Social workers and general practitioners—some problems of working together

Generally, relations between general practitioners and social workers are poor. Differences in approach, role perception, working situations and the organisation and staffing of the two professions may create difficulties. Conflicts of statutory roles, authority and accountability, record keeping, and confidentiality all produce problems. Finally unrecognised attitudes may also interfere with good co-operation. We hope to stimulate vigorous discussion of these important issues by members of both professions.     

Working with community mental health professionals: a survey among general practitioners.

Links between general practitioners and mental health professionals, such as counsellors, psychiatrists, community psychiatric nurses, clinical psychologists and social workers, are increasing in number and type. The aim of this survey was to elicit general practitioners' attitudes to these workers, comparing those with a link with a mental health worker and those without. General practitioners in two district health authorities were surveyed and a response rate of 70% was obtained. General practitioners linked to a mental health professional were more likely to have made a referral to that service in the previous three months and, on the whole, were more satisfied with that service. The commonest problem reported by respondents was the length of waiting lists. Regarding liaison with social workers, inadequate feedback and difficulty with contact were the problems mentioned most by doctors. A number of general practitioners expressed a desire for closer contact with all these mental health services. While caution is required in ascribing causality to these relationships, it is clear that a closer working relationship between general practitioners and mental health workers is productive and is valued by general practitioners. The challenge for policy makers is to structure mental health provision in such a way that more general practitioners are able to benefit than at present.     

Referrals from general practitioners to a social services department

One year's referrals from general practitioners to a social services department were studied. There was a low referral rate and a bias towards women, the elderly and the less affluent. The referrals were predominantly made for practical help with problems of ill health. A high proportion of clients were allocated to non-social work staff, and the social service intervention, generally of short duration, showed a sympathetic response to the practical requests of general practitioners. The limited use of social workers by doctors is considered to be the result of ignorance or scepticism about psychodynamic social work skills. Closer liaison between general practitioners and social workers, and a clearer presentation by social workers of their professional skills, are suggested solutions to this problem.     

Effect of information about waiting lists on referral patterns of general practitioners.

In a two year trial general practitioners in the West Midlands were provided with extended waiting time information for hospital consultation and treatment in general surgery. Selected general practitioners were sent monthly bulletins on comparative times to wait for both outpatient appointment and inpatient treatment throughout the region. Their referrals to consultant general surgeons were monitored, alongside those of a matched control group not receiving such information. Differences were found between the two groups which indicate the willingness of general practitioners to change their referral practice when adequate information is available. In addition, patients referred to their local hospital had longer waiting times than patients matched for clinical condition and district of origin who were sent to hospitals where it was indicated that a shorter wait might be expected.     

Social work in general practice

A questionnaire seeking details of working arrangements and problems encountered was circulated to social workers working in general practice.

The main difficulties were: insufficient preparation for the scheme, poor communication between general practitioners and social workers, and the inadequate provision of facilities for social workers in practice premises.

Most of the respondents had not experienced big difficulties. Two thirds had enjoyed a rewarding professional experience, which is a testimonial to interdisciplinary co-operation.

     

Some suggestions for teaching about co-operation between social work and general practice

This discussion document emphasizes the importance of co-operation between general practitioners and social workers during their training. Sample aims and objectives suitable for trainees in both professions are listed and discussed.     

Variation in general practitioners' referral rates to consultants

The variation in the number of patients general practitioners refer to hospital is a source of concern because of the costs generated and the implications for quality and quantity of care This paper compares 32 general practitioners with high referral rates with 35 doctors with low referral rates drawn from a study of 201 doctors. The mean referral rate for all 201 doctors was 6.6 per 100 consultations – for those with high referral rates the mean was 11.8 and for those with low referral rates 2.9. Differences between doctors with high and low referral rates with respect to age, sex, social class and diagnostic case mix of patients consulting were small. Doctors with high referral rates referred more patients in all categories. There were also few differences between the two groups with respect to the characteristics of the doctors themselves or their practices. The findings are discussed in the context of proposals to provide general practitioners with information on their own referral rates compared with those of other doctors.     

Effects of a community mental health service on the practice and attitudes of general practitioners.

Recent years have seen closer links developing between general practitioners and mental health specialists. A study was undertaken in Manchester to determine the effects of a new community mental health service on the practice and attitudes of general practitioners. Ten doctors had access to the community based psychiatric team over a three year period while another 10 doctors continued to use hospital services. Those with access to the team were significantly more satisfied with the specialist support services, and were more likely to give high priority to community psychiatric nurses and psychiatric social workers working as part of a primary health care team than those without access to the service. Those with access were more willing than those without access to share with psychiatrists the care of patients with chronic neurotic disorders. The community mental health team was considered particularly helpful in reducing the burden posed by patients with neurotic and psychosocial problems, but this resulted in the general practitioners doing less counselling themselves. The study did not find that the new service had an effect on the general practitioners' ability to detect or manage psychiatric illness.     

Primary care teams and the elderly in Northern Ireland

The results of a questionnaire were used to examine how primary care workers set about the management and surveillance of their elderly patients. The majority of practices had attached visitors (76 per cent) and attached district nurses (59 per cent), while 61 per cent of general practitioners worked in health centres. Over half of the responding practices had agesex registers. Few of the practices (14 per cent) had screened their elderly patients in the last five years and maintained an `at-risk' register. Twenty per cent of practices held a regular meeting concerning their elderly patients but only half of these reviews involved the available health visitors and district nurses.

At least half of the general practitioners and district nurses plus three quarters of the health visitors felt dissatisfied with the care of the elderly.

A single and systematic review of elderly patients conducted jointly by general practitioners, health visitors and district nurses would do much to improve the care of this group of patients and the morale of these workers.

     

Common sense and consulting

Three hundred and forty-two general practitioners in Scotland presented their views on content and training in relation to consulting with patients. Differences in responses from trainers, non-trainers, and trainees are examined and possible reasons for the divergences are discussed.     

Social workers and their clients: a comparison between primary health care and local authority settings

A social work attachment scheme to several general practitioners was established. Data from the first 300 referrals to the scheme were compared with data from a previous study of referrals to the `intake' teams of the social services department of the same London borough. In addition, data about the activities of the social workers in the `attachment' were collected, and the work was found to be predominantly short-term.

The populations referred to social workers in both settings were found to be similar in age and sex. Although general practitioners in the area referred only a few clients to social services departments, the clients in both groups were generally in poor health.

The psychiatric morbidity of those referred to the attached social workers was significantly higher, however, than those referred to the intake team (p < 0·01), and their problems were also more likely to need psychological help rather than practical measures. These differences were considered to be due mostly to the different types of referral agencies operating in the two settings and to their perceptions of the social worker's role.

The findings support the argument for closer liaison between medical and social services in the community: the attachment of social workers to general practices proved to be particularly valuable in the management and treatment of patients with emotional and mental illness.

     

The Objective structured clinical examination for general practice: design, validity and reliability

This paper describes and analyses an experimental clinical examination for general practice. Differences in the results obtained by fourth year students, fifth year students and trainee general practitioners highlight some of the dilemmas of medical education. It is concluded that examinations which include clinical tests can increase the credibility of general practice examinations, can be reliably applied to small groups of candidates and therefore have considerable potential for formative assessment. The constraints of assuring inter-examiner reliability in a multicentre design, together with its labour intensive nature, would however make this type of examination difficult to adapt to the needs of national end-of-training examinations.     

Primary care psychiatry: the case for action.

Since the introduction of the National Health Service a number of epidemiological enquiries have established the importance of mental disorders in the field of primary care. Examples are provided from the work of the General Practice Research Unit at the Institute of Psychiatry in London. The results furnish a rational basis for collaborative action between research workers, general practitioners and policy makers.     

Referring patients to geriatric hospitals: a survey of general practitioners' opinions

Many geriatric day hospitals are under-utilized. A survey of general practitioners' opinions on referral systems to day hospitals in east Surrey produced an 85% response rate. Of the 80 general practitioners who responded 58% referred occasionally, 39% frequently and 4% never. When asked about referring patients directly to the day hospital via the coordinator instead of via the consultant geriatrician, 58% of general practitioners said they would like to have direct access, and 87% were in favour of other health workers involved with the elderly initiating referrals with the general practitioner's consent. Rehabilitation was mentioned as the main reason for referral by 76% of general practitioners, medical assessment by 56% and social care by 48%. Comments received suggested that the hospital day was too long and that early rising associated with attendance caused stress in the elderly attenders. It is concluded that the present system of referral via the consultant is not always satisfactory and that a referral card system which permits general practitioners to refer directly to the geriatric day hospital may increase utilization.     

General practitioners'' experience of the chronic fatigue syndrome.

In order to examine the prevalence of patients with symptoms fulfilling the criteria for the chronic fatigue syndrome an extensive survey was carried out of general practitioners on 10 local government lists in two health boards (91% response rate). At the same time practitioners' attitudes to the syndrome and their experience in terms of workload and the characteristics of patients affected were documented. The majority of general practitioners (71%) accepted the existence of chronic fatigue syndrome, but 22% were undecided. The doctors reported a prevalence among their patients of 1.3 per 1000 patients (range 0.3-2.7 for the 10 areas) with a peak in the 30-44 years age group. Female patients were more commonly affected than males (sex ratio 1.8:1.0), but the severity of illness and the use of general practitioner's time was the same among male and female patients. Patients in occupations where they were exposed to infection were affected (teachers and students, 22% of sample; hospital workers, 7%), but many patients were unskilled (8%) and skilled workers (9%). Patients suffering from the chronic fatigue syndrome appear to be a real and distinct group for general practitioners and may represent a substantial part of the workload of doctors in particular areas.     

Health surveillance project among single homeless men in Bristol

The establishment of a health surveillance system for the single homeless is described. Health checks were performed in two Salvation Army hostels by a district nurse supported by general practitioners and other workers from one health centre. High levels of morbidity were discovered and the residents were largely treated by the primary health care team. Those residents who were referred to other agencies were shown to have a high attendance rate. An open access clinic was later set up by the district nurse in one of the hostels. This was well received by residents and staff and reduced the call out rate for the general practitioners.

In some parts of the UK, special medical centres for the single homeless have been established on the premiss that it is unrealistic to expect general practitioners to provide an adequate service. However, this study describes an effective service based on primary care which is acceptable to homeless people while being relatively cheap and easy to administer. We recommend the development of a peripatetic service as outlined in this study, offering health care at hostels, day centres and other places where the homeless are to be found.

     

Analysis of referrals of mental health problems by general practitioners.

The majority of people in the community who have a psychiatric disorder will consult their general practitioner. Referrals from general practice to specialist services are, however, relatively rare. The filter between primary care and specialist care has been characterized by Goldberg and Huxley as the least permeable of the filters separating psychiatrists and other specialists from the populations they serve. These referrals form the subject of this study in the Netherlands. Using a large database of doctor-patient contacts, the proportion of mental health disorders resulting in a referral and the characteristics of the patient and general practitioner that are involved in such a referral have been determined. In addition, the type of mental health institution or specialist to which referrals were directed and the characteristics influencing this choice were examined. Only 6% of patients presenting with a psychiatric disorder during surgery hours were referred to specialist care. Younger patients, male patients and patients with severe diagnoses had a greater probability of being referred. The percentage of patients referred was higher in urban areas than in rural areas. Doctors with a limited task perception regarding mental treatment tended to refer more often. Although the diagnosis did have some relationship with the institutions to which patients were referred (psychotic conditions to psychiatric services and social/material problems to social workers), the most prevalent diagnoses (neurotic conditions and relationship problems) seemed to be more or less randomly distributed over the various possibilities. Preferences appeared to be related to the existence of regular meetings between general practitioners and specialists and a positive evaluation by general practitioners of the institution concerned.     

Towards a rationalization of counselling in general practice

While there is good evidence to show that counselling may be beneficial to those patients in general practice with non-organic problems, deployment of the available resources lacks standardization and rationalization. The Counselling in Medical Settings Working Party of the British Association for Counselling is pressing for standardized training and accreditation of counsellors so that general practitioners will feel more confident about taking on workers who will ultimately be incorporated into the NHS team.     

What do general practitioners and community mental health teams talk about? Descriptive analysis of liaison meetings in general practice.

BACKGROUND: Liaison meetings between psychiatrists and general practitioners are now well established. Much has been written about their purpose and structure but little about their content. AIM: A study aimed to describe the clinical focus of meetings between a community mental health team and general practitioners and the nature of the professionals' interactions. METHOD: Audiotapes of six consecutive monthly meetings between a community mental health team and general practitioners in two general practices were analysed. RESULTS: Attendance rates among professionals were over 70%. Over 90% of discussion time was focused on patient-centred clinical matters. Almost two thirds of interactions were focused on patients receiving ongoing joint care; few interactions were devoted to new referrals or to patients who had not been assessed. Psychotic patients, although accounting for 15% of referrals, occupied 54% of patient-centred discussion time. Most interactions consisted of reciprocal information exchange between members of the community mental health team and general practitioners. CONCLUSION: The high attendance rates indicate that both general practitioners and community mental health team members considered these meetings as high priority. The steady move towards management of severely ill psychiatric patients in the community rather than in hospital requires close collaboration between primary and secondary care teams. The meetings described in this paper appear to be a simple, manageable and sustainable response to this need.     

Social and sexual contact between general practitioners and patients in New Zealand: attitudes and prevalence.

BACKGROUND. Doctor-patient social and sexual contact is increasingly acknowledged as an issue of importance for the medical profession. However, there is little research concerning general practitioners on this topic. AIM. A study was undertaken to obtain data on social and sexual contact between general practitioners and their patients. METHOD. An anonymous questionnaire was mailed to a nationwide randomized sample of 217 general practitioners in New Zealand. RESULTS. A response rate of 86% was obtained. Dating and sexual contact with patients was considered to be sometimes or usually acceptable to 35% and 10% of general practitioners, respectively. Of respondents, 6% reported having dated a patient, 4% reported having had sexual contact with a patient at some point during their career and 2% reported having engaged in sexual contact with a former patient. General practitioners who had personally known of a colleague who had engaged in sexual contact with a patient were more likely to believe this behaviour had negative consequences than general practitioners who themselves reported having engaged in sexual contact with a patient. CONCLUSION. The study results have implications for developing behavioural guidelines and educational interventions for general practitioners.