We need to learn from other doctors

The analysis of current trends in English psychiatric services by St John-Smith et al ¹ outlines some real problems but does not provide the jobbing clinician (or manager) any practical solutions. I believe other front-line medical services, notably military and primary care, do provide some solutions to help with quality, safety and accessibility in our field.

There needs to be a robust triaging service for urgent referrals, readily accessible to general practitioners (GPs) and other referrers. Consultants should be available on a shift basis to review joint assessments carried out by two (ideally multidisciplinary) staff, also working shifts. This approach has a greater likelihood of avoiding biases in judgements (diagnosis, risks) and decisions (when and where to refer). The UK military field hospitals have much to offer in triaging expertise, as it utilises multidisciplinary assessment and prompt specialist review. The equivalent to field hospitals could be local accident and emergency sites, providing safety and logistic support. Urgent triaging is currently carried out by crisis and home intensive teams, who thereby get put off their main role of avoiding inappropriate psychiatric bed use.

Furthermore, there is an emerging debate whether (or not) a mental health polyclinic staffed by GPs with special interests jointly with non-medical mental health staff would be useful in triaging cold referrals such as anxiety or depression, medically unexplained symptoms and cognitive or memory problems. The relevant experiences stem from musculoskeletal clinics held in primary care or at cottage hospitals around the UK, staffed by GPs with special interests and physiotherapists. A mental health polyclinic could contact a dual-trained consultant for advice or consultation, possibly via a telemedicine link. A polyclinic should be able to provide a second opinion to a GP with the patient returned with a diagnosis and treatment plan (including a risk or relapse plan).

St John-Smith et al ¹ are right to point out the finite number of community mental health team (CMHT) staff. Perhaps CMHT staff and primary care mental health staff would need to be seconded for these triaging duties including an appropriate shift pattern to avoid burnout. General practice registrars will find triaging experience particularly relevant for their future role (which might include competency to work as a GP with a special interest).

We live and work in uncertain times. I suspect most of the politics that surround secondary care mental health is influenced by fears of job losses (particularly managerial) in this financial climate, worsened by lack of clarity on payment by results in terms of the relative priority given to new assessments compared with continuing secondary care. Hopefully, these matters will be resolved over the next 18 months, but in the meantime it is well worth studying successes in other medical fields to inform the next wave of reforms, most likely driven by a new set of clinical commissioners from primary care.