Mental health triage in a rurual setting

Mental Health Nursing,  May/Jun 2001  by Hardisty, Sylvia

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Case study

Waiting times for mental health treatment are always critical but there are extra pressures in a rural area. Sylvia Hardisty, below, describes how one team in Dorsetshire tackled the problem

The North Dorset CMHT was faced with long waiting times for people referred from Primary Care, of which a number of referrals were often inappropriate. People already living in isolated settings were facing long delays in getting a response, when referred to their practice counsellor, and when referred to the local CMHT or psychology service. At the same time, referrals to those services were increasing steadily.

In 1997 as CMHT leader, I met with GPs and counsellors from two local fund-holding practices to try to find a way to improve services for people presenting with mental disorder.

Three objectives were agreed:

* to reduce waiting times for people referred to the practice counsellor, or to the CMHT or clinical psychology service;

* to ensure that people are screened for risk at an early stage;

* and - for those people who are referred - the provision of ways to manage their illness until they could he seen.

The group focused their attention on the point at which the patient made contact with the GP It was felt that specialist skills were required in order to make the initial assessment and route the patient appropriately. A 'triage' system was devised with the two practices, through which patients would be referred by their GP to a senior CPN who would provide initial assessment/screening sessions in the practice.

Initially, between three and five appointments per week were funded by the practices, to replace the CPN's time. GPs would refer the patient to the CPN by letter and appointments were made by the practice for the patients to be seen by the CPN within the practice setting. A local standard of a maximum two-week waiting time for triage was established. The patient's notes were available to the CPN if required.

Thirty minutes were allocated to each patient to allow for a broad-- based assessment and screening for risk. This provided an opportunity for the CPN to identify whether the patient required an urgent response from the specialist mental health service, or referral on to the practice counsellor or other agency such as Relate, alcohol and drug services, social services or housing.

The patient was given information about the disorder, how to manage symptoms, options for help, and how agencies might assist. A management plan could be agreed, particularly where there might be a delay in accessing some services. Emergency contact numbers were given, and also literature about conditions and self-- help measures where appropriate.

The CPN would inform the GP in writing about the outcome of the initial assessment, indicating what action had been agreed with the patient and, where appropriate, how the GP might provide further advice, assistance and interventions.

The triage service was received positively by GPs and patients. In both practices, in the first two years, more than twice as many women as men were referred to the service. Of those assessed, the majority of men required referral to the specialist mental health services, and proportionately more women were referred on to the practice counsellor.

The response from GPs has been positive: they value the opportunity for their patients to be seen quickly; and for the provision of the service on their doorstep. They find the feedback from the CPN helpful and informative; they feel more confident in the outcome of the initial assessment:

"...before Triage, we used to guess",

"...before Triage, patients had to wait up to three months, but at least now they get the initial appointment quickly, which is good; and it does not seem such a problem then having to wait before treatment commences".

Communications with practice staff have improved by having a regular CPN presence at the surgery. Importantly, the patients like the service because it is prompt, easy to access, and because it gives them information and puts in place ways for them to manage their distress - at least in the short term:

"It was very helpful: I didn't know what was on offer and was hoping to be told what was best for me."

The triage model may have applications in other service settings. Originally devised to address waiting times and provide a better service for patients in a rural setting, early indicators of success suggest that it may be a useful vehicle for collaborative work between specialist mental health services and primary care. In line with the National Service Framework for Mental Health, a step beyond this would be to extend the specialist mental health worker's role in primary care to include training, advice, case review and supervision for the wider primary health care team.

* Sylvia Hardisty is team leader, North Dorset CMHT at North Dorset Primary Care NHS Trust

Copyright Community Psychiatric Nurses Association May/Jun 2001
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