Free training, free valuation and free materials failed to persuade GPs to show interest in a mental health selfcare package. Ann Richards and colleagues tried to explain the apathy

It is no secret that a quarter of all GP consultations are related to common mental health problems.

The proportion rises to 40 per cent when taking account of sub-clinical mental health problems.

1It is now over a year since the launch of the national service framework for mental health, which emphasises the role of primary care groups and trusts.

But our research, looking at takeup of an education package, suggests general practices are reluctant to become more involved in mental healthcare.

The PHASE programme (psychological health: assessing self-help education in primary care) is testing a self-care package for people with mild to moderate mental health problems, which is implemented by practice nurses in primary care. It provides general practices with training for nurses and materials for their patients to use.

But when we contacted 900 practices, interest was shown by only 12 per cent, and fewer than 2 per cent agreed to take part. This was despite targeted letters and telephone calls, mailshots and personal approaches to GPs, practice nurses and PCG/PCT clinical governance leads. In primary care mental health, free training, free materials and free evaluation seem to cut little ice.

We investigated the reasons why practices were reluctant to engage in the initiative. Our findings are illuminating. Although poor recruitment to research projects is a situation familiar to health researchers, it appears that the combination of research and mental health turns off primary care practices to a quite inordinate degree.

2A very small number of practices even reported that no-one in the practice was interested in mental health - a worrying statement considering the fundamental role of primary care within the national service framework.

The most common reason given for not taking part was reluctance to increase workloads, particularly nursing workloads. Also, the fact that it did not provide any financial remuneration for extra time incurred by practice nurses was seen as bad business by some GPs.

Many practice nurses welcomed the opportunity to gain some formal preparation in an area in which they are dealing with patients' problems without training.

Nonetheless, even in some of these 'forward thinking' practices the key to engagement was the offer of some local funding.

What has also become apparent is the huge variability in new framework-driven mental health initiatives in PCGs/PCTs. Some PCGs have installed a mental health worker in every primary healthcare team. Their role is mixed - some see patients with a wide range of mental health problems for a variety of treatments while others act as gatekeepers, referring on as appropriate.

Another approach has been to set up a multidisciplinary mental health team acting as a resource for the whole of a PCG.

Worryingly, where there are existing services in place or initiatives are planned, there seems to be no room for other evidence-based, innovative alternatives. Often limited service developments seem to be naively offered as the complete solution to framework demands and are not seen as part of a range of service options. Many PCG/PCT managers fail to see the potential of different approaches running in parallel with each other, working in an integrated manner to enhance patient choice. They risk repeating the mistakes of the 1990s when general practice uncritically adopted practice counselling as their mental health modus operandi.

If the mental health framework is to work in primary care, general practice needs to overcome its apathy towards mental health, its aversion to new activities which contain no financial incentives and its simplistic notion that there is room for only one solution to the mental health needs of the practice population.

Despite the growth of mental health specialists in primary care, GPs and practice nurses have still to recognise that they have a major role to play in identifying and treating patients with mental health needs in their own practices.


1 Goldberg D. Epidemiology of mental disorders in primary care settings. Epidemiologic Reviews 1995; 17(1):182-90.

2 Prescott RJ et al. Factors that limit the quality, number and progress of randomised controlled trials. Health Technology Assessment Report 3 (20). Stationery Office, 1999.