‘If I Ruled the World…’
| Date | 01 December 2004 |
| Pages | 3-6 |
| DOI | https://doi.org/10.1108/13619322200400035 |
| Published date | 01 December 2004 |
| Author | Alan Cohen |
| Subject Matter | Health & social care |
‘If I Ruled the World…’
Alan Cohen
GP and Director of Primary Care,
Sainsbury Centre for Mental Health
Personal Perspective
ou’re right, this is an article by a GP!
It fulfils all the stereotypes, doesn’t it? Arrogance,
imagination and more! But then the brief was a
personal perspective on primary care mental health
services and their development, so it’s not surprising
that both arrogance (a little) and imagination (lots of) is
necessary. Necessary because although we know the
statistics, we seem to be incapable of making the
changes that are necessary to provide a service that
meets the needs of our patients.
So in this article I will concentrate on an area of care
for which there is evidence of need, and evidence of
successful interventions, which would deliver benefits
for both patients and the health service, but which are
not implemented.
Of course, if I ruled the world, then they would be!
Somatisation
General practitioners frequently see patients with
physical complaints for which there is no apparent
physical cause. Many of these patients fulfil criteria for
anxiety and/or depression, and are considered to be
‘somatising’ (ICD, 2001). It is estimated that between
25% and 50% of all consultations with a GP involve
patients who are somatising (Gureje et al, 1998). There
is evidence that somatisation is associated with
significant physical distress (Bass et al, 1999) as well as
mental distress (Smith et al, 2003; Harter et al, 2001;
Barsky et al, 2001a). Several surveys of referrals to
medical specialists in both the UK and the US have
found similar results: that up to 50% of patients
referred to medical outpatients have physical
symptoms for which no physical cause can be found
(Reid et al, 2002; Jackson et al, 2000).
The mental health conditions associated with
Ypeople who somatise, frequently depression and
anxiety, have effective interventions that improve the
outcome of those conditions (von Korff et al, 2001;
Oxman et al, 2002). These effective interventions
include medications, such as anti-depressants, or
therapists providing some form of talking therapy.
These can be provided in either a primary or secondary
care setting.
It has been shown in the US that people who
somatise have significantly higher utilisation costs of
physical health care than people who do not somatise
(Holder-Perkins et al, 2000; Barsky et al, 2001b). In the
UK the costs associated with somatisation are rarely
recorded in financial terms, since there is no ‘financial’
impact on either the purchaser, currently the primary
care trust, or the provider, be it the primary care
practice or the acute trust, since both are funded
through block transfers of cash. Indeed such a funding
system could be perceived as a negative incentive to
behavioural change (Light & Cohen, 2003.
The costs of somatisation are therefore great. In the
US the care is paid for by the employers and insurers
and by the federal government through Medicaid
payments; in the UK the costs are met by the tax
payer, via the NHS. There is also the cost to the
healthcare providers, the specialists in secondary care
who see people unnecessarily, together with the costs
of inappropriate investigations and treatments,
increased waiting times and delayed access to suitable
care. There is a cost to primary care specialists who
have more numerous contacts with patients who
somatise and prescribe symptomatic treatments.
Finally, there is a cost to the patients who are led down
a care pathway that will not address the mental health
component of their physical health presentations.
So, if I ruled the world, I would introduce screening for
depression and anxiety for all patients for whom the GP
was considering referring to a number of specialist clinics
such as gastroenterology, endocrinology, back pain and
gynaecology, to name just a few.
The Mental Health Review Volume 9 Issue 4 December 2004 ©Pavilion Publishing (Brighton) 2004 3
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