Two-thirds of people with long-term physical health conditions (LTCs) also experience mental health problems. This impacts patients and the staff caring for them. This training website seeks to support you in thinking and talking straightforwardly about the links between physical and mental health with your patients. The materials have been created by clinicians from the Tavistock and Portman clinic and local Improving Access to Psychological Therapies (IAPT) services.
Long-term conditions and mental health: making the case, with Dr Warner
To start us off, Dr Alex Warner, Camden GP and CCG lead for mental health, explains why this area matters. If you feel aware already of the importance of this area for clinicians and patients, feel free to move to the Finding the Language, Body and Mind, and Improving access to psychological therapies sections of the site.
00:04 Can you say a bit about yourself?
I’m Alex Warner, I’m a GP at the Caversham Group Practice in Kentish Town in Camden. I’m also a Clinical Lead for mental health at Camden CCG. And I teach mostly about mental health at University College London and this is an area that’s a particular interest of mine
00:24 And what’s this all about?
It’s about thinking about the emotional impact of long-term conditions, of the links between mental health physical health, and making use of appropriate resources. So, in primary care settings such as GP surgeries, some of the understandable concerns among staff are, well how do GPs, nurses, healthcare assistants open the door in a brief consultation to a patient’s emotional and psychological needs. Why should they? With all of the push to return provision of services to primary care, haven’t we got enough to do already? How will this help rather than create more work? How do we prevent opening up “a can of worms”? And, once that conversation is had we can walk to the next steps. The hope would be that through the various videos and materials on this website as well as the upcoming training events can address these questions and provide some useful tools for your consultations and to think about within your teams
01:28 Sounds like hard work, why does this matter?
You may be aware 30% of the population have one or more long-term conditions now and it’s going up. There’s a recent King’s Fund paper and it makes it clear that a third of women and more than 20 per cent of men with all types of arthritis may have co-morbid depression. Depression is also two to three times more common in a range of cardiovascular diseases and in diabetes. Anxiety problems are also common in these conditions. Mental health problems are around three times more prevalent among people with COPD, chronic obstructive pulmonary disease, than in the general population. Panic disorder is up to 10 times more prevalent than in the general population in that group
Economically, the Department of Health estimates that long-term conditions account overall for about 70% of total health spending. The presence of poor mental health increases the average cost of an NHS service use by each person with a long-term condition from approximately £3,900 up to £5,670 a year
More importantly, for the patients themselves, we’re talking about lower quality of life, frustration, low mood, worry, isolation, but also lack of adherence to medications, a worsening of their physical symptoms and increased risk of early death. There’s big implications for practices. So, we recognise a greater burden on staff, frustration when we’re unable to understand that lack of adherence or the increase in patients neglecting themselves, sometimes guilt at not feeling able to do enough for them, and sometimes splits and divides as the impact affects the rest of the team. Sometimes that then means higher sickness levels or staff burnout. To put it the other way around, supporting patients with their psychological health doesn’t only impact on their mood but also on physical health outcomes, and on the relations with staff and the surgery
03:40 So which patients are we talking about?
So, potentially talking about a range of different patients. Newly diagnosed patients, say, with arthritis, diabetes, COPD or other long-term conditions, who are struggling to adjust to a new routine, to limitations perhaps, or changes in their lives. They might be struggling to hold onto a sense of meaning or value, or worry about specific symptoms, so people worrying about their breathlessness in COPD, or about hypos in diabetes. In might be people who have unnecessarily restricted their life after diagnosis or may not yet have had any conversation about psychological support. Some of these patients may well tell you that they’re worried or low or frustrated. Most won’t. You may be like this yourself, you may prefer to just get on with things. That certainly can have its place, but sometimes a slight nudge or prompt is all that’s needed to allow somebody to say, actually, I wouldn’t mind talking to someone for a little longer about some of this
It could be that, once mentioned, this is the type of conversation – the checking in about support, about coping, about how a person is doing – that can be had regularly then by a practice nurse, GP or healthcare assistant. Often, it is the anxiety about that opening “a can of worms” with that first conversation which can actually prevent it. But it might be that actually further support, more time, from psychological services, groups and local support networks for each condition, could be useful. In terms of who might be sent to IAPT services – with their new provision for long-term conditions – we’re talking about the patients with the same sort of mild-to-moderate group who you would already think about for IAPT for
05:29 But these aren’t the patients I struggle with most, what about more difficult consultations?
It’s true that a lot of these patients are below the radar at the moment, but we are talking about a group of people who in several years will potentially be struggling much more with their physical and psychological difficulties due to their untreated mental health needs, their lack of medication adherence, perhaps their restricted social life or inactivity. So, we say, opening the door now to these types of conversations will go a long way toward saving resources for you and for your team later
That said, you’ll find links to resources, tips, advice, for complex consultations such as people experiencing medically unexplained symptoms, persistent physical symptoms, comorbid presentations, where difficult feelings arise and solutions aren’t clear
Central to these more complex consultations is the way you’re left feeling: frustrated, overwhelmed, guilty. This isn’t a side issue that reflects a failing on the part of you or the patient, nor are they feelings that you wouldn’t get with the right tools or if you were doing something different. Phrases like heart sink don’t come out of nowhere – it is an indicator of anxiety, perhaps fear, dread, incoming distress for patients and clinicians. And it is the affecting nature of these consultations, whichever way they stir us up, that is central to the challenges that are involved in these consultations. Accepting that this is a core part of the thinking that needs to go into these consultations is difficult but essential
From this starting point, you might want to think about how yourself and your staff are supported within the surgery. There are links to further training and suggestions, from simple things like longer consultations, ensuring that not only 1 or 2 very receptive staff members get given the complex patients, ensuring regular case meetings to think about, to offload, and share the load; considering releasing staff for training and seeking one to one and group consultation or input from psychology or other services in your borough
Much of this you may well already know but struggle to implement with the pressure of targets and outcomes. In this case, the aim is simply to re-introduce the idea maybe for further thought within your team, with your practice manager, with your commissioners who also have a vested interest in ensuring staff are supported in the care of patients with long term and complex conditions
08:15 Ok, so what now?
Have a click around. Hopefully the links to the videos and other resources will provide some straightforward tools and information on ways of talking, information about services and upcoming free training, and support with seeing patients with persistent physical health difficulties. If you find that you are quite experienced already in this area, maybe the resources might be thought of for new starters, for training clinicians at your practice, the videos will all have the transcript beneath with timings of where a particular question is covered if you’d like to skip ahead.
Thinking about practice nurses, with Carol Sibanda
Practice and community nurses take on a lot responsibility for the ongoing care of patients with long-term conditions. Carol Sibanda, Nurse Psychotherapist, thinks about the essential role of the practice nurses and how, if nurses are to have conversations with patients about mental health, they, in turn, need to feel supported to do so.
For further information on support for practice nurses in each borough, such as existing practice nurse forums, please contact Paula (firstname.lastname@example.org) for Enfield, Karen (email@example.com) for Islington, Nicole (Nicole.firstname.lastname@example.org) for Haringey, Charlotte (email@example.com) or Carry (firstname.lastname@example.org) for Camden, and Amita (email@example.com) for Barnet.
00:11 Can you tell us a bit about yourself?
My name is Carol Sibanda. I’m a psychotherapist working in primary care psychotherapy consultation services – that’s a mouthful. I’m based in City and Hackney
00:25 Why might it be difficult for practice nurses to begin talking about mental health with patients?
One of the things that, forms of conversations that I’ve had with some of the nurses, is they feel quite isolated. Maybe that’s a really big area to look at, whether its around supervision or training or just a reflective space to really think about how then, how do you feel able enough to open up those kind of avenues. How well do you feel supported? Primary care’s got so many demands. And finding space for their own supervision… I mean if you think of nurses on a ward, say, they say have a supervisor from different bandings. Practice nurses it’s slightly… I’m not quite clear how they’re supported, maybe they meet as a small group, but… it hasn’t been very present in terms of how they support each other or how they get supported in a GP surgery
01:36 What might this support involve?
People bring a case or different cases that they just want some thoughts to it with colleagues. Not necessarily to get an answer but just a space to reflect. That’s used quite well with GPs. I don’t see why that can’t be offered for practice nurses
02:03 What’s mental health got to do with treatment for a long-term condition? Can you give an example of how a case discussion has helped?
We have quite a high percentage of patients who get referred to us who find it really difficult to manage their diabetes, say. Some of it can be used alongside self-harming behaviours, which may not necessarily be quite apparent in a routine check. You might get a pattern from what they say that they see somethings going on with someone not taking their insulin all the time, or they don’t use their pump for their breathing difficulties. But I suppose it’s taking that conversation a little bit further to try and understand why that might be, why someone might be doing that
02:52 And how does that link to referral to psychological services for long-term conditions?
For that referral to feel meaningful to the patient, to be able to go to different psychological services, it starts from that conversation with the nurse. That, if anything, helps whether someone engages or not
03:19 Why might further support for nursing staff be worth thinking about at a service level?
We all work with vulnerable individuals. We all go through different experiences, as patients as well. So, for the practice and the GP, its an investment in your clinicians to really look after your patients
The role of Adverse Childhood Experiences in the management of LTCs
Recent research indicates that Adverse Childhood Experiences (neglect, trauma, abuse, loss) can lead to a range of physical as well as psychological difficulties in later life. Sometimes, difficulties in the management of a long-term condition can be due to the habits, relationship patterns and self-perceptions that are left over from these experiences. Tim Kent, Consultant Psychotherapist and Social Worker, describes how such experiences can, in turn, create challenges for the staff caring for patients with LTCs.
Living with a long-term condition, with Maria
Whether it’s mental or physical healthcare, patients’ experiences of their care are often the best guide to good practice. Maria works for the NHS and lives with arthritis. She explains what she values from her encounters at her GP practice and what she gets from the Enfield Arthritis Social Club.
00:08 Can you say a bit about yourself?
My name is Maria, I have arthritis in my right knee. Its progressively getting worse and I’ve been told I’m going to need a knee replacement. I work for the NHS and have for almost 20 years. I started out as a qualified dental nurse but now I work in mental health coming up to two years in September
00:37 What makes living with the condition difficult?
Waking up first thing in the morning, it’s the stiffness in the joints and also it’s quite painful. I mean, it might wear off after ten minutes but it’s always there. That’s the hard thing, just getting from A to B. I suppose it’s like a hidden disability: on the outside you like fine, you look normal, you’re going about your business, okay some people might notice a limp here and there. But, inside, in the knee for me, it’s quite painful. Its just day to day actually, sometimes I feel that yes I want to go out somewhere or other days I think I’ll just wait until the pain lessens. So, I just keep each day as it comes. Obviously, if I’m using public transport, for instance, where I might sit down on the disability chair, some people might think ‘oh they look fine’, but it’s a hidden disability, it’s like a lot of things, you can’t see it but the person is in pain
01:43 What do you value about your consultations with your GP?
For me, it’s the empathy. They look like they’re interested. They listen, they take what I say seriously
01:56 What do you think might make it difficult for GPs, nurses and healthcare assistants to talk about mental health?
I think for me, maybe for other patients, you’re aware that for a lot of GPs, they don’t actually have sufficient time with their patients, they might have maybe 8-10 minutes, if that. You’re always aware there are always other people in the waiting room that want to be seen. It’s not that the GP means to hurry you, but sometimes patients can feel a bit hurried, you know, they go in and the GP has already got the prescription pen in hand, or nowadays it’s typed or finger on the keyboard – and you just feel a bit rushed. So, for me, if they have or ask any more leading questions, you know, ‘how do you feel emotionally?’, that’s going to lead on obviously to the patient talking. That’s going to eat into their time which they’re limited on already
02:57 What do you think can happen in this climate of pressure on primary care?
Yeah, and often as well, you know, when the doctor is finished and when the patient is leaving the room, as their hand is on the door handle to leave the room, they might turn around and say to the GP, ‘you know, by the way, I meant to ask you…’ and that was probably the first question that they actually wanted to ask. I mention that because I read an article in the medical section last year by a GP who was saying the door-handle syndrome, when someone’s leaving and they ask that question that’s probably the most important one they wanted to ask. But they felt oh well I’ll just kind of side-track and ask something a bit softer and that’s it. But that GP surgery might just have, you know, one GP! So that as well, they’re under stress. They’ve got targets, they’ve got budgets to meet, so there’s only so much that one human being can do
03:55 Can you tell us where you’ve managed to find some support?
For me, for instance, last summer… I know I said in summer it can be a bit better, but I was finding it quite painful… I just happened to search engine arthritis groups in north London. Luckily, not far from where I live, there was a group on the first Wednesday of each Monday. And I thought, okay, so I emailed the person who I’d read about and said about details on the blog. She emailed back and invited me, and it’s between 6pm and 8pm the one I go to. I went along and saw there was other people even younger than me who are in more pain. Some can’t work, some are lucky to be able to work from home. And I was kind shocked. As I said, I was aware of juvenile arthritis, children with arthritis. But there were so many twenty-somethings. As one lady said, she likes to wear these tight jeans but sometimes with the swelling she just can’t get her leg in the jeans because it’s swollen up so much. And I just thought wow. So sometimes it’s good to be able to share any problems you have because even with your nearest and dearest, if they’ve heard it once they’ve heard it again. So, it’s good just to share that with other people who are going through and experiencing the same thing as you are. I found that really helpful, definitely. And the social side of it as well. It’s held in a lovely restaurant that’s not so expensive. And it’s nice, the ambience, and it’s laid back. It doesn’t feel formal even though there’s a lot of information to be gained. So, I like that, I enjoy going