Graduated delays

Although nine out of 10 people with mental health problems will only use primary care services, any kind of specialised service can be hard to access in such settings. The availability of talking therapies is of particular concern.

Among the numerous NHS plan recruitment aims, the target of 1,000 graduate primary care workers in place by the end of 2004 was key, with funds available to train and retain two or three for each of the old primary care trusts.

The workers would have three main aims: brief therapy work with clients; working as part of a team; and working with other statutory and non-statutory agencies in the wider community.

Department of Health figures showed that only around 600 were in place by 2005; it now says there are 720.

Quality of care, levels of risk and the ability to retain the new workers were all concerns raised when the target was published. But would they dissipate when the workers had bedded in? A national evaluation of the role carried out by the National Primary Care Research and Development Centre has looked at developments since the original 2004 target.

The results make uncomfortable reading. Although of around 360 graduate workers in post in 2004, almost all said that they were working as part of a team, only two thirds were seeing patients. Some had caseloads of only a handful of clients. To meet the target of 300,000 being seen by such workers, each one would have to take on a caseload of 25.

For Linda Gask, professor of primary care psychiatry at Manchester University and one of the report's co-authors, such under-use is a missed opportunity.

Linda, who also works as a consultant psychiatrist at Salford PCT, says: 'These workers can reduce the number of people who need to go into specialist care and give better access to cognitive behavioural therapy for those who would find it difficult to do so in specialist care,' she says.

Professor Gask adds that there has been a lack of understanding in PCTs on what the role entails and an absence of structures to help support staff. Combined with the unwillingness of some GPs to extend the work they do in mental health, the result is a lack of opportunities for graduate workers.

Although most survey respondents reported being satisfied or very satisfied with their jobs, they were largely unsatisfied with pay (salaries are in the£13,000-£17,000 bracket) and access to resources. The research also found that almost half (42 per cent) reported feeling isolated, and some did not have any physical space in which to work with clients.

There are, though, opportunities to stretch the role. As specified in the national guidance, the vast majority are working with people with mild to moderate mental health problems. Professor Gask says that in areas with a high incidence of severe problems, where more people with long-term illness live in the community, graduate workers may include this group in their client list.

But half of all survey respondents said they intended to leave the role within six months. The low salary and lack of a clear career structure means many are using it as a stepping stone before going on to clinical psychology training or other mental health and primary care roles.

'Some GPs who have graduate workers in their practices feel they are training them up only for them to move on,' says Professor Gask, who feels that the creation of a career pathway and a national training programme are vital.

However, graduate worker Riskah Cohen, who works in GP practices for Salford PCT, says the workers are beginning to feel part of the wider workforce.

'We are getting client work, and many are happy in the role - not using it is a stepping stone to something else. Some are also starting to work in new areas such as prisons,' she says.