The rising demand on child and adolescent mental health services was highlighted last year in evidence to the House of Commons health select committee.1 It is difficult to determine the increase in referrals to specialist services nationally, but the child and adolescent mental health service in Portsmouth and South East Hampshire health authority has been overwhelmed. Waiting lists for these services are the longest in the HA, and reducing lists has proved difficult.
The Health Advisory Service recognises this pressure. Among its suggestions on how to meet the mental health needs of children and young people is strengthening the role of primary care staff.
Primary care attachment
The HA ran a pilot study to evaluate the effectiveness of a primary care mental health worker in assisting primary care teams to manage children and adolescents with mental health problems. The worker would provide expert support and advice to general practices and mobilise and co-ordinate existing professional skills. This would be done through an adapted liaison- attachment model.4,5
Objectives were to:
determine the effectiveness of the primary care mental health worker in assessing referrals and selecting alternative agencies to refer to;
determine the effectiveness of liaison clinics in managing children with mild to moderate mental health problems;
develop models of collaboration between the specialist worker and primary care teams; and
determine the impact on waiting lists.
The worker's role was to organise and develop liaison clinics with members of the primary care teams and to act as solo clinician (see table 1). Liaison clinics were defined as a structured approach to collaboration between primary care teams and child and adolescent mental health services, with the aim of strengthening management of children with mental health problems in primary care.
Sixteen GP practices were randomly selected from 32 practices in Portsmouth. Eight received the help of the primary care mental health worker, with the remainder acting as a control group. Around 50 GPs took part in the study. The study population consisted of children aged 0 to 16 years with mental health problems.
A nine-month pilot was conducted between September 1996 and July 1997. The number of referrals to the child and adolescent mental health services during these months was compared with a similar period in 1995-96. A pre- coded form was used to obtain data on referrals and a structured questionnaire was used to collect qualitative data from members of the 'intervention' practices, using the skills of the specialist worker. Log books from the child and adolescent mental health service were also examined.
Number of referrals
During the pilot study, 154 referrals were made to the liaison clinics, of which 55 per cent were by GPs, 40 per cent by health visitors and 5 per cent jointly by GPs and health visitors. In all, 56 per cent were judged to be appropriate for this level of care and 41 per cent were classed as high priority.
Almost two-thirds (60 per cent) of the referrals were managed either by the primary care teams with support from the mental health worker (33 per cent) or with the latter acting as a solo clinician (27 per cent). Eight per cent of cases were referred on to child and adolescent mental health services.
Nearly a third of the children referred (32 per cent) were redirected to agencies other than child and adolescent mental health services or primary care teams. Of these, nearly half went to social services, with 38 per cent requiring no further treatment. During 1995-96, 102 children were referred to child and adolescent mental health services from both groups of practices. Referrals from GPs and health visitors accounted for over half of all referrals to specialist services.
After the appointment of the primary care mental health worker, referrals from GP practices fell to 78, mainly due to a 39 per cent drop in referrals from the intervention practices. A slight decrease of 8 per cent was noted in the control group - probably caused by the new referral guidelines that were being introduced at that time (see table 2).
Quality of referrals
The intervention practices made 31 referrals to child and adolescent mental health services following the appointment of the mental health worker, most of which (74 per cent) were classified as high priority. Sixty-eight per cent of referrals to specialist services from intervention practices were classified as appropriate, compared with 51 per cent from control practices. The proportion of high priority and appropriate referrals increased in intervention practices throughout the pilot study but showed a decreasing trend in control practices.
Consequently, referrals from intervention practices were more likely to be accepted for assessment. Only 7 per cent of referrals to child and adolescent mental health services from intervention practices had to be redirected to more appropriate agencies, compared with 19 per cent of referrals from control practices.
Effectiveness of liaison clinics
All the GPs (25) and 13 health visitors from the intervention practices were interviewed in a qualitative analysis of liaison clinics.
Twenty-two GPs and all the health visitors had used the services of the primary care mental health worker. All of these agreed or strongly agreed with the statement that the liaison clinics were accessible. Discussion with the worker was the preferred means of liaison for all primary care team members who had used the service, and direct referral was the second most popular option (preferred by 20 GPs and 11 health visitors). A high proportion (15 GPs and 12 health visitors) used liaison clinics to discuss other resources available in the community.
An impressive 94 per cent of the primary care team members (21 GPs and 12 health visitors) agreed or strongly agreed that services provided by the liaison clinics were appropriate.
GPs and health visitors referred a similar proportion of cases to liaison clinics. All strongly agreed that having access to a liaison clinic greatly improved communication with the child and adolescent mental health service.
More health visitors (92 per cent) than GPs (32 per cent) agreed that access to the liaison clinics increased their knowledge and awareness of children and family mental health needs. Most primary care team members (89 per cent, comprising 19 GPs and 12 health visitors) felt that access to a liaison clinic increased their knowledge and awareness of alternative sources of help for families in the community.
All the health visitors agreed that access to liaison clinics increased their knowledge and skills in working with children and families with mental health needs. But only one-third of GPs agreed and more than 40 per cent were undecided. All the health visitors and most GPs (80 per cent) agreed or strongly agreed that having access to liaison clinics had been of value for their practice.
The service quickly established itself in the intervention practices and was fully supported by the teams. Liaison clinics increased primary care teams' awareness of the mental health problems of children and their families.
An increase in referrals was successfully met by liaison clinics and, where appropriate, patients were referred to alternative services in the community. The work of the primary care mental health worker with intervention practices resulted in fewer and better quality referrals to child and adolescent mental health services. Joint assessment by the primary care mental health worker and primary care teams provided an opportunity to exchange skills and knowledge.
Following the pilot, the primary care mental health worker scheme and adapted liaison clinic model has been expanded to include all general practices in the HA. This has involved the employment of eight workers. Extending the model to other services is being discussed.
There is a need to increase the clinical skills of primary care teams. The primary care mental health workers will play a major role through the development of training on evidence-based clinical guidelines. Part of the liaison clinics' role should be to develop a joint clinical protocol. The primary care mental health worker role should also be extended to encompass education and social services.3