‘We try to remove all barriers to accessing a psychologist’

It's 2022 and pandemic-inspired NHS claps and superhero motifs already feel like distant memories In their place, we have regular reports of GP surgeries with clogged phonelines and unavailable appointments, leaving distressed patients unable to speak to their overwhelmed doctors. Patients justifiably complain, and NHS England respond by allowing GP practices to deregister patients with 'persistent or unrealistic service demands' (NHS England, 2022; Nursing Notes, 2022). GPs are overworked, stressed and at burn-out point. The numbers of GPs and training places are declining; retaining GPs is an understandable but increasing problem (Marchand & Peckham, 2017). The news tells us about the ever-growing NHS burden of mental health appointments, where people are encouraged to 'speak out' about their distress even as services are crippled under the growing demand.

In response, in March 2022, Lucy Marks MBE led on a report highlighting the need for Clinical Psychologists within GP practices (BPS, 2022). Today, I write as a Trainee Clinical Psychologist on placement at Launceston Medical Center in a model which works within these recommendations. The setting is a rural Cornish GP practice serving approximately 19,000 patients in the surrounding area. The approach is known locally as 'The Lanson Model'. I have interviewed my supervisor, Dr Rebecca Magill, to discuss this exciting development.  

[Pictured: Dr Amit Dhulkotia, Dr Rachel Parkinson, Dr Rebecca Magill, Pip Wood]

You started this post in March 2021. But take us back a moment; how did it come about?

In January 2020, I was sat in a group of mixed health and social care professionals, and I said that one thing I wanted to change within the NHS was access to psychosocial input and intervention. I was distressed by how hard it was to reach psychology within services, with the onus being put on the pathologising of distress and medicalisation of experience. The pathway prioritised a medical view and psychologists couldn't get to patients quickly enough. There was a GP and a social prescriber in the group. They were also worried about the increasing quantity of mental health appointments in practices and unmet needs in the community. The following year, I had signed a contract to work in Launceston Medical Centre practice, much like a GP, but with my qualification as a Clinical Psychologist.

Why a Clinical Psychologist and not Mental Health Practitioners?

Whilst MHPs are now routinely being employed by GP practices around the country, they generally offer one-off mental health appointments and signposting. It's valuable because it takes several the appointments away from GPs themselves, and because these professionals have got specific mental health assessment training. What's different about Clinical Psychologists is that we can all also provide intervention from the outset, and this might reduce onward referral or plug some gaps between services. MHPs are valuable for absorbing some of the overwhelming quantity of mental health appointments, but Clinical Psychologists should offer more than a repository for a group of patients. We also work to change the system around them and the views of the primary care clinicians, which is liable to be quite medical.

I also think it is possible to underestimate the value of the variety and diversity of Clinical Psychology training. We can work across neurodiversity like ADHD and autism, learning disabilities, dementia, as well as within health psychology and health promotion. Clinical Psychologists are trained across the age span too. It's refreshing to get you apply all your learning every week. The Lanson Model does not have an inclusion or exclusion criteria at all. If a patient calls and wants to speak to a psychologist, then we are available. It is not a mental health service but a service that promotes the psychosocial factors in any presentation, from depression to diabetes, addiction to arthritis, bereavement to bariatrics. Similarly, GPs can access our input by popping up the corridor or just booking a joint appointment with us.

I like to think I contribute indirectly by thinking about practice policy, staff wellbeing and how we communicate with the population too. Clinical Psychologists are used to tackling the system at the same time as thinking about individuals.

What does the Lanson Model look like on a day-to-day basis?

I'm full-time and there are now two trainees and a Social Prescriber too. There is a Psychology clinic that looks much like any of the GPs with a set number of appointments each day. There are between 18 and 24 appointments per day.

These slots are filled by a psychologist booking in a follow up contact, GPs putting one of their patients into a slot, and patients that come via our receptionists. If a patient self identifies as having a mental health concern or is asking about neurodiversity, bereavement, school refusal, self-harm, sleep, or addiction then they are automatically offered psychology. Our telephone receptionists are trained to ask other patients if their difficulty might be about emotions/stress/mental health and offer a psychologist instead of a GP too.

So on a 'typical' day, I may have a mix of telephone, face-to-face and emergency appointments. I might encounter issues such as bereavement, postnatal depression, long Covid, eating difficulties, and stress or low mood.

We try to remove all barriers to accessing a psychologist. Most appointments are one-off assessment/formulation/signposting. However, we also offer follow up to do more detailed specialist assessments, formulation work and/or therapy. We hold joint appointments with teachers, addiction workers, domestic violence, and sexual assault services, CMHT staff and/or family. We get to be entirely flexible and work creatively to hold a truly person-centered approach.

What do you like most about the model?

I like that we are committed from the moment we start with each patient. It's both validating, and trauma informed. Psychologists routinely use formulation to understand difficulties before delivering appropriate assessment and intervention for a broad range of service users. Sadly, we are so often governed by policy, procedure, and inclusion/exclusion criteria that we can overlook those who do not reach arbitrary thresholds.

I think there are three problems with that. One, we wait until people are experiencing significant, potentially avoidable, distress and are at risk to themselves or others. Two, the very process of screening, triaging, and assessing against criteria can create waitlists too. And three, I do wonder if clinicians constrained by the traditional models might sometimes fail to convey their congruence and unconditional positive regard to patients. Of course, the clinician cares, but they are still often listening out for ways to say 'no', and patients' sense this.

I'm proud that The Lanson Model uses our broad but specialist training alongside the ethos of normalising life experiences without always reaching a diagnosis. It teaches those at the very front door of services how to hold and help individuals before they need secondary and tertiary services. Sometimes this also means we can help before the vicious cycle is embedded.

I'm learning this also means patients aren't awaiting the inevitable rejection of discharge. When you take away the threat of abandonment (because they can always just call tomorrow), then patients don't need to 'cling on' so hard.

I feel refreshed by this way of working. Under the pressures of inadequately funded systems, burn out and moral injury can lead to resulting difficulties with staff retention and service provision. The other way didn't align with my values, but it felt like commissioning arrangements left me no choice. I truly feel part of the Launceston community and I have the autonomy and discretion to work in a way that benefits an awful lot more patients. If the service doesn't exist, then we can either do the work ourselves or we can help the community to grow it.

What does this mean for patients?

It means they will likely be seen on the day but if not, it will be scheduled for within the fortnight. They will be offered face-to-face, video or telephone consultations. The numbers sound overwhelming, but the reality is, a lot of people just need a validating, listening space to help them decide for themselves; books and self-help resources, relaxation, and value-based activity, as well as community integration make such a difference. We also engage in service liaison and signposting as well as crisis prevention plans. The appointments often dovetail with the work of our Social Prescriber. We reduce the need for psychotropics for many patients. When I refer on to my friends and colleagues in the surrounding mental health services, I hope that it is more likely to be acceptable to both patients in terms of readiness, and services in terms of their criteria. This means both services are taking a step towards a trauma-informed delivery. It means that a patient that falls in a therapeutic gap will likely get treated by a psychologist at the practice. We do an array of one to one and systemic therapies and are just now getting larger scale groups off the ground too. Where there are services, but they have protracted waitlists, we can start psychological work whilst patients are waiting.

What does this mean for patients who might benefit from medication?

The aim of the psychology team is not to negate the use of medication; instead, it offers the opportunity to explore other means of support. We often find that patients come to us wanting to explore options that do not involve medication, but that does not mean it's not a conversation we have. If patients feel they might benefit from medication, then this is something we will speak about and then refer to the relevant medical professionals and prescribers, as necessary.

The beauty of having psychology within the medical centre means that we can call upon their registered GP to support them with medication if they request this, whilst also informing them of additional avenues. We find that many patients will take some time to consider options and come back to us for further consultation at a later date.

How does having psychology within the GP practice benefit services on a systemic level?

The in-house psychology model allows for joint working with the medical staff, consultation slots, CPD and training for GP staff as well as team coaching and reflective practice activities. The GPs say they feel supported by knowing that there is someone in the building ready and able to help with more complex presentations of mental health or physical health with comorbid psychological factors. This model has also allowed for more direct liaison between the surgery and other primary and secondary services. Our latest ventures include providing CPD to the community college, building up a resource library for the GPs and engaging in community work alongside the Social Prescriber at the local library. My new ambition is to establish a Community Hub from which we can joint work with voluntary sector services and the parts of the NHS around us that accidentally became fragmented by current commissioning, like those that specialize in addiction, abuse, emotional instability, chronic pain, or loneliness.

This must have taken time to develop. What do you think the GPs expected from a psychologist when you first started?

In my first few weeks, I ran a survey to find out. 11 out of 14 replied and said autonomous care and intervention was most needed, and they hopefully anticipated a reduction in their mental health workload. The dominant narrative within the service was an expectation of timely assessment and treatment that was readily available for their patients. The presence of mental health expertise was thought to be sensible in relation to the increase in mental health related appointments. It was hoped that a byproduct of this would be a reduction in episodes of staff sickness and burn-out. I did not hear a lot about the indirect or systemic work that psychologists do, and there was less about meeting unmet needs than I expected.  

I am interested in the anticipation of a reduced mental health workload. It is concerning that psychology might be used as a container for mental health and disallow the progression of primary care in managing difficulties themselves? Has the narrative changed over time?  

I suppose it really could be concerning, yes. It would be disappointing to accidentally work to de-skill staff or create a new bottleneck. After six months, I repeated my qualitative survey and again 11 staff responded. This time they said that having a psychologist in house resulted in feeling more supported both indirectly and directly. They reported that having scaffolding around managing mental health within their work was beneficial for feeling held by the system. Despite having anticipated managing less mental health presentations themselves, practitioners reported starting to feel more able to hold uncertainty with support provided by psychology within the building. In this survey, the role of psychology feels more proactive rather than reactive and staff are appreciating regular communication and feedback around working with this service user group. For example: "Takes a large amount of GP workload and stress away. Easy access to advice about patients with complex psychological problems, upskills GPs by seeing how a psychologist approaches common GP presentations and how they document the consultation… ongoing education about psychology, support and training for staff has really helped."

This all sounds positive. What do the service users think?

We have conducted a survey about this too. This time we texted a link to all the 'patients' I'd seen in the practice within the first six months. Responses were positive regarding the new roles, with 119 out of 137 respondents reporting the service to be 'good' or 'very good'. It's interesting that the public essentially repeat the advice given by the 2022 BPS guidance on Clinical Psychology in Primary Care. Service users reported feeling held 'in house' and able to access 'an expert' for support and advice alongside their regular GP.  

"I was very pleased to have been able to see the psychologist.  She is very approachable, easy to talk to, empathetic and thoughtful, and gave a lot of consideration to my situation."

"This service should be classed as essential and implemented in all surgeries throughout England"

"I found the support I received timely and informative. The signposting was totally appropriate to my situation especially when I was so distressed. I would like to take the opportunity to thank the psychologist who listened and helped me get back on track. I am grateful for their guidance."

Those respondents who reported being 'neutral' (N=5), 'unsure' (N=4) or 'unsatisfied' (N=8) raised concerns regarding the lack of face-to-face appointments due to the pandemic and a preference for their regular GP. Feedback also highlighted a discrepancy in the community's expectations and understanding of the psychology provision.

"The clinical psychologist was really informative, friendly and listened. The only downside especially in this current climate with mental health etc was that the surgery is hard to get through to for a consultation... I would like to see doctors seeing people face to face because telephone appointments are not satisfactory"

We've increased the amount of psychology appointments and doubled our staff since then. It's far more possible to do home visits and face to face contacts in September 2022 than during the peaks of the pandemic too. We are therefore in the process of repeating the text survey now.

Can we finish with you, Pip? I'd like to hear what motivated your placement.

I wanted to become a clinical psychologist because I wanted to hear the voices of those not listened to. I have always been that person that notices small things and using that in my work feels integral to me. I want to be a clinician that gives service users a good experience of professionals, to be a step in their journey and allowing them to feel able to move forwards. Not only that, but I felt a passion for having conversations about the importance and beauty of diversity.

And is that still the case, now that you're well into your placement?

Yes – all these things, I am now more determined to achieve. At times, this placement has been quite intense and overwhelming, but I'm grateful for what it has taught me. I've developed my confidence working across the lifespan, and become more aware of my own biases and assumptions that come with this. I know more now about the psychologist I want to become and why. Gabor Mate said in one of his books 'we can't let our experiences be barriers to our work' and I agree, but we can let what they teach us fuel the fire that helps us become better people and ultimately, better clinicians.

The power to influence

Despite being in its infancy, The Lanson Model aims to provide something bespoke to the local community, combining the need of the town and surrounding areas with the therapeutic flexibility that psychology offers. It is important for us to think about the importance of these primary care providers and how we, as psychologists, have the power to influence them even when it feels as though we might be powerless against the litany of policies and procedures that govern our practice. By sitting within these services, we can shape the experiences of therapeutic intervention that individuals are able to access and conceivably lessen the impact on secondary and tertiary services.

Our role, then, is a privileged one. By sharing our experiences and knowledge with GPs and other primary care clinicians, we can influence this cohort of practitioners to feel safe and confident to manage the increase in mental health need to a higher degree. We can help services to stop decanting patients into 'mental health' or 'physical biological difficulties', merging the biopsychosocial at the very gateway to services.

It is our experience that, even with a global pandemic, people have been enthusiastic about helping set up this novel service. Those involved express a keen interest in promoting the model with the hope of inspiring other practices to consider psychology within their settings. The Launceston Medical Centre continues to take two Trainee Clinical Psychologists each year and we, as a team, would be delighted to talk the model through with other psychologists, practice managers, PCNs or GPs that might be interested.

References

Department of Health. 2001. The Government's Expenditure Plans 2001-2002 to 2003-2004 and Main Estimates 2001-2002. Department of Health.

Marchand, C. & Peckham , S. (2017). Addressing the crisis of GP recruitment and retention: a systematic review. British Journal of General Practice, 67(657): e227-e237. DOI:

Mind (2018, June 5). 40 per cent of all GP appointments about mental health. Mind.

NHS England (June 2022 update). Primary Medical Care Policy and guidance Manual (PGM). NHS England. 

Nursing Notes (2022, June 2). GP practices can now deregister patients for 'unrealistic service demands'. Nursing Notes.

The British Psychological Society (2022). Clinical Psychology in Primary Care – how can we afford to be without it. Guidance for Clinical Commissioners and Integrated Care Systems. 

Wilkie, V., & Ralphs, A. (2016). The pressures on general practice. Bmj, 353.