General practitioners’ perceptions of community psychiatric nurses in primary care

Journal of Psychiatric and Mental Health Nursing, 1999, 6, 453–459

© 1999 Blackwell Science Ltd 453

Introduction

As the 1990s draw to a close the majority of mental health

provision is now firmly established within primary care.

Increasingly the work of the general practitioner (GP) is

concerned with both psychiatric illness and the psycho-

logical complications of physical disorders (Casey 1997).

These services will in the future not only include the treat-

ment and management of mental health problems, but also

the provision of strategies for the prevention of illness and

the promotion of mental health in the general population

(Ustun 1998). Effective mental health services require,

ease of access for clients, the availability of personnel to

give practical help, and the provision of care and treat-

ments which are scientifically sound and socially accept-

able (Costa e Silva et al. 1998). Such services should also

allow patients to self-refer thus facilitating early diagnosis

and treatment, and so minimising the possible effects of the

problem becoming more serious and the stigmatization

associated with mental health services (Ustun 1998).

The ultimate challenge for primary care groups (PCGs),

when they eventually take responsibility for the total health

care needs of localities, will be to address the sociopoliti-

cal factors that are implicated in the causation of mental

ill health, e.g. unemployment, poor schooling and housing,

as well as lack of social stability (DoH 1997; Goldberg

1998). Though these factors are important, the reduction

of their impact on people’s lives are not in themselves

sufficient. Of far more importance are the knowledge,

attitudes, beliefs and values held by individual general

General practitioners’ perceptions of community psychiatricnurses in primary careF. BADGER1 rgn rm bsc msc & P. NOLAN2 phd med bed (hons) ba (hons) rmn rgn dn rnt1Research Associate,School of Health Sciences, The Medical School, The University of Birmingham, BirminghamB15 2TT, UK & 2Professor of Mental Health Nursing, School of Health Sciences, The Medical School, TheUniversity of Birmingham, Birmingham B15 2TJ, UK

BADGER F. & NOLAN P. (1999) Journal of Psychiatric and Mental Health Nursing 6,

453–459

General practitioners perceptions of community psychiatric nurses in primary care

The management of and responsibility for the care of people with mental health problems

in the community is increasingly being assumed by general practitioners (GPs) and primary

care personnel. As primary care groups (PCGs) evolve, so must their expertise in manag-

ing people with a wide range of mental health problems. It is expected that all mental health

professionals will participate in this development, although it is likely that community psy-

chiatric nurses (CPNs) will be the largest professional group involved, with a significant

part to play in the shaping, management and delivery of mental health services. To date,

there has been little research into how CPNs are perceived by other primary health care

professionals. This study seeks to provide an insight into how GPs assess the contribution

of CPNs in primary care. Overall, the results of the study suggest that GPs view CPNs

favourably and consider that they have an important role to play. Greater involvement in

primary care raises issues about the education and preparation of CPNs, their professional

development and supervision needs.

Keywords: collaboration, CPNs, GPs, mental health, perceptions and primary care

Accepted for publication: 9 August 1999

Correspondence:

F. Badger

Research Associate

School of Health Sciences

The Medical School

The University of Birmingham

Birmingham B15 2TJ

UK

F. Badger & P. Nolan

454 © 1999 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 6, 453–459

practitioners about people who develop mental health

problems and those who care for them (Warner et al.1993). This study reports the perceptions of GPs on what

could possibly be one of the largest groups making a

significant contribution to developing mental health ser-

vices in primary care, namely CPNs.

The work of CPNs has been studied systematically over

the last few decades, largely by CPNs themselves, focusing

mainly on roles, knowledge and skills (White 1991,

Brooker & White 1997). However, relatively little has been

done on examining their work from the perspective of

other professionals. The future effectiveness of PCGs will

depend largely on the degree of collaboration that can be

achieved by primary, secondary and social services as well

as local organisations, e.g. housing departments, housing

associations and voluntary organizations. Achieving col-

laboration between health care personnel is dependent on

how well various disciplines know and understand each

other’s roles. The literature on GPs’ views of CPNs is

limited and there is almost nothing on the perceptions of

other members of the primary care team about CPNs. The

importance of understanding how individuals or groups

are perceived by others has been emphasized by social psy-

chologists in general and attribution theorists in particular

(Hogg & Vaughan 1995). An intractable obstacle to good

collaboration among health professionals is that created by

negative stereotypes of each other, and patient care fre-

quently suffers as a result (Beattie 1995).

Literature

An understanding of GPs’ perspectives on service provision

will become increasingly important as the role of PCGs in

commissioning services develops (Meads 1996). Although

PCGs will become increasingly multidisciplinary in nature,

nevertheless, it is logical to expect that GPs will have con-

siderable influence over all decision making relating to

types of services provided. New visions of health care

delivery dictate that primary care staff must be ever more

flexible, informed, committed and able to adjust to the

needs of local communities (DoH 1997). It is incumbent

on health care professionals that they begin to learn more

about each other’s roles because the changes envisaged in

primary care have wide ranging implications for shared

development, training, and resource management. For

many GPs, CPNs are the ‘face’ of community mental health

services and any attempt to strengthen collaboration

between primary care and mental health must there-

fore examine GPs’ understanding of the role and function

of CPNs.

Community psychiatric nurses came into existence in the

1950s in an attempt to improve the after care of people suf-

fering from severe psychiatric illnesses and by 1966 there

were approximately 225 full and parttime psychiatric

nurses with some community remit (Royal College of

Nursing 1966). In the early days, the work of CPNs was

mainly concerned with the dispensing of medication and the

administration of electro convuisive therapy (ECT) (Hunter

1974), although by the early 1970s, the importance of the

therapeutic relationship was coming to the fore (Altschul

1972). Between 1966 and 1976, the number of CPNs

increased by 35% largely as a result of the disappearance of

the psychiatric social worker (Hargreaves 1979) and by

1990, there were approximately 4500 CPNs in England,

Scotland and Wales. Although their numbers were increas-

ing, the way in which they were employed was idiosyncratic

(Skidmore & Friend 1984, Griffith & Mangen 1980), with

great variation between health authorities (Brooker &

Fergusson 1996). The 1980s saw increasing referrals from

GPs to CPNs of people with depression and anxiety and the

caseloads of CPNs began to be less concentrated on people

with serious mental illnesses. It has been argued that this

shift towards primary care has been driven by the CPNs’

desire to escape the control of consultant based medical

treatment and to retain their autonomy (Shepherd 1991),

and that this has been achieved at the expense of people

suffering from serious mental illness (Brooker 1990). The

recent adoption of the title ‘community mental health nurse’

could be interpreted as further evidence of the CPNs

decreased involvement with people with severe mental ill-

nesses. Feldman et al. (1998) and Bowers (1997) confirm

that the care and management of a large proportion of

mental health problems in primary care can be greatly

improved by the interventions of CPNs.

Monkley-Poole (1995), in a postal survey of fundhold-

ing practices, established that the majority of GPs rated

CPN services as ‘very useful’ and thought that CPNs

should be based in primary care. General practitioners

considered CPNs to be most effective in dealing with

anxiety, depression and phobic disorders. The survey had

a low response rate (27%), suggesting that only those

GPs with an interest in mental health care responded.

More recently, Hannigan et al. (1997), surveying GPs in

London, found that although 60% expressed dissatisfac-

tion with community mental health team (CMHT) ser-

vices, a similar percentage wanted closer liaison with them.

Within the CMHT, CPNs were the most highly thought of

because of their ability to offer a wide range of interven-

tions. Warner et al. (1993) established that GPs with good

access to community mental health teams were happy to

share the care of patients with chronic neurotic disorders

and felt that the burden posed by patients with neurotic

and psychosocial problems had thereby been considerably

reduced.

GP’s perceptions of CPNs

© 1999 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 6, 453–459 455

Stansfeld et al. (1992) surveyed GPs in the north-east

Thames region and reported that the vast majority wanted

closer liaison with psychiatrists and direct access to CPNs.

The survey covered three areas and when asked about the

most appropriate role for CPNs, respondents’ views varied

according to the area in which their practices were located.

In one area, GPs judged people with depression/anxiety to

be a priority for CPNs, but in the two other areas, people

suffering from schizophrenia were seen as the province of

the CPN. While it was acknowledged that psychiatrists

should focus primarily on the care of people with severe

mental illness, GPs also believed that people with less

severe psychological disorders should receive specialist ser-

vices. Collectively, these studies indicate that the views of

GPs’ may not entirely be in accord with the mental health

nursing review ‘Working in Partnership’ (DoH 1994)

which directed CPNs to concentrate their expertise on the

care of people with serious mental illness.

Bowers (1997) supports the view that to dismiss CPN

work in primary care on the grounds that it is work with

the ‘worried well’ is to diminish both the services that can

be provided by CPNs and the suffering of the people they

are seeing. He found that, far from being the ‘worried

well’, patients with nonpsychotic conditions had, on

average, five years contact with psychiatric services and

suffered from symptoms that blighted their work and

personal lives. However, Gournay & Brooking (1994) de-

monstrated little evidence for the effectiveness of the inter-

ventions of CPNs with nonpsychotic patients and

concluded that CPNs were not cost effective in primary

care settings and should be directed to manage those with

serious mental illnesses. However, a number of studies,

including Wells et al. (1992); and Kendrick et al. (1993)

found that GPs valued the contribution of CPNs in reduc-

ing the number of referrals to psychiatrists, although there

was great disparity amongst them about what exactly the

role of the CPN should be.

Although a survey of 115 GP practices (Corney 1996)

demonstrated a large increase in the number of mental

health professionals based in general practice, recent evi-

dence suggests that CPNs are less likely to be based in

primary care than they were five years ago. Brooker &

White’s 1997 survey of ‘Community Mental Health

Nurses’ showed an expected decrease in the number of

CPNs working from hospital bases, but also a decline from

21% to 14% in the percentage based in GP practices or

health centres. Most of this decrease was accounted for by

a large increase from 21% to 50% in the percentage of

CPNs working from community mental health centres.

Thirteen percent of CPNs had some of their time con-

tracted out to GPs. What these figures do not reveal are

the number of CPNs who have regular, formal or informal,

face to face contact with practice staff. The move towards

primary care seems inevitable, but close attention is

required in order to monitor the developing role of the

CPN and the type of clients whom they are allocated

(Nolan et al. 1998). Currently there exists little evi-

dence as to the preferred model of working (Gask et al.1997).

Methods

A purposive sample was made up of GPs with an interest

in developing and improving mental health services and

who were willing to provide data through the medium of

a questionnaire. A 10 item questionnaire was designed to

elicit the perceptions of GPs in the following areas: their

use of and views on mental health services, and their

opinion of the current and potential role of CPNs in

primary care. The questionnaire was piloted with five GPs

who had an extensive knowledge of mental health services

in primary care. The instrument was modified in the light

of criticisms and suggestions made in the pilot phase of

the study.

Questionnaires were administered to GPs in the West

Midlands who were attending a PGEA approved study day

organized by the authors on medication management of

depression, anxiety and bipolar disorders in primary care

and were completed anonymously. Thirty-seven out of 38

questionnaires were returned, a response rate of 97%. The

high response rate was probably attributable to the fact

that the questionnaires were handed in at the same time as

the GPs were given their PGEA forms, coupled with the

fact that the sample comprised those who were motivated

to improve mental health services in primary care.

Results

GPs’ relationship with and use of mental

health services

Just over one third of GPs (35%) rated their relationship

with mental health services as ‘good’, whereas almost two

thirds (64%) assessed it as being only ‘fair’ or ‘poor’

(Table 1). None of the GPs rated their relationship with

mental health services as either ‘excellent’ or ‘nonexistent’.

In response to the question: ‘To whom do you refer

patients with mental health problems?’ GPs indicated that

they favoured referrals to CPNs (89%) and psychiatrists

(84%) in preference to other agencies (Table 2). Approxi-

mately half the sample (51%) referred patients to special-

ist teams for alcohol addiction and just under half (49%)

referred to psychologists and to counsellors (43%). It

is possible that lower referral rates to counsellors and psy-



chologists reflect the unavailability of, or difficulty in,

accessing their services. Voluntary organizations were

accessed by almost one third of GPs (32.4%) and health

visitors by one quarter (27%), but only five GPs (13.5%)

said they referred patients to practice nurses. Just two GPs

(5.4%) reported that they referred patients to mental

health teams who would then decide to which profession-

als the patient should be allocated. It would appear that

GPs are more likely to refer patients to voluntary services

than they are to health visitors or practice nurses, to whom,

presumably, they have easy access.

Of all the agencies to which GPs refer patients, CPNs

were judged to be by far the most cost-effective (Table 3).

Four respondents did not answer this question, arguing

that cost effectiveness is dependent upon a number of vari-

ables including the nature of the patient’s problem.

GPs’ perceptions of CPNs’ skills

GPs were asked to rate the areas in which they considered

CPNs to be ‘most skilled’. In responding to this question,

many respondents indicated more than one category

(Table 4).

Over half the respondents (55.8%) considered CPNs to

be most skilled at managing people with anxiety, while

48.6% felt that CPNs were most skilled in problem solving

and 41.1% in assisting people with depression. Just under

30% of GPs rated CPNs as most skilled in dealing with

people with psychotic states. Two GPs did not answer this

question and one felt that CPNs’ skills were dependent

upon the interests and training of the individual nurse.

CPNs in the primary care team

An overwhelming majority (92%) felt that CPNs should

be an integral part of the primary care team and 13 (35%)

gave reasons as to why this should be so. The most com-

monly cited reason was the importance of improving com-

munication between mental health services and the

primary care team. The following is a typical response:

‘If CPNs are not part of the primary care team com-

munication between primary care and secondary ser-

vices will inevitably suffer. Currently it can take months

before a GP receives any communication from mental

health services about patients that have been referred.

General practitioners are more likely to hear from

patients themselves about their experiences than they

are from the professionals.’

Another reason for including CPNs was so that they

could assist primary care staff in improving their knowl-

edge of mental health care. This point was made very suc-

cinctly by one GP who stated:

‘Collaborative working increases mental health aware-

ness in all primary care staff and consequently patients

receive a much better service. Having direct access to a

CPN and being able to consult about the management

of a particular patient greatly increases my job satisfac-

tion. At our monthly meeting we always invite a CPN

Table 3 Which service is most cost-effective*?

n† %

CPN 19 44Counsellor 6 14Psychiatrist 4 9Voluntary organsations 3 7Practice Nurse 2 5Psychologist 2 5Health Visitor 1 2Myself 1 2No response 1 2

* Six GPs identified more than one agency, bringing the total numberof responses to 39† n = 33

Table 1How would you rate your relationship with the mental healthservice?

n* %

Excellent 0 0Good 13 35Fair 22 59Poor 2 5Non-existent 0 0

*n = 37

Table 2 To whom do you refer patients with mental health problems*?

n† %

CPN 33 89Psychiatrist 31 83.7Alcohol Team 19 51.3Psychologist 18 48.6Counsellor 16 43.2Voluntary organsations 12 32.4Health visitor 10 27.0Practice Nurse 5 13.5Mental health team 2 5.4

* Most of the respondents indicated more than one agency.† n = 37

Table 4With which conditions are CPNs most skilled in dealing*?

n† %

Anxiety 19 55.8Problem solving 18 48.6Depression 14 41.1Psychotic states 10 29.4

*Most of the respondents indicated more than one category†n = 34



to give a brief presentation about some aspect of mental

health care’.

Only two GPs (5%) thought CPNs should not be part

of the primary care team, one of whom suggested that

primary care teams risked becoming ‘too dilute’.

Responsibility for prescribing and

medication management

GPs were asked whose responsibility they considered it to

be to prescribe and manage medication for people with

mental health problems. In choosing between CPNs, GPs,

pharmacists, practice nurses and psychiatrists, 28 GPs

(76%) thought that they alone should prescribe medication

for people with mental health problems. Nine (24%) con-

sidered that psychiatrists should also be involved in pre-

scribing so as to improve the accuracy of diagnosis and

patient management.

With regard to medication management, 16 GPs (43%)

thought that they alone should take responsibility for this,

while 14 (38%) felt that management was the joint res-

ponsibility of the GP and CPN. Four GPs (11%) identified

three or more disciplines whom they thought should be

involved in medication management. Altogether, 20 GPs

(54%) considered that CPNs had some role in medication

management. Giving his view of the importance of team-

working one GP stated:

‘We work as a team. General practitioners prescribe,

nurses arrange routine blood tests. Community psychi-

atric nurses monitor and administer. Pharmacists stock

and dispense and sometimes query doses. For the most

part this arrangement works reasonably well although

we never meet formally to discuss it.’

Two GPs (5%) felt that psychiatrists had a role in

medication management and five (14%), practice nurses.

Team meetings in primary care

Sixty-two percent of GPs (23) stated that practice meetings

were held at their place of work. However, there was great

variation in terms of the personnel who were invited to

attend. Only nine respondents (24%) indicated that all

primary care staff were represented, with others reporting

attendance only of practice nurses and GPs, or of practice

staff and one community group. Four respondents (11%)

stated that CPNs attended practice meetings regularly, but

a further two (5%) described CPNs’ attendance as merely

‘occasional’.

Discussion

It must be borne in mind that the GPs who participated in

this study had a declared interest in mental health care and

were not therefore representative of the GP body at large.

Nevertheless, the study has yielded valuable insights which

are broadly in line with the findings of previous studies.

Despite their commitment to mental health care, only one

third of GPs considered their relationship with the mental

health services to be good, with the majority describing it

only as fair or even as poor.

General practitioners considered CPNs to be competent

in the areas of anxiety, depression management and

problem solving, with a substantial minority rating highly

their skills in dealing with people suffering from psychotic

states. These findings are supported by previous studies

(Hannigan et al. 1997, Monkley-Poole 1995) although

Stansfeld et al. (1992) found that a majority of GPs

thought that CPNs should be working mainly with people

suffering from schizophrenia. It is probable that GPs per-

ceive CPNs to be skilled in the areas in which they would

most wish to use them.

The study suggests a strong desire on the part of GPs to

see CPNs become an integral part of the primary care team.

The strength of this feeling was much greater than that

reported by Hannigan et al. (1997) and Monkley-Poole

(1995). The difference may be owing to recent changes in

GPs’ perceptions of the value of CPN services, although it

may also be attributed to the limitations of the sample.

While there is ongoing debate about how best to deploy

CPNs in community and primary care settings (Bowers

1997, Department of Health 1994), this study indicates

that many Primary Care Groups will favour closer involve-

ment with CPNs.

Practice meetings would seem to present an ideal

opportunity for CPNs to mix with other primary care

professionals and contribute to team discussions, thereby

enhancing the expertise of all members of the primary care

team in the area of mental health. Further investigation

into attendance at practice meetings is merited. From this

study, it would seem that attendance is probably accord-

ing to which members of staff work on the practice

premises, rather than being on a planned basis. While

nonattendance at practice meetings does not necessarily

indicate that there is no contact between practitioners (and

given the varying agenda items to be addressed – clinical,

administrative, business – it may not be appropriate for

community staff always to attend); nevertheless, some

contact is required for successful collaboration.

The immediate need is for mental health and primary

care professionals to develop their distinctive roles within

a collaborative framework. Closer ties between CPNs and

primary care will provide future opportunities for advanc-

ing current nursing practice and developing new nursing

roles in primary mental health care. This will have impli-

cations for CPNs’ pay and conditions of service. Issues



around the education and clinical supervision of CPNs will

also need addressing, and service developers must consider

the dangers of CPNs’ experiencing professional isolation

from fellow CPNs, burnout and role ambiguity.

Moves towards greater integration of CPNs with the

primary care team must be made on the basis of a clear

understanding of the implications for patient care. If CPNs

are to become more involved in primary care and in

working with people with emotional and psychological

problems, safeguards will need to be put in place to ensure

that the needs of severely mentally ill people are not

neglected.

Mental health services must receive input from PCGs and

other agencies in order to ensure that they are affordable

and responsive to the health needs of local populations. It

appears that PCGs and mental health services will decide

how to involve CPNs at local level and it is important that

CPNs have regular discussions with whoever assumes the

leadrole for mental health in the PCGs. Current models of

CPN involvement with primary care include: CPNs being

based in primary care; non primary care based CPNs having

regular daily, weekly, or monthly contact; CPNs holding

occasional clinical sessions in primary care; and colleagues

who attend practice meetings or caseload review meetings.

At present, there is insufficient research evidence to identify

which model is preferable (Gask et al. 1997). Arrangements

will have to be made on a local basis with PCGs taking into

account a range of factors, including whether the area

served is rural, urban or mixed, population profiles and

epidemiological indicators.

It is important to recognize that it is not the steadfast

adherence to any one model that creates a good service,

but the regular evaluation of that model. The individual,

professional and clinical implications of transferring CPNs

either wholly or partly from community to primary care

settings are complex. Appropriate preparation and support

to combat negative stereotypes that CPNs may hold of

primary care professionals, or that such staff may hold of

CPNs (Nolan et al. 1998) will be necessary to ensure effec-

tive collaboration. CPNs will want to be reassured that

they will have access to peer support, that their profes-

sional identity will be preserved, and that they will have

quality supervision whilst they are in the process of

defining their role in primary care. All primary care pro-

fessionals will need to engage in an ongoing debate to

evaluate the role of the CPN in the newly emerging

primary care context.

Conclusions

Differing opinions exist about the mechanisms for improv-

ing mental health provision in primary care. General prac-

titioners are consistent in their view that CPNs have a key

role to play and are cost effective and skilled in the man-

agement of a range of mental health problems. The major-

ity of GPs see CPNs as an integral part of the primary care

team, increasing mental health awareness in primary care

staff and assisting them in the acquisition of skills to enable

early recognition and treatment of mental health problems.

They hope that increased involvement of CPNs in primary

care will result in a reduction in the number of referrals to

secondary services. These aspirations reflect the goal of

Government health policy which is to improve the early

identification of mental health problems and the preven-

tion of mental illness. Further study is required to identify

more precisely how the role of the CPN in primary care

can be developed and strengthened in the future.

Acknowledgments

We would like to thank all the GPs who took part in this

study.

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Documents

General practitioners’ perceptions of community psychiatric nurses in primary care