Hearing Voices: Qualitative Inquiry in Early Psychosis

4. Primary Care Perspectives of First Episode Psychosis

59 4 primary care perspectives of First episode psychosis Helen Lester Introduction This chapter explores the potential roles and responsibilities of the primary care team in providing care and advice for people with first episode psychosis (FEP). It starts with a discussion of the meaning of the term primary care. The chapter then focuses on the strengths and weaknesses of primary care and the role that primary care currently plays, and could play, at the point of diagnosis. The chapter concludes with a discussion of recent primary care education initiatives and some reflections on service users’ views of care and international work at the “cutting edge” in this field (see Box 1). Some Definitions of “Primary Care” There is enormous international variation in what is meant by the term “primary care.” According to the US Institute of Medicine of the National Academies (1996) primary care is the “provision of integrated, accessible healthcare services by clinicians who are accountable for addressing a box 1: key points • Most primary care practitioners will see only one or two new people with FEP each year. • While FEP is relatively rare, it is a life-changing event for the person and their family. High quality primary care at the outset offers the possibility of a less traumatic and shorter pathway into mental health services and the hope of improved longer-term outcomes. • Primary care’s recognition of early changes, clinical intuition, and ability to act on family worries are key to earlier detection. • The primary care role may become even more important as the markers for those at highest risk become more refined. 60 helen lester large majority of personal health needs, developing a sustained partnership with patients, and practicing in the context of the family and community.” In the United Kingdom, Martin Roland, Dave Wilkin, and Robert Boyd (1996, p. 5) suggest that primary care provides first-contact generalist continuing care to the great majority of health problems presented to the NHS...Primary care is, in general, located geographically close to patients’ homes. It treats people in the context of their communities, and is potentially more accountable to its local community. Primary care systems can be categorized according to whether they act as gatekeepers to specialist services (as in the United Kingdom), provide free-market services in parallel to specialist services, or function in a complex system containing both free-market and gatekeeper functionality (as in the United States); whether they are free to patients at the point of care delivery; whether they are led by doctors or non-medical personnel; and the degree to which they provide continuity of care. Primary care in the United Kingdom has a number of unique strengths (see Box 2). It offers rapid access for routine and crisis care in a low stigma setting. It occupies an important space at the interface of users, families, communities, and professional worlds and is able to address mental, physical , and social aspects of care. Under ideal circumstances, it is also able to guarantee a cradle-to-grave doctor–patient relationship, with informational , longitudinal, and interpersonal cojntinuity of care (Saultz, 2003). Primary care is also a place of great complexity. As Iona Heath (1999, p. 565) has suggested, “uncertainty, contradiction and complexity are the stuff of general practice and the measure of much of its fascination for us.” Each day, people arrive to see their general practitioner (GP) or other member of the primary care team with coughs, colds, cancer, and depression and have, in the United Kingdom, ten minutes on average to explain their problems and negotiate a solution. This arrangement compares to box 2: key strengths of primary care • offers a low stigma and accessible setting; • enables a holistic approach to problems; • provides informational, longitudinal, and interpersonal continuity of care; • sees individuals in the context of their past, their social networks, and the wider community ; and • is able to deal with both the general and the particular. PriMary care PersPectives of first ePisode Psychosis 61 the twenty-to-thirty minutes that a patient may spend in a hospital setting , to which he or she has been referred by letter to see a doctor who is an acknowledged specialist in that clinical area. In this latter case, primary care is, by way of contrast, delivered by “specialists in generalism”—by people taking an interest in whatever is of interest to the patient (Willis, 1995). Primary care, however, has developed...