Tower Hamlets Primary Care Service are a team of senior nurses, peer support and carer's workers working in GP's surgeries across Tower Hamlets.
We see service users who have made excellent progress in their recovery and are well enough to be discharged from their Community Mental Health Team (CMHT) to the care of their GP with added support from a senior mental health nurse attached to that surgery.
In addition to referrals from CMHT, service users who are under primary care and not open to CMHT can be referred by their GP to the service. The service user and GP agree that some extra support is required which can be provided in primary care settings and does not meet the threshold for secondary care services such as CMHT.
The nurse and service user work to an agreed recovery care plan using as many community resources as necessary while regularly monitoring their mental health and encouraging them to attend physical health monitoring appointments.
The appointments generally take place at the service user's GP practice. People are normally seen for up to 2 years, once every three months, after which, all being well they are discharged from the service back to their GP.
Should a service user's mental health deteriorate seriously, then there is a system for 'fast tracking' them back to the Community Mental Health Team.