Manuela Maletta, Mental Health Practitioner, looks to bridge some gaps.
15 May 2025
'Lara' was referred to me by her GP. She had struggled with mixed anxiety and depressive disorder for years and had gone through several antidepressants – each discontinued either due to intolerable side effects or a brief period of effectiveness. She had also completed two courses of Cognitive Behavioural Therapy with limited benefit. Her GP felt they had exhausted all alternatives available in primary care – therapy, medication – and believed Lara's case was not severe enough to meet the criteria for secondary care intervention, usually reserved for people who score high in risk assessments, or who present with eating or personality disorders and subsequently experience complex mental health issues.
This is a situation I see increasingly often in the course of my work as a Mental Health Practitioner. In my early years as a behavioural therapist working with neurodiverse clients, with a complementary career in the performing arts, I became quite sensitised to the matters of narratives, time, and dissonances. It is through this lens that I now observe people with complex and longstanding mental health difficulties, caught between the limitations of primary care and the thresholds of specialist services. People who don't quite 'fit' the system.
Lara
The NHS Long Term Plan (2019) called for the creation of integrated models of care, aiming to promote collaboration within Primary Care Networks (PCNs) and Community Mental Health Services. These models were designed to help people like Lara (all names here have been changed) – people whose needs fall in the gap between IAPT (Improving Access to Psychological Therapies) and secondary care. According to the King's Fund, between 2010/11 and 2014/15, referrals from primary care to community mental health teams in England increased by 19 per cent. During a similar time frame – from 2005 to 2015 – the British Medical Association reported that prescriptions for antidepressants doubled. This signals a system under pressure, where medication often becomes the default response to complex emotional distress.
In a 2018 survey by Mind, involving 1,000 GPs, around 40 per cent of respondents estimated that mental health was a significant component of their daily appointments. This aligns with what many practitioners experience: mental health now represents a substantial part of the GP caseload, and yet primary care is not always equipped with the time, training, or pathways to support these patients fully.
Long waiting times and stretched resources create bottlenecks. GPs are left managing patients with increasingly complex needs, often without access to timely support or clear clinical pathways. This results in fragmented care, where mental and physical health are rarely addressed in a coordinated way. Barriers to integration include logistical challenges, funding limitations, and the absence of shared systems or protocols. The result? Patients feel unsupported, GPs feel overwhelmed, and practitioners are left to try and bridge the gap, often without formal authority or structure to do so.
This is where the integration of Mental Health Practitioners (MHPs) into primary care comes into focus – not just as a theoretical improvement but as an urgent, practical solution. A shift towards compassionate, timely, and holistic care. Lara came to me with a deep sense of hopelessness and the belief that every option had already been tried and failed. She felt like a lost cause. But I believe mental health professionals are, at their core, creatures of hope (just like philosophers are 'functionaries of mankind'!).
And so, we began. Not with a new medication or a fresh referral, but with presence – with time. We were standing in front of a puzzle with scattered pieces and had been told perhaps they were the wrong ones. But no, Lara – these were your pieces. Our work was to look at them from the right angle.
This is the gift that working in primary care integration can offer: the gift of time. The time that GPs and many other professionals simply don't have. Unlike the strict 10-15 minute appointment slots common in general practice, MHPs are typically able to offer 30 or even 60 minute sessions. This extended time allows for deeper exploration – not just of symptoms, but of the stories, patterns, and social contexts behind them. We are positioned at the intersection of medicine, psychology, and community support, and often act as bridges across systems. In doing so, we have the potential to bring a uniquely integrative and human approach to care, one that values presence as much as intervention. And sometimes, this approach is what changes everything.
Joseph
Joseph had always found it hard to talk about his feelings. Stigma – especially around masculinity and mental health – was deeply embedded in his narrative. At one point, he had briefly mentioned his emotional struggles to his GP and had been given the link to self-refer to IAPT. But he never did. He felt like 'jumping in the dark'.
Joseph didn't know what to do with a self-referral link. He needed a person – someone to walk alongside him as he took the first steps. From our early sessions, it became clear he wasn't looking for therapy in the conventional sense. He needed human connection and validation. He needed someone who could listen without judgement and offer some structure and support for the isolation that was weighing on him.
As we explored his story, it also became clear that much of his discomfort stemmed not from generalised anxiety but from the internalised stigma of growing up as a gay man in an environment where this was not safe or accepted. This wasn't just about mental health – it was about identity, shame, and isolation.
We investigated LGBTQ+ community groups, connected him with our social prescriber, and explored opportunities for volunteering, so that Joseph could try to take a step outside of himself. These small but significant interventions helped Joseph begin to reconnect with others, and consequently with himself. His mental health improved not through clinical intervention alone, but through validation, connection, and a sense of belonging.
Craig
Craig was a young offender from an ethnic minority background. Recently released from prison, he had been issued several fit notes excusing him from probation appointments, though these were inconsistently granted by different clinicians, with varying descriptions of his symptoms. It raised an important question: what exactly was he being excused from?
When Craig came to see me, his presentation revealed layers of trauma that had never been named or supported. He described severe anxiety dating back to early childhood, significant behavioural issues at school that had led to exclusion, and clear symptoms of PTSD following his incarceration.
He hadn't shared any of this with his probation officer. He didn't know how to. He said he found it difficult to leave the house at all. The only reason he had made it to the appointment was because 'the GP practice is local, and the doctors are there to help'.
His PCL-5 scores indicated severe PTSD. He was supported to share these findings with probation, and adjustments were made to ease his attendance. We also referred him for trauma therapy while continuing to meet regularly while on the waiting list to maintain engagement.
Despite a history of reoffending, Craig became determined to break the cycle. He developed a new vision for his future.
What made this possible? A safe space, presence, and time.
Integration in practice
Integrated models of care have demonstrated improved outcomes for individuals with mental health conditions or long-term physical illnesses. Research shows that collaborative approaches within the NHS can reduce hospital admissions, increase patient satisfaction, and improve cost-effectiveness.
In my day-to-day work, integration means everything from supporting people on the SMI register to engage with annual health checks, to providing brief interventions such as grounding techniques and motivational interviewing. I refer patients to other services and advocate for patients with rejected referrals, attend MDTs and interface meetings, liaise with consultant psychiatrists and clinical psychologists, and work across both the GP practice and the Trust.
This dual-anchored role has its complexities. In the beginning, there was little clarity. I essentially have two managers, two sets of supervision, and often two conflicting sets of expectations. It took a few joint meetings and some honest conversations to clarify my remit and strike the right balance.
I now feel fortunate to work for an excellent trust and an equally nurturing and collaborative GP practice. Both are aligned with my values – patient-centred care, empathy, and teamwork. I've been granted a clear remit, along with the flexibility to adapt it to the needs of the people I support.
One of the most valuable aspects of this role is being able to choose the length of a session, whether 30 minutes or a full hour. While I technically offer a maximum of 4-5 sessions, I continue to see patients for longer when needed, if the intervention remains beneficial or if periodic welfare checks are part of the plan.
There have been times when admin has felt overwhelming, especially during referral surges, but honest communication led to increased protected time for documentation and referrals. Boundaries were also clarified around medication – I'm not trained to manage pharmacological care, and in such cases, I refer patients back to the GP.
Revisiting Lara
Returning to Lara, one of the key themes in our early sessions was the word 'overwhelm'. She often described feeling 'incapable of coping like other people'. Over time, I've come to recognise this word – overwhelm – as a flag. It's worth exploring deeply.
I began to ask about sensory sensitivities and social interactions. Lara gradually identified patterns that hinted at neurodiversity. We completed the AQ-10 screening tool for Autism and the ASRS for ADHD. Her scores were high enough, and with the Right to Choose, she accessed the appropriate diagnostic assessments relatively soon, which confirmed both ASC and ADHD.
This opened a new narrative for Lara – one that finally made sense. We discussed how unrecognised neurodivergence may have shaped her experiences of anxiety and low mood for years. We developed a sensory care plan, particularly around transitions and holidays, to prevent future overwhelm. She joined a support group and began reading about neurodivergence in girls. She later started supporting her younger brother through his own diagnostic journey.
Her life improved. Not overnight – but with time, patience, and validation.
Reflections on practical implementation
To strengthen this model, several practical elements need to be prioritised. First, co-location is vital. Physically embedding Mental Health Practitioners within GP practices enhances both access and visibility. When patients see that mental health care is a routine part of their local surgery, stigma is reduced and engagement increases.
Equally important would be ensuring that MHPs are included in the multidisciplinary discussions within both GP practices and Primary Care Networks. Being part of these integrated meetings not only improves continuity of care but would also allow for more nuanced and timely support across services.
Shared care pathways should also be clearly established. Patients, clinicians, and support staff need to understand when it's most appropriate to involve a Mental Health Practitioner, when a GP should take the lead, and when an urgent referral to secondary or specialist services is necessary. Without these guidelines, care can become inconsistent or delayed.
Finally, the principle of 'no wrong door' should underpin the entire system. No one should be turned away simply because they don't fit neatly into an existing category or meet arbitrary thresholds. If someone finds the courage to reach out – regardless of the severity or complexity of their presentation – they deserve to be heard, held, and supported.
The stories of Lara, Joseph, and Craig reflect the core truth of integrated care: healing happens when people feel seen, heard, and held, especially in systems where they've long been overlooked.
Integration is not just a buzzword. It is a necessary transformation. It calls for investment – not just in resources, but in relationships. In time. In presence. In human connection.
We must continue to build models that are flexible, collaborative, and above all, person-centred. The policy frameworks are there – the NHS Long Term Plan, the Community Mental Health Framework – but real integration happens in conversations. In listening. In adapting. In showing up.
Are we really making a difference?
Yes. When we're given the space and trust to do so, we make all the difference.
For Lara.
For Joseph.
For Craig.
And for everyone still waiting to be heard.
References
British Medical Association. (2024). "It's broken": Doctors' experiences on the frontline of a failing mental healthcare system. BMA. Retrieved from
https://www.bma.org.ukDepartment of Health and Social Care. (2019). The NHS Long Term Plan. NHS England. Retrieved from
https://www.longtermplan.nhs.ukKing's Fund. (2017). Understanding NHS financial pressures: How are they affecting patient care? Retrieved from https://www.kingsfund.org.uk/publications/understanding-nhs-financial-pressures
Mind. (2018). GP mental health training survey summary. Retrieved from
gp-mh-2018-survey-summary.pdfNHS England. (2021). The Community Mental Health Framework for Adults and Older Adults. Retrieved from
The Community Mental Health Framework for Adults and Older Adults | Royal College of PsychiatristsNHS England. (2023). What are integrated care systems? Retrieved from
NHS England » What are integrated care systems?Royal College of Psychiatrists. (2021). Long Term Plan for the NHS in England. Retrieved from
Long Term Plan for the NHS in England| Royal College of PsychiatristsThornicroft, G., Mehta, N., Clement, S., Evans-Lacko, S., Doherty, M., Rose, D., ... & Henderson, C. (2016). Evidence for effective interventions to reduce mental-health-related stigma and discrimination. The Lancet, 387(10023), 1123–1132. https://doi.org/10.1016/S0140-6736(15)00298-6
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