LONDON Love&Hate 愛と憎しみのロンドン

1999年のクリスマス・イヴにロンドンに。以来、友人達に送りつけていたプライヴェイト・メイル・マガジンがもと。※掲載されている全ての文章の無断引用・転載を禁じます。
Home未分類 | Dance | Sylvie Guillem | Royal Ballet | Royal Opera | Counselling | Sightseeing | Overseas Travel | Life in London(Good) | Life in London(Bad) | Japan (Nihon) | Bartoli | Royal Families | British English | Gardens | Songs | Psychology | Babysitting | Politics | Multiculture | Society | Writing Jobs | About this blog | Opera Ballet | News | Arts | Food | 07/Jul/2005 | Job Hunting | Written In English | Life in London (so so) | Speak to myself | Photo(s) of the day | The Daily Telegraph | The Guardian | BBC | Other sources | BrokenBritain | Frog/ Kaeru | Theatre | Books | 11Mar11 | Stage | Stamps | Transport | Summer London 2012 | Weather | Okinawa | War is crime | Christoph Prégardien | Cats | Referendum 23rd June | Brexit | Mental Health 

Mental Health in Primary Care 2

2011.07.15
Mental Health Policy: No health without mental health
Mental health has become a core part of primary care in the UK. However, this central role has only recently been recognised through policy imperatives around the new mental health workforce and opportunities to re-examine how mental health services can be constructed and organised in primary care (Lester and Glasby, P.75, 2010).

In 2011, the UK government made their latest policy of mental health: No health without mental health. The core strategy of this demonstrates a set of “shared objectives to improve mental health outcomes for individuals and the population as a whole”. The six shared objectives are as follows:

More people will have good mental health
More people with mental health problems will recover
More people with mental health problems will have good physical health
More people will have a positive experience of care and support
Fewer people will suffer avoidable harm
Fewer people will experience stigma and discrimination
(DoH, P. 6, 2011a)

According to the government, this new approach means a different approach to direction setting: developing strategies to achieve outcomes. Outcomes strategies focus on how practitioners on the front line can best be supported to deliver what matters to service users within an ethos that maintains dignity and respect (DoH, P. 11, 2011a). In line with the discussion of how the quality of mental health in primary care is improved, what changes the third object, More people with mental health problems will have good physical health, is expected to make is focused on.

As we have already explored, society has improved its awareness of how physical health affects mental health and vice versa. The government has also recognised the relationship as it presents some of the data; having a mental health problem increases the risk of physical ill health and depression increases the risk of mortality by 50% and doubles the risk of coronary heart disease in adults (DoH, P. 23, 2011a). Since about 90% of people with mental health problems are now managed entirely in primary care, ensuring that all people have access to effective primary health care is fundamental to improving the recognition and management of mental health problems (DoH, P. 33, 2011b).

In order to realise the government’s mental health strategy in primary care, improving the skills of primary care staff to enable them to recognise mental health problems earlier and to deliver appropriate treatments in a primary care setting is recommended by the National Institute of Health and Clinical Excellence (NICE) guidelines (DoH, PP.33-34, 2011b). In addition, different types of treatments, such as psychological therapies, in primary care are considered. Psychological therapies have been shown to improve outcomes for people of all ages with long-term physical conditions and mental health problems (DoH, P.61, 2011b). The expansion of psychological therapies has become a government priority, which should make psychological treatment more easily accessible in primary care (RCPSYCH and RCGP, P. 80, 2009). This clear understanding reflects an understanding that investing in mental health has a pay-off through physical health (CEP, P. 7, 2006).

While some GPs show their interest in developing a therapy capacity within their practice, the majority welcome the provision of a psychological treatment outside the practice, to which they can refer their patients (CEP, P. 9, 2006). Partly because of this situation, the government is accelerating a programme for people to have more access to psychological therapies in primary care.
This plan is not new as NHS proposed a plan a decade ago that one thousand new graduate primary care mental health workers would be employed to help GPs manage and treat common mental health problems in all age groups (DoH, 2000, cited in Lester and Glasby, P.70, 2010).

The current programme is called the Improving Access to Psychological Therapies (IAPT) programme and aims to improve delivery of talking treatments to service users with mental health problems (RCPSYCH and RCGP, P. 7, 2009). The policies and details of the programme are;

The IAPT programme began in October 2007 when the government announced annual investment rising to £173m by 2010/11 to fund the roll-out of evidence-based psychological therapy services across England for people experiencing depression and anxiety disorders. The treatments offered are those approved by NICE for treating common mental health problems (NHS, P. 4, 2011b).

Investing around £400 million over the four years to 2014/15 enables every adult that requires it should have access to psychological therapies to treat depression (DoH, P. 2, 2011c).

More people with long-term physical health conditions, medically unexplained symptoms or severe mental illness are routinely offered evidence-based psychological treatments when appropriate, as part of personalised care planning (DoH, P.4, 2011c).

The IAPT programme was created to offer patients a realistic and routine first-line treatment for depression and anxiety disorders, combined where appropriate with medication – which had traditionally often been the only treatment available. The programme was first targeted at people of working age. The economic case on which it was based showed that providing therapy could benefit not only the individual but also the nation, by helping people come off sick pay and benefits and stay in or return to work (DoH, P.5, 2011c).

It is based on a ratio of around 40 therapists serving a population of 250,000 (DoH, P. 13, 2011c).

In the next section, we will explain how IAPT works in primary care setting by introducing its two pilot sites, and then discuss what IAPT can further offer to the society.


How IAPT works in primary care
Psychological, or ‘Talking’, therapy is a broad term covering a range of therapeutic approaches; they involve talking, questioning and listening to understand, manage and treat people’s problems. (NHS, P.19, 2007). A meta-analysis on psychological treatment finds that the psychological treatment of depression is effective in primary care patients. (Cuijpers et al, 2009). Thus, for the government, the Improving Access to Psychological Therapies (IAPT) programme is the main focus on the delivery of psychological therapies as part of a primary care setting.

The IAPT programme is at the heart of the Government’s drive to give greater access to, and choice of, talking therapies to those who would benefit from them and aims to implement NICE Guidance for people with depression. The government calculates that one in six working adults, who are current targets patients group, at any one time are suffering from clinical depression. In the first phase of the programme, two demonstration sites were established in Doncaster and Newham with funding to provide increased availability of cognitive-behaviour therapy-based (CBT) services to those in the community who need them. The services opened in late summer 2006 (CEP, 2008; NHS, P.4 & P.8, 2007).

By September 2007, the number of the patients who attended at least two sessions at both demonstration sites were 1654 at Doncaster and 249 at Newham. Both sites achieved good recovery rates (52%) for people who had depression and/or an anxiety disorder for more than 6 months. Another finding which can be highlighted is to offer patients a self-referral route to psychological therapies in primary care setting. GPs act as a “gate keeper” to specialist treatment services. However, concern that a GP only access system may disadvantage some individuals with mental health problems led the Newham Demonstration site to experiment with self-referral (Clark et al, 2009).
Although the rate of the self-referral at Doncaster was less than 1 %, 21% of the patients at Newham accessed to the treatment were as self-referral (CEP, P. 30, 2008). In addition, providing a self-referral route appears to enable the service to access disabled individuals in the community who are not well served by existing GP only referral systems routes (CEP, P. 2, 2008).

Another notable result is that the two demonstration sites succeeded in helping people off sick pay and benefits so that they could stay in or return to work (DoH, P.5, 2011c). As a worked example, IAPT programme delivers efficiency and possible cash savings to local NHS of an estimated £1,060 on average for each additional person who recovers from depression or anxiety disorder (NHS, P. 2011a).

There are some points about how the IAPT will be developed for the society. Firstly, the current target patients group is working-age people with common mental illness, such as depression and anxiety disorder, but the government is to extend the programme for people with severe mental illness (DoH, P. 16, 2011c). In addition to this group, the government is also to include people with long-term physical health conditions, such as diabetes, cardiovascular disease or chronic obstructive pulmonary disease. The reason is that these people often have comorbid mental health conditions, but they are rarely referred for psychological interventions, despite good evidence that such management of mental health problems can reduce their need for GP appointments (DoH, P. 19, 2011c).

Secondly, the point of who delivers appropriate psychological therapies in primary care should carefully be assessed. In line with the efficiency of CBT, Haby et al (2006) raise an issue. Although they find CBT effective when offered by a psychologist, they are not clear whether psychiatrists, social workers, nurses, general practitioners or other professional groups can achieve the same efficacy. The British government say that the IAPT programme requires a total of 6,000 new IAPT High Intensity and Psychological Wellbeing Practitioners (PWP) workers (NHS, P.18, 2011b) for full coverage across the NHS. The training programme which they propose may better be updated in regular timing in order to keep the quality of the service to the society in primary care setting.



Conclusion
As demonstrated, both government and society have improved their understandings of how mental and physical health affect each other. Their awareness has also motivated primary care staff, for instance GPs, to provide appropriate treatment for mental illness as well as physical health problems. In addition, the government has keenly implemented the specific programmes to ensure the depressed can have more easy access to get psychological treatments in primary care setting. Needless to say, however, GPs are not trained as psychological therapists while the therapists in the programme cannot treat physical health problems. It is a vital point for us to know from whom we can have necessary treatment for either mental or physical health problems in a primary care setting.
(4349 words)


References
The Centre for Economic Performance’s Mental Health Policy Group (2006): The Depression Report
http://cep.lse.ac.uk/textonly/research/mentalhealth/DEPRESSION_REPORT_LAYARD2.pdf

The Centre for Economic Performance’s Mental Health Policy Group (2008): Improving Access to Psychological Therapy: Initial Evaluation of the Two Demonstration Sites
http://cep.lse.ac.uk/pubs/download/dp0897.pdf

Clark, D.M., Layard, R., Smithies, R., Richards, D.A., Suckling, R. and Wright, B. (2009): Improving access to psychological therapy: Initial evaluation of two UK demonstration sites. Behaviour Research and Therapy, Vol. 47, 910-920

Cuijpers, P., van Straten, A., van Schaik, A. and Andersson, G. (2009): Psychological Treatment of depression in primary care: a meta-analysis. British Journal of General Practice, February, e51-e60

DoH (2000): a plan for investment, a plan for reform cited from Mental Health Policy and Practice by Lester and Glasby (2010)

DoH (2011a): No health without mental health: A cross-government mental health outcomes strategy for people of all ages
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_124058.pdf

DoH (2011b): No health without mental health: Delivering better mental health outcomes for people of all ages
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_124057.pdf
DoH (2011c): Talking therapies: A four-year plan of action
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_123985.pdf

Haby, M.M., Donnelly, M., Corry, J., Vos, T. (2006): Cognitive behavioural therapy for depression, panic disorder and generalized anxiety disorder: a meta-regression of factors that may predict outcome. Australian and New ZealandJournal of Psychiatry 40, 9-19

Lester, H. and Glasby, J. Mental Health Policy and Practice second edition (2010) Palgrave Macmillan, Hampshire, UK

NHS (2007): Commissioning a brighter future
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_074821.pdf

NHS (2011a): Commissioning Talking Therapies for 2011/12
http://www.iapt.nhs.uk/silo/files/commissioning-talking-therapies-for-201112.pdf

NHS (2011b): Guidance for Commissioning IAPT Training 2011/12 – 2014/15
http://iapt.nmhdu.org.uk/silo/files/guidance-for-commissioning-iapt-training-201112-201415.pdf

The Royal College of General Practitioners (2005): Mental Health and Primary Care
http://www.rcgp.org.uk/PDF/clinspec_printed%20version%20mental%20health.pdf

The Royal College of Psychiatrists and Academy of Medical Royal Colleges (2010): No Health without Mental Health: the supporting evidence
http://www.rcpsych.ac.uk/pdf/No%20Health%20without%20mental%20health%20the%20Evidence.pdf

The Royal College of Psychiatrists and the Royal College of General Practitioners (2009): The management of patients with physical and psychological problems in primary care: a practical guide
http://www.rcpsych.ac.uk/files/pdfversion/cr152.pdf

Pilgrim, D. Key Concept in Mental Health second edition (2010) Sage, London, UK

Running On Empty report (2005)
http://www.psychminded.co.uk/news/news2005/july05/runningonempty.pdf

Schreuders, B., van Marwijk, H., Smit, J., Rijmen, F., Stalman, W. and van Oppen, P. (2007): Primary care patients with mental health problems: outcome of a randomised clinical trial. British Journal of General Practice, November, 886-891


関連記事
スポンサーサイト
Template by まるぼろらいと

Copyright ©LONDON Love&Hate 愛と憎しみのロンドン All Rights Reserved.