London GP mental health scheme helps hundreds, skills up primary care staff and saves thousands

More than 600 people now visit their GP instead of the hospital for regular physical and mental health checks thanks to a successful London scheme saving the NHS thousands.

Across Newham CCG’s 61 surgeries four teams Community Psychiatric Nurses (CPNs) are on stand-by to see patients with stable severe mental illnesses who have opted into the service.

They no longer visit the psychiatrist in outpatients and can instead be seen at their local practice where they and their carers can get physical health checks.

The initiative has saved thousands of pounds for the CCG some of which has been reinvested with East London NHS Foundation Trust to establish new services.

Dr Lise Hertel, who has been commissioning the scheme with Newham CCG for the last three years, said: “Lots of people were going to out-patients once or twice a year for a review which was a waste of their time and the psychiatrist’s. So we came up with the idea we would bring people with a stable serious mental illness back into their GP practices, after first providing training and support for the practice as well as the service users.

Despite some initial resistance to the change, regular face to face discussions with GPs, psychiatrists, practice nurses and patients settled the issues and better patient outcomes became the focus.

“The psychiatrists initially didn’t want to let the patients go and the practice nurses were nervous about some of the challenges they might face but we overcame all of those things by being supportive and proactive and our teams are always there to support individual practices and the service users,” said Dr Hertel.

“The teams started off with strict rules about which patients could be discharged to the service but as both primary care and specialist mental health services have become more confident, they have moved to patients with a wider range of conditions where appropriate.

“We’re working towards a Parity of Esteem and integrated mind and body care with this initiative ,” Dr Hertel said.

“This service achieves appointments that are closer to home and the patients can be seen more often. The GPs and practice nurses can also carry out any physical health checks and start treatment immediately with patients and their carers, not done previously at the outpatient checks at the hospital, including vaccines such as flu, blood pressure monitoring and cardiovascular disease and diabetic checks. The GPs QOF scores have increased as a result and this has helped fund the primary care mental health development

The CCG has just a 10 per cent relapse rate for these discharged patients who go into a crisis and have to return to psychiatric care , but when they are better they want to return to the care of thieir GPs and the practice linked CPNs.

Dr Hertel said: “Everyone is happier, patients get healthcare in a normalised setting, we’ve got heart-warming stories from our patients and their carers, GPs get support and training through MDTs and can provide a seamless and integrated service to their patients.” And the workforce is happier as the GPs are better supported, the CPNs are happy to be working in this service and there is no shortage of CPNs wanting to join. Patients are asked to give regular feedback which reports significantly higher levels of satisfaction with the service and there is no sign of this changing three years in.

Dr Geraldine Strathdee, NHS England’s National Clinical Director for Mental Health, said: “Newham is an excellent example of the partnership working between commissioners , service users and specialist services, all committed to work together to make sure people get the right care in the right place.

“The key to the success here is the clarity about the standards of care people need, the outcomes each person wants, and training for primary care staff to deliver it, backed up by specialist staff. What is also critical is the focus on easy access and integrated mind and body care.

“Often outpatient clinics can become incredibly busy seeing relatively stable people,  and the capacity to respond to crises to prevent a deterioration or prevent an unnecessary admission is then very limited.

“Where there is no longer a need for people to visit an outpatient unit, it is better for them to have their appointment in their GP surgery close to home. Not only is it better for the patient, but it also frees up appointments with specialists for those who need more serious interventions.

“The parallel is diabetes – 15 years ago most diabetes care was provided in secondary care hospital clinics. A programme of planning with patients, primary care training for GPs and practice nurses, now means that the majority of people with diabetes receive their treatment in primary care, with advice and input from specialists when needed. In mental health, this is a journey that is starting in many parts of the country. Newham shows how it can be done collaboratively and with excellent training.”

But Newham has further aspirations to help its population with mental health problems which in this very deprived area currently cost, per head of the population, £138 each year.

The CCG is aiming for better outcomes, one of which is to get more people with mental health problems back into work through a variety of new initiatives including buddying people with those who have been through similar issues but are now recovered and back in work or volunteering.

Two unexpected challenges the service and the GPs faced related to social care issues:  firstly, ensuring that patients did not lose their Freedom Passes, often only awarded because the person is in touch with secondary care, which allow free travel of public transport, a vital way to support people to remain active and self-care. Secondly, the potential risk of a patient losing their housing because they had been discharged from secondary care. This last remains a challenge and is dealt with on a case by case basis.

“There will always be challenges with any change and we are still working on some things,” Dr Hertel said.

“But it has been so worthwhile because the patients are much happier, it saves money, the psychiatrists can concentrate on the sickest patients and the GPs are well supported around mental health. It has enabled us to consider bringing other services back into shared care in primary care such as eating disorders and to achieve a higher level of mental health awareness and promotion.

“There’s much better understanding of mental health illness which is better for everyone and I’m extremely proud of all the people I work with both professionals , service users and carers without them this would never have been possible. They were all brave enough to work together to see if this model would work despite initial worries – and it has!”


  1. Helen says:

    This sounds great – please can we have more details on how the scheme was funded – how was resource moved from secondary care into primary care ?

  2. Roger S. says:

    This sounds like a good idea. What is shocking is comparing the NICE guidelines to what happens on the ground. It’s laughable.

    For an organisation that has no money, mental health services sure do spend it easily.