from six months to one year, and a new training syllabus introduced. The health visitors' duties, as defined by their Training Council,19 now comprise, in addition to health education, early detection of ill-health; identification of need and mobilisation of resources; provision of care and support in times of stress and illness, and prevention of mental, physical and emotional ill-health or the alleviation of its consequences." The remit may sound a trifle over-ambitious, but the change of emphasis is clear enough. The proportion of health visitors attached to general practice has increased sharply during the past decade: from six per cent in 1964to over 60 percent in 1971.3,15 There is good evidence that, as a result, communication between doctors and health visitors has improved; that the latter now spend more time in direct contact with patients, and that their work-satisfaction has increased.2,43 In view of this success, it has been urged that the future pattern should be almost complete attachment of health visitors to general practices, wherever feasible ",74 A prominent feature of attachment schemes has been the increased involvement of health visitors in psychosocial problems. A survey of over 2,000 home visits by 72 health visitors found that mental health and social care together accounted for nearly half the topics discussed; among elderly patients, and those referred by general practitioners, the proportion was even higher.15 Current trends suggest that, in future, health visitors will devote more time to high-risk groups, such as old people living alone and families suffering from bereavement.90 It seems clear that the training of this' new breed' of health visitor should incorporate a firm grounding in the principles of mental health care, and that psychiatrists can make a valuable contribution both through formal teaching and in case-discussion. "

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98 Peter Brook, Brian Cooper

Here, a note of caution must be sounded. It is important to remember that health

visitors

are concerned with prevention, and that preventive psychiatry is still in its infancy. Exaggerated claims for the scope of prevention in this field could easily lead to disillusionment among the trainees. Fortunately, British psychiatry as a whole is noted for its empiricism and caution. (3) The home nurse Developments in community nursing during the past 15 years have been in some ways analogous to those in health visiting. In both instances, liaison with general practitioners has been greatly strengthened by attachment schemes, with a consequent improvement in communication and work-satisfaction.38,52,72 There are, however, important differ¬ ences: the nurse's job-specifications are simpler and her relationship with the doctor more clear cut; for her, in-service training is not yet a firm requirement,37 and member¬ ship ofthe primary care team has not coincided with any marked change in work content. Though less well equipped by her training than the health visitor, the home nurse has an important part to play in mental health care. Many of her patients are old; nearly all are physically ill or infirm, and so at increased risk for mental disorders.27,80 She is often in touch with such patients over long periods, gets to know them well and becomes familiar with their domestic circumstances. Even without special training, she can recognise and report mental disturbance among the elderly and thus can serve as an effective screening agent.34,60 Her scope in this regard is all the greater because so many psychogeriatric conditions are unknown to the family doctors.67,83 A major limitation may be the sketchy nature of many doctor-nurse contacts. Attachment schemes do not automatically ensure teamwork; in some instances, they may amount to little more than regular calls by the nurse to collect names and addresses from the practice receptionist. Although it is widely accepted that doctor-nurse liaison has been improved by attachment, there is no firm evidence that patients have benefited as a result.36 Nursing attachments are perhaps best regarded as merely a first, though an essential, step in the direction of integrated health care. (4) The social worker It would be superfluous here to rehearse once more the case for social-worker attach¬ ments in general practice. The arguments have been adduced in a series of reports 6>20'22»78 and a number of successful experiments have been described.16,29,31,70 These latter studies have demonstrated how much enthusiasm can be generated among both primary physicians and social workers by the experience of a closer working liaison. Fears that collaboration with social workers might impair the doctor-patient relationship have not been confirmed; instead, the doctor has been given more time to practise his own unique skills. The rapid growth of one area scheme indicated that most practitioners can be converted to the idea of medicosocial teamwork once they appreciate the practical

benefits.16 The high prevalence of mental disorders in the community, summarised in table 1, underlines the need for this type of collaboration. The social problems of families with dementing, mentally retarded, or schizophrenic members have been abundantly docu¬ 32»84'93 in these mented; instances, social dysfunction is largely secondary to the mental disorder. Cause-and-effect relationships are much less clear cut in neurotic illness, but here too a strong association has been found between the clinical symptoms and various problems of social adjustment.17,88 In a recent controlled study, the effective¬ ness of social-worker intervention was tested by means of an experiment in one group practice. Patients with chronic neurotic symptoms were found to improve more, both clinically and socially, than comparable patients in neighbouring practices with no such

facility.18

Community mental health care: primary team and specialist services

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Progress in this field is hampered by staff shortages and a lack of co-ordinated policy. The current shortage of trained social workers has been aggravated by the demands of new legislation and the worsening housing situation in many areas. Social service directors, rightly or wrongly, are often unwilling to commit any of their hardpressed staff to local medical agencies. By mid-1972, only 1 5 per cent of local authority social workers were in attachment schemes, and most of these were hospital based.71 The situation is complicated by doubts about the social worker's role in the com¬ munity. Before the Social Services Act of 1970, all social workers, trained or untrained, were specialists in the sense that they were engaged in special fields of activity: medical, psychiatric, or child care. By the same token, all are now in theory generalists. It may be doubted whether, in the long run, the present extreme position will prove any more tenable than its predecessor. What is required is a clear differentiation of generalist and specialist function within the social-work profession. Confusion on this score is reflected in medical uncertainty about the respective roles of health visitor and .

social worker.

Health visitor and social worker The Seebohm Committee 78 affirmed that the functions of health visitor and social worker are distinct and possibly incompatible in the same person, and deprecated the view that the health visitor should act as a social worker in general practice. In sharp contrast, many health visitors see their social work" role as of primary importance15 and many practitioners regard their health visitors as ideal as' generalist' medicalsocial workers." 74 Hence it is not surprising to find two distinct models being proposed for primary care: in one, the health visitor deals with social problems, referring only the most taxing to the local social services department;15,74 in the other, a generically-trained social worker is a key member of the team, though she too can refer difficult cases to specialist colleagues, with whom she maintains close links.22,29 The respective merits of these two models could best be established by means of local evaluative studies. To function successfully, each requires close collaboration between two professional groups who, in the past, have too often had a poor relationship, based perhaps on under¬ lying anxieties about their own and each other's competence, as well as on mutual jealousy and suspicion ",44 Though the problem cannot be entirely resolved by a demarcation of functions, there is a strong case for providing each group with a clear job description. The health visitor has the major role in screening and early case detection, and in preventive work with high-risk groups. Her contact with the families of young children takes her into many homes a social worker would not normally visit, while her training as a nurse helps her to recognise medical conditions at an early stage and to assess mental as well as physical ill-health. Social workers as a rule make few routine visits and are not accustomed to thinking in preventive terms. By training, they are equipped to deal with family crises and contingencies; at the same time, they are more skilled than health visitors in long-term supportive casework. Assimilation into the primary care team seems to reduce, rather than to exacerbate, inter-professional difficulties. The fact that health visitor and social worker are now members ofthe same team makes each more keenly aware of the other's skills; as a consequence, any initial tensions tend to disappear after a time.29,31 That tbere is ample scope for both groups can hardly be doubted. Of social workers, it has been justly remarked that They have far more work than they can possibly tackle and must welcome help from any other profession in a position to give it." 44 The number of health visitors also falls well short of what is deemed necessary,15 and the ...

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104 Peter Brook, Brian Cooper

target figure of one for a population of 3,000-3,500 seems unlikely to be attained within the next decade.90 The contribution of the specialist team The need for multi-disciplinary teamwork has long been accepted in psychiatry, as in all hospital-based specialties. More recently, the concept has been extended to cover the community mental health team, a group comprising psychiatrists, a community physician, psychiatrically-trained nurses and social workers, psychologists, and occupa¬ tional therapists.86 The roles of several of these professions have been examined in recent reports5'75'86 and will not be reconsidered here. Discussion of the specialist service as a whole will be restricted to the question of its liaison with primary care units and, in particular, to the primary team's relationships with the consultant psychiatrist, the community psychiatric nurse, and the mental health social worker.

(1) The consultant psychiatrist Most psychiatrists in their NHS work see little of the local general practitioners. Con¬ tact is usually indirect, through a system of outpatient referral which, in big cities at least, tends to be impersonal: as a result, communication between the two groups is often defective.49,95 Domiciliary visits provide an opportunity to meet, but are not always used for the purpose. Steps are being taken to remedy this situation. An increasing number of psychiatrists now take part in weekend, day-release, and intensive courses for general practitioners, as well as in occasional conferences and symposia. A few run groups on the lines pioneered at the Tavistock Clinic,9 though these involve only a small frac¬ tion of family doctors. Some consultants have opportunities to train practitioners who work with them as clinical assistants, or who take psychiatric appointments as part of their postgraduate training. The need for closer contact between psychiatrists and family doctors has been stressed repeatedly; 1,4°'95 as yet, however, only a handful of experimental schemes have been reported. Brook has described a service for family doctors 9 ; more recently, this has developed into meetings with all members ofthe primary care team, so that the psychiatrist can help nurses and social workers, as well as doctors, to improve their skills in recognising and treating psychiatric disturbance.8 Similar experiments have been conducted in Winchester,30 Belfast,54 Liverpool53 and North London.39 In these projects, psychiatrists have undertaken a number of inter-related tasks, including consultative work; assessment of difficult problems; review of patients who are respond¬ ing poorly to treatment; intervention in crisis situations and participation in group teaching activities. The practitioners involved in such schemes have welcomed them as providing support and guidance from the psychiatrist without interruption of normal doctor-patient contacts. In many areas, an additional problem arises from the lack of co-ordination between adult and child psychiatric services. Closer liaison between child guidance clinics and primary care units would undoubtedly be helpful in the treatment of many emotionallydisturbed and maladjusted children: how this can be achieved is an open question. It would not be economically feasible for most child psychiatric consultants to undertake consultative work in general practice. Co-ordination might best be ensured by less direct links; for example, by liaison between practice health visitors and social workers on the one hand, and the child guidance team on the other. Experimental schemes along these lines are urgently required. (2) The community psychiatric nurse Follow-up supervision of discharged hospital patients by psychiatric nurses was being

Community mental health

care: primary team and specialist services

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undertaken in Croydon as early as 1954.58 Since then, an increasing number of psychiat¬ ric hospitals have adopted the system and joint nursing appointments have been made by many hospitals and local authorities. Some schemes are based on day hospitals and after-care hostels;55 others are mainly concerned with domiciliary supervision.59,65 In this second type of service, the nurse pays regular home visits to ensure that drugs are being taken as prescribed; to give injections of long-acting phenothiazines; to check for signs of mental deterioration; to supervise patients' general welfare and to provide support for the relatives. In a few areas, community nurses help to keep down the rates of psychogeriatric admission, both by supporting patients' families and by mobilising community resources. While the emphasis is thus placed firmly on major mental illness, some housebound phobic patients are also visited. Most of the cases are referred by consultant psychiatrists, direct referral by general practitioners being still unusual. Information on the numbers of community mental nurses, their organisation and working methods is still scanty, though the Royal College of Nursing is planning an enquiry.61 Studies of the effectiveness of this type of care, and of its co-ordination with local medical and social agencies, are also lacking. It seems clear that the scope for community psychiatric nursing is still largely unrealised, since it is practised in relatively few areas and even there is restricted to work with discharged hospital patients.33 The community nurse of the future can be expected to serve a wider function, and to provide a more effective link between hospital and local services.13 The Joint Board of Clinical Nursing Studies 46 has prepared a curriculum for a 36-week course of training, designed to teach skills in five principal tasks: (1) Assessment of the needs of psychiatric patients and their families, (2) Co-operation with other services to promote rehabilitation, (3) Provision of advice on health care and sources of support, (4) Assessment of priorities when confronted by demands for mental health services, (5) Participation in research programmes. To fulfil these tasks, community mental nurses will need regular contact with primary care teams as well as with the psychiatric services. Part-time attachments may be justified, though the mental nurse will remain essentially a specialist worker. There remains a serious problem ot recruitment. Mental nurses are in short supply and hospitals under-staffed. While community nursing may offer inducements that the hospital ward lacks, it would be wrong to promote this kind of service at the expense of inpatient care. There is an outstanding need to attract, from outside the ranks of hospital staff, married women and others who have been trained in mental nursing.

(3) Mental health social work At present, psychiatric social work in Great Britain is in a state of flux, as a result of recent administrative changes. Probably, a minority of social workers will continue to specialise in the field of mental health, and some, at least, to work in hospital-based units.86 Their future role in the community, vis-d-vis their less-specialised colleagues, has yet to be defined. This is a large issue, but one aspect directly relevant to primary care is that of procedures for hospital admission. The functions of the mental welfare officer (MWO), responsible under the Mental Health Act of 1959 for statutory admissions to hospital, are not at present clearly categorised as either generalist or specialist in character. This uncertainty has arisen partly because such duties have never been thought to require formal training or qualifications; partly because of the fashionable view that generically-trained social workers can deal with the whole range of social problems.

106 Peter Brook, Brian Cooper

After the 1970 Social Services Act, some local authorities arranged that all trained social workers, with those who, though untrained, had had long service, should go on duty rotas for any kind of emergency work, including statutory hospital admissions. Others maintained a degree of specialisation by restricting psychiatric emergency and statutory duties to workers who, by dint of their qualifications, experience or interest, seemed best suited to undertake such work. A return to the narrow specialisation of the old-style duly authorised officer' now seems unlikely. Nonetheless, there are good grounds for arguing that social workers who are responsible for arranging acute psychiatric admissions should have some special interest and training in this field. The issue is important for medicosocial collaboration, if only because many doctors judge mental health services largely by the speed and efficacy with which they can resolve acute crises. Mental hospital admission is one important aspect of crisis intervention, requiring expedition, skill and tact to minimise distress to the patient and his family, and to encourage their future co-operation. There are signs that in many areas this kind of skill is lacking or under-used, and that admission procedures are proving unduly traumatic. An expansion of mental welfare training for social workers, combining formal instruction with practical experience, appears to be urgently required. '

Manpower The logistics of community mental health care are far from simple. To begin with, health service statistics vary from year to year, and estimates based on current staffing ratios may be seriously inaccurate by the time a new policy can be implemented. Target figures are often employed for this reason, but in the event targets are not always achieved. Secondly, although national returns can be used to compute staffing ratios for a hypo¬ thetical average population, health service workers of all kinds are unevenly distributed across the country: a rate of provision that seems modest in the metropolis could be wholly impracticable in, say, Wales or the Scottish Higblands. Finally, the priorities recognised in deploying established staff may vary enormously from one area or local authority to another. For these reasons, estimates derived from national manpower statistics are of limited value in planning area services. They may be of some help, nonetheless, as guides to the approximate scale of provision and ratios of the various professional workers, and hence to the feasibility of suggested innovation. Table 2 illustrates this, being based not so much on notional standards as on the numbers in established posts in England and Wales.24 The table is not intended to provide a complete picture; it excludes, for example, clinical psychologists and occupational therapists from the specialist team, secretaries and receptionists from the generalist team, and trainees of various kinds from both. While it is clearly impracticable and, indeed, undesirable that real district popu¬ lations should be divided up into equally-sized units for medical care, the figures suggest that, where local psychiatric and primary care teams are formed, and direct liaison does develop, the patient-populations concerned need not receive more than their due share of available resources. Some of the estimates in table 2 are over-cautious in being based on 1971 staffing ratios which have already been surpassed and are certainly well below recommended levels. The Tripartite Committee,86 for example, proposed that each psychiatric sector team should have two consultants and one medical assistant. Similarly, the target for health visitors of one to 3,500 people implies a total of 70, rather than 40, in a district service.

Community mental health care: primary team and specialist services

107

TABLE 2 Mental health care for a district population: staffing of specialist and primary care teams

Disputes are most likely to arise about the numbers of community psychiatric and social workers. Eight community nurses would have to be drawn from a pool of about 90 registered nurses, responsible chiefly for inpatient and day-patient care. A deployment of nine per cent of trained mental nurses in the community seems reasonable, but nursing shortages in many areas are now so acute that special recruitment would be essential for such a development. The scope for social-worker attachment will be restricted by factors in general practice, as well as by manpower shortages. An immediate target of attachment for ten per cent of local authority social workers (other than those already seconded to hospitals) would provide a basic minimum of five to a district population of 250,000, a number which could be taken up at once among the larger primary care units. In relation both to community mental nursing and to social-worker attachments, evaluative studies are badly needed. nurses

Conclusions To promote community mental health care, closer working links must be established between the specialist services and primary care teams. Psychiatrists should maintain direct contact with primary care teams in their sectors, and should act in a consultative role. A proportion of psychiatric nurses should be seconded to community work on a full-time or part-time basis, and they too should have direct contact with primary care units. There is no simple formula for strengthening the primary health team in its manage¬ ment of mental and emotional disorders. How this aim can best be achieved will depend on the type of community, the resources available and, perhaps most important, on the training and attitudes of professional workers. There is ample scope for pluralism, and for evaluation of local experimental schemes. Some of the outstanding research needs have been indicated. At the simplest level, information is lacking about numbers of professional workers already operating in community teams, and their distribution across the country. Secondly, operational studies are required of the content of the work of different professional groups engaged in community care; their management and disposal of cases, and the amount of overlap between their respective functions. Finally, evaluative studies are necessary to examine the relative merits of differing types of service organisation, in terms primarily of benefit to patients and their relatives, but also of the economics of health care and the morale of professional workers. In the meantime, enough information already exists to permit tentative job descriptions to be drawn up for each group of workers, as an essential first step towards the formulation of aims and objectives in their training.

PETER BROOK, BRIAN COOPER

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Acknowledgements Work for this review was undertaken while one of us (P.B.) was attached for two months to the Institute of Psychiatry, University of London, at the suggestion of Professor Michael Shepherd and under the auspices of the British Postgraduate Medical Federation. Of the many people who gave generously of their time, we should like to thank especially Drs Hugh Faulkner, Michael and Ida Fisher, J. P. Horder and T. A. Madden and their colleagues (general practice); Drs A. Brook, J. D. W. Fisher, Sonia Holmes and K. Weekes (psychiatry); Mrs M. M. Connolly, Mr P. Mellor and Miss E. E. Wilkie (nursing and health visiting); Dr Peter Draper, Professor Margot Jefferys and Dr J. Hayward (social medicine and social sciences) and members of the General Practice Research Unit, Institute of Psychiatry. REFERENCES

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79. Shepherd, M. (1972). In Approaches to Action (Ed., McLachlan, G.). London: Oxford University Press for Nuffield Provincial Hospitals Trust. 80. Shepherd, M., Cooper, B., Brown, A. C. & Kalton, G. (1966). Psychiatric Illness in General Practice. London: Oxford University Press. 81. Shepherd, M., Oppenheim, A. N. & Mitchell, S. (1971). Childhood Behaviour and Mental Health. London: London University Press. 82. Smith, J. W., O'Donovan, J. B., Hoyle, G., Clegg, D. F. G. & Khalid, T. (1973). British Medical Journal, 2, 471-474. 83. Stokoe, I. M. (1966). In Psychiatric Disorders in the Aged. Report on World Psychiatric Association Symposium. Manchester: Geigy. 84. Tizard, J. & Grad. J. C. (1961). The Mentally Handicapped and their Families. Maudsley Monograph No. 7. London: Oxford University Press. 85. Todd Repoit (1968). Royal Commission on Medical Education, 1965-1968. Report. London: H.M.S.O. 86. Tripartite Committee (1972). The Mental Health Service after Unification. London: British Medical Association. 87. Watts, C. A. H., Cawte, E. C. & Kuenssberg, E. V. (1964). British Medical Journal, 2, 1351-1359. 88. Weissman, M. M., Paykel, E. S., Siegel, R. & Klerman, G. L. (1971). American Journal of Orthopsychiatry, 41, 390-405. 89. Wertheimer, J., Gilliand, P., Bircher, L. & Perier, M. (1973). In Roots of Evaluation. (Ed., Wing, J. K. & Hafner, H.). London: Oxford University Press for Nuffield Provincial Hospitals Trust. 90. Wilkie, E. E. (1973). Personal communication. 91. Williamson, J., Stokoe, I. H., Gray, S., Fisher, M., Smith, A., McGhee, A. & Stephenson, E. (1964). Lancet, I, 1117-1120. 92. Wing, J. K. (1971). Psychological Medicine, 1, 188-190. 93. Wing, J. K., Monck, E., Brown, G. W. & Carstairs, G. M. (1964). British Journal of Psychiatry, 110, 10-21. 94. World Health Organisation (1961). The Undergraduate Teaching of Psychiatry and Mental Health Promotion. Technical Report Series No. 208. Geneva: W.H.O. 95. World Health Organisation (1973). Psychiatry and Primary Medical Care. Geneva: W.H.O. Addendum Dr Brian Cooper's present addiess is: Social Psychiatry Clinic, University of Heidelberg, r6800 Mannheim 1, Hebelstrasse 13. Requests for reprints should be sent to Dr Peter Brook at Warley Hospital, Brentwood, Essex CM14 5HQ.

A SURVEY OF GENERAL PRACTITIONERS' REFERRALS TO A PSYCH1ATRIC OUTPATIENT SERVICE

The 689 patients referred for specialist psychiatric treatment were of low mean age (35 years), and neurotic character, and behaviour disorders were the most common diagnoses. Sixty-eight per cent were prescribed psychotropic drugs by their general practitioner; 55 per cent of these failed to take their drugs as prescribed, and 50 per cent declared untoward events. Women consulted their general practitioners more frequently, were seen at home more often, and were referred for specialist treatment later than men. Sixty-seven per cent of patients were satisfied with the treatment that they had received from their general practitioner and 62 per cent welcomed psychiatric referral. Gardiner, A. Q., Petersen, J. & Hall, D. J. (1974). British Journal of Psychiatry, 124, 536-413. (Author's summary).

Community mental health care: primary team and specialist services.

REVIEW ARTICLE 93 Community mental health care: primary team and specialist services Peter Brook, m.d., F.R.c.Psych. Psychiatrist, Warley Hospital, B...
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