General practice and clinical psychology.some arguments for a closer liaison
THE HEALTH TEAM 882
General practice and clinical psychology.some arguments for a closer liaison
J. A. KlNCEY, B.Sc, B.Phil., A.B.Ps.S.
Senior clinical psychologist, Manchester Royal Infirmary
A closer liaison between general practitioners and clinical psychologists could be of considerable value to the two professions and to patients in the National Health Service. This paper contains four sections.
(1) The training and career structure of clinical psychologists
All clinical psychologists possess an initial undergraduate qualification in psychology, usually an honours degree in psychology, followed by further professional training in clinical psychology, either by a postgraduate university degree (usually two years) or through clinical training and experience within the NHS itself (usually three years). The psychologist who trains in the NHS
may or may not have taken the Diploma in Clinical Psychology of the British Psychological Society.
After the completion of this probationary grade training, the psychologist usually takes up an NHS post as a basic grade psychologist, and within the career structure may progress to the grade of senior psychologist, to principal psychologist, and, in a few cases, to top grade psycho¬ logist. From the time of appointment as a basic grade, a psychologist can operate independently of the supervision of other psychologists. There are at present about 420 trained psychologists in the NHS with an average annual net increase in occupied posts of between 40 and 50 (British Psychological Society, 1973).
(2) The psychologist's skills
The areas of expertise of the clinical psychologist can be subsumed under two main headings.
Firstly, the use of psychological techniques in the individual case and, secondly, the contribution of psychology to more general clinical or organisational research problems.
Table 1 contains an outline and a possible classification of individual clinical problems in which psychologists have been involved and a list of techniques of assessment and intervention which they have used.
The classification used in table 1 is not definitive, nevertheless it provides a framework into which a large number of clinical problems can be fairly readily classified. This it is hoped may be of value as a " shorthand " in terms of which a general practitioner might assess cases for suitability for psychological opinion or involvement.
The second major contribution of clinical psychologists relates to more general problems occurring in the setting of general practice.
It has for example been clearly shown (Ley and Spelman, 1967) that patients often forget a large proportion of the information they receive during a consultation with the doctor. The relationship of such forgetting to anxiety and to the amount and nature of material presented has been established (Ley and Spelman, 1967) and one effective procedure to reduce such forgetting has been suggested (Ley et al., 1973). This area of research will have obvious implications for the general practitioner who often has limited time in which to present information to patients in the surgery.
Related to problems of forgetting are those of non-comprehension of information. Ley et al. (1972) have shown how memory for written medical material can be increased by using simpler language as assessed by a formula of readability. Identification of techniques to ensure the adequate comprehension of verbally presented material could be of tremendous importance in general practice.
Journal of the Royal College of General Practitioners, 1974, 24, 882.888
General practice and clinical psychology.some arguments for a closer liaison 883 Satisfaction with the quality of general practice as a whole has been a matter of considerable recent debate (Honigsbaum, 1972; Marson et al, 1973; Sidel et al, 1972; Varlaam et al, 1972). Of particular interest to the psychologist is the problem of satisfaction with communications. Ley et al (1973) have suggested a technique for increasing satisfaction with communications among hospital medical inpatients which stresses the need to ensure adequate comprehension by the patient of what he has been told by the medical staff.
A pilot study in general practice (Kincey et al, 1973) has suggested a high general level of patient satisfaction, but has still indicated some need for attempts to increase patients' satisfaction with communications. The same study has shown a relationship between the variables of satisfaction, comprehension, and patients' ratings of their compliance with advice received from the doctor.
The presence of patient non-compliance with advice is clearly established and widespread.
It includes not following dietary advice, failure to stop smoking, failure to take medication as prescribed, failure to carry out antenatal advice, and postnatal care of infants (Ley et al, 1971).
The results of Kincey et al. (1973) suggested several important variables involved in noncompliance as reported by patients. These included problems of " will power," economic difficulties, and forgetting or non-comprehension of advice. The further application of psychoGeneral practice and clinical psychology.some arguments for a closer liaison 885 logical principles to reduce non-compliance and increase satisfaction could therefore be of great value in terms of reducing patient discomfort, demands on doctors' time, and cost to the NHS.
Other subjects ofresearch such as the evaluation of health education procedures or the exami¬ nation of communication patterns among staff could well involve psychologists where appro¬ priate. Research projects might be specific to a particular practice or have general application to many doctors and with increasing interaction between general practitioners and psychologists new areas of research would almost certainly become apparent.
(3) Where should the clinical psychologist be situated?
Historically, clinical psychology developed in close proximity to psychiatry and neurology with the majority of psychologists working in psychiatric hospitals. During the last decade an in¬
creasing number of psychologists have worked in the general hospital undertaking a wide range of work such as that discussed by Hetherington (1967). Even more recently a few com¬ munity psychologists have been appointed to local government posts and now a very few posts have come into existence within the NHS for psychologists to work in health centres. It is interesting to note however that in the report Present state andfuture needs ofgeneral practice, Royal College of General Practitioners (1973) there is no mention of psychologists as members of the health team involved in general practice nor of referrals from general practice to psycholo¬ gists in a hospital.
In the reorganised NHS many, if not most, psychologists will continue to work in hospital (either general, psychiatric, or sub-normality). Here, they will deal with problems such as those outlined in table 1 and others arising specifically from their position in hospitals. There will always be psychological problems specific to the hospital environment which do not occur in gen¬ eral practice. These include, for example, psychological reactions immediately before and just after major surgery, and problems of patient-nurse relationships on the ward. Psychologists will also continue to be involved closely with particular medical specialties in hospitals.notably psychiatry and neurology.
There are several arguments to suggest that some clinical psychologists could also be usefully employed in geographically closer liaison with general practice, either on a peripatetic basis serving several practices or by attachment to health-centre teams.
By operating at the usual point of first contact between patient and doctor the psychologist should be able to help identify psychological problems at an earlier stage than often seems to happen at present. An example of this is the data supplied by Marks (1969) concerning agora¬ phobic patients eventually treated in hospital by psychologists and psychiatrists. Among a sample of such patients the average duration of symptoms before the general practitioner be¬ came involved was 17 months, and before hospital involvement was 34 months. Such problems could possibly be identified and treated more quickly if psychologists were involved directly in primary care.
There are also compelling theoretical reasons for dealing with problems in the situation in which they arise rather than treating them only in hospital which is so different from the home or work. An increasing number of the techniques of the clinical psychologist involve the parents, spouse, or other key figures in the patient's life. Such people could probably be more easily contacted and effectively involved in therapy in the home than in the hospital clinic, often geographically some distance from the home and involving considerable disruption of their lives.
The prophylactic value of psychological intervention at an early stage in a problem could sometimes prevent hospital being necessary. If programmes effectively modifying behaviour such as helping obese patients to lose weight could become well-established, the possible eco¬ nomic saving in terms of the hospital time and money dealing with the medical sequelae of obesity could be enormous. A similar argument applies to tobacco smoking.
Although as yet untested, the above claims seem to have considerable theoretical importance and should be open to experimental study.
(4) Problems raised by the suggestion of closer liaison
The first problem of closer liaison is that of referral policy. Where the general practitioner refers direct to a psychologist, whether in hospital or within the practice, who assumes responsibility for that patient? In accordance with the British Psychological Society (1973) recommendations, it 886 J. A. Kincey seems appropriate that "it is the responsibility of a referring medical practitioner, whether a consultant or a general practitioner, to assure himself that the clinical psychologist is qualified.
Thereafter the psychologist is responsible for whatever acts he carries out in treatment, and the referring medical specialist should not be considered responsible beyond the act of referral except insofar as the general practitioner retains primary care responsibilities. The clinical psychologist's responsibility covers all acts which are within his competence. As is the case with all independent professionals, it is part of his competence not to exceed the boundaries of his skills. Where a clinical psychologist and a medical practitioner are jointly engaged in the care of an individual, they should establish by agreement their specific areas of responsibility."
The argument has in the past been advanced that if problems are referred directly to the psychologist rather than to a medical specialist there is a danger that an important medical element in a problem may be missed. This possibility cannot be denied. It must, however, be balanced against two other factors. At present it seems likely that a great number of possible opportunities for contributions by psychologists are missed and that these omissions could often have equally serious, if less acute, effects than could result from the missing of a significant medical element in any problem referred directly to the psychologist. It also seems likely that on occasions a psychologist's intervention in general practice might lead to quicker identification of a medical problem than would occur without such intervention. This might be particularly true in a case where psychological factors were involved in a problem with neurological or psychia¬ tric factors, and where psychological assessment proceedings might highlight these factors.
General practice and clinical psychology.some arguments for a closer liaison
J. A. KlNCEY, B.Sc, B.Phil., A.B.Ps.S.
Senior clinical psychologist, Manchester Royal Infirmary
A closer liaison between general practitioners and clinical psychologists could be of considerable value to the two professions and to patients in the National Health Service. This paper contains four sections.
(1) The training and career structure of clinical psychologists
All clinical psychologists possess an initial undergraduate qualification in psychology, usually an honours degree in psychology, followed by further professional training in clinical psychology, either by a postgraduate university degree (usually two years) or through clinical training and experience within the NHS itself (usually three years). The psychologist who trains in the NHS
may or may not have taken the Diploma in Clinical Psychology of the British Psychological Society.
After the completion of this probationary grade training, the psychologist usually takes up an NHS post as a basic grade psychologist, and within the career structure may progress to the grade of senior psychologist, to principal psychologist, and, in a few cases, to top grade psycho¬ logist. From the time of appointment as a basic grade, a psychologist can operate independently of the supervision of other psychologists. There are at present about 420 trained psychologists in the NHS with an average annual net increase in occupied posts of between 40 and 50 (British Psychological Society, 1973).
(2) The psychologist's skills
The areas of expertise of the clinical psychologist can be subsumed under two main headings.
Firstly, the use of psychological techniques in the individual case and, secondly, the contribution of psychology to more general clinical or organisational research problems.
Table 1 contains an outline and a possible classification of individual clinical problems in which psychologists have been involved and a list of techniques of assessment and intervention which they have used.
The classification used in table 1 is not definitive, nevertheless it provides a framework into which a large number of clinical problems can be fairly readily classified. This it is hoped may be of value as a " shorthand " in terms of which a general practitioner might assess cases for suitability for psychological opinion or involvement.
The second major contribution of clinical psychologists relates to more general problems occurring in the setting of general practice.
It has for example been clearly shown (Ley and Spelman, 1967) that patients often forget a large proportion of the information they receive during a consultation with the doctor. The relationship of such forgetting to anxiety and to the amount and nature of material presented has been established (Ley and Spelman, 1967) and one effective procedure to reduce such forgetting has been suggested (Ley et al., 1973). This area of research will have obvious implications for the general practitioner who often has limited time in which to present information to patients in the surgery.
Related to problems of forgetting are those of non-comprehension of information. Ley et al. (1972) have shown how memory for written medical material can be increased by using simpler language as assessed by a formula of readability. Identification of techniques to ensure the adequate comprehension of verbally presented material could be of tremendous importance in general practice.
Journal of the Royal College of General Practitioners, 1974, 24, 882.888
General practice and clinical psychology.some arguments for a closer liaison 883 Satisfaction with the quality of general practice as a whole has been a matter of considerable recent debate (Honigsbaum, 1972; Marson et al, 1973; Sidel et al, 1972; Varlaam et al, 1972). Of particular interest to the psychologist is the problem of satisfaction with communications. Ley et al (1973) have suggested a technique for increasing satisfaction with communications among hospital medical inpatients which stresses the need to ensure adequate comprehension by the patient of what he has been told by the medical staff.
A pilot study in general practice (Kincey et al, 1973) has suggested a high general level of patient satisfaction, but has still indicated some need for attempts to increase patients' satisfaction with communications. The same study has shown a relationship between the variables of satisfaction, comprehension, and patients' ratings of their compliance with advice received from the doctor.
The presence of patient non-compliance with advice is clearly established and widespread.
It includes not following dietary advice, failure to stop smoking, failure to take medication as prescribed, failure to carry out antenatal advice, and postnatal care of infants (Ley et al, 1971).
The results of Kincey et al. (1973) suggested several important variables involved in noncompliance as reported by patients. These included problems of " will power," economic difficulties, and forgetting or non-comprehension of advice. The further application of psychoGeneral practice and clinical psychology.some arguments for a closer liaison 885 logical principles to reduce non-compliance and increase satisfaction could therefore be of great value in terms of reducing patient discomfort, demands on doctors' time, and cost to the NHS.
Other subjects ofresearch such as the evaluation of health education procedures or the exami¬ nation of communication patterns among staff could well involve psychologists where appro¬ priate. Research projects might be specific to a particular practice or have general application to many doctors and with increasing interaction between general practitioners and psychologists new areas of research would almost certainly become apparent.
(3) Where should the clinical psychologist be situated?
Historically, clinical psychology developed in close proximity to psychiatry and neurology with the majority of psychologists working in psychiatric hospitals. During the last decade an in¬
creasing number of psychologists have worked in the general hospital undertaking a wide range of work such as that discussed by Hetherington (1967). Even more recently a few com¬ munity psychologists have been appointed to local government posts and now a very few posts have come into existence within the NHS for psychologists to work in health centres. It is interesting to note however that in the report Present state andfuture needs ofgeneral practice, Royal College of General Practitioners (1973) there is no mention of psychologists as members of the health team involved in general practice nor of referrals from general practice to psycholo¬ gists in a hospital.
In the reorganised NHS many, if not most, psychologists will continue to work in hospital (either general, psychiatric, or sub-normality). Here, they will deal with problems such as those outlined in table 1 and others arising specifically from their position in hospitals. There will always be psychological problems specific to the hospital environment which do not occur in gen¬ eral practice. These include, for example, psychological reactions immediately before and just after major surgery, and problems of patient-nurse relationships on the ward. Psychologists will also continue to be involved closely with particular medical specialties in hospitals.notably psychiatry and neurology.
There are several arguments to suggest that some clinical psychologists could also be usefully employed in geographically closer liaison with general practice, either on a peripatetic basis serving several practices or by attachment to health-centre teams.
By operating at the usual point of first contact between patient and doctor the psychologist should be able to help identify psychological problems at an earlier stage than often seems to happen at present. An example of this is the data supplied by Marks (1969) concerning agora¬ phobic patients eventually treated in hospital by psychologists and psychiatrists. Among a sample of such patients the average duration of symptoms before the general practitioner be¬ came involved was 17 months, and before hospital involvement was 34 months. Such problems could possibly be identified and treated more quickly if psychologists were involved directly in primary care.
There are also compelling theoretical reasons for dealing with problems in the situation in which they arise rather than treating them only in hospital which is so different from the home or work. An increasing number of the techniques of the clinical psychologist involve the parents, spouse, or other key figures in the patient's life. Such people could probably be more easily contacted and effectively involved in therapy in the home than in the hospital clinic, often geographically some distance from the home and involving considerable disruption of their lives.
The prophylactic value of psychological intervention at an early stage in a problem could sometimes prevent hospital being necessary. If programmes effectively modifying behaviour such as helping obese patients to lose weight could become well-established, the possible eco¬ nomic saving in terms of the hospital time and money dealing with the medical sequelae of obesity could be enormous. A similar argument applies to tobacco smoking.
Although as yet untested, the above claims seem to have considerable theoretical importance and should be open to experimental study.
(4) Problems raised by the suggestion of closer liaison
The first problem of closer liaison is that of referral policy. Where the general practitioner refers direct to a psychologist, whether in hospital or within the practice, who assumes responsibility for that patient? In accordance with the British Psychological Society (1973) recommendations, it 886 J. A. Kincey seems appropriate that "it is the responsibility of a referring medical practitioner, whether a consultant or a general practitioner, to assure himself that the clinical psychologist is qualified.
Thereafter the psychologist is responsible for whatever acts he carries out in treatment, and the referring medical specialist should not be considered responsible beyond the act of referral except insofar as the general practitioner retains primary care responsibilities. The clinical psychologist's responsibility covers all acts which are within his competence. As is the case with all independent professionals, it is part of his competence not to exceed the boundaries of his skills. Where a clinical psychologist and a medical practitioner are jointly engaged in the care of an individual, they should establish by agreement their specific areas of responsibility."
The argument has in the past been advanced that if problems are referred directly to the psychologist rather than to a medical specialist there is a danger that an important medical element in a problem may be missed. This possibility cannot be denied. It must, however, be balanced against two other factors. At present it seems likely that a great number of possible opportunities for contributions by psychologists are missed and that these omissions could often have equally serious, if less acute, effects than could result from the missing of a significant medical element in any problem referred directly to the psychologist. It also seems likely that on occasions a psychologist's intervention in general practice might lead to quicker identification of a medical problem than would occur without such intervention. This might be particularly true in a case where psychological factors were involved in a problem with neurological or psychia¬ tric factors, and where psychological assessment proceedings might highlight these factors.
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