Subtheme 1a: GPs were reluctant to manage APM without psychiatrist support.

Most GPs reported their training did not encompass APM management and stated they lacked skills to manage APM without psychiatrist support. GPs were also concerned that patients lacked confidence in their ability to advise on APMs appropriately:

“I don’t think that my [junior doctor psychiatric] training necessarily made me more confident in relation to antipsychotics… . I don’t think I’m confident enough to do that without some input.” (GP-07)

“It’s not just a GP thing…the patient might not have the confidence in us to do it either… They’ve often demanded to be referred to psychiatry, because the GP couldn’t make them better… to be then told by the same GP ’well actually, I’m going to stop your antipsychotic’- the patient may not have the confidence that stopping it will be OK.” (GP-11)

Psychiatrists recognised GPs’ reluctance to manage APM when patients were discharged, but some psychiatrists stated that GPs should manage APM independently:

“Your average GP has excellent capabilities to manage someone on antipsychotics… . The thing I think they lack… would be the confidence to do so.” (PSY-01)

Potential facilitators to help GPs manage patients prescribed APM independently included support from psychiatric pharmacists optimise APM prescribing:

“Psychiatry pharmacists are very easy to contact… . they tend to give detailed letters as to…what you could do. There are alternatives. I wouldn’t necessarily make a decision straight away without just sending the pharmacists a quick letter to say, “this is a situation what would your advice be” and they might say “aripiprazole… .and then you need to do x, y, z”…. I don’t think I would just switch [APMs] myself because I don’t necessarily have the confidence or the knowledge to do that.” (GP-07)

Subtheme 1b: Psychiatrists were reluctant to address cardiometabolic risks.

Respondents said psychiatrists often disregarded cardiometabolic risks. Psychiatrists explained they lacked the skills to address cardiometabolic risks, but there was also a reluctance to consider physical health as their responsibility:

“I would feel unqualified to do that [manage a diabetic patient on their ward]. I don’t feel I’ve got the knowledge to be able to do that in a helpful way….I would be pretty likely to be doing the wrong thing and causing more trouble.” (PSY-03)

Respondents suggested this limited opportunities to ameliorate cardiometabolic risk for these patients. Psychiatrists acknowledged patients with SMI might not see their GP on discharge, and this put them at greater risk of poorer cardiovascular outcomes:

“I received no training in general practice… that’s never been part of my psychiatric training. The idea that I would comfortably manage hypertension… I don’t feel comfortable with it” (PSY-07)

“It’s all ’go and talk to your GP’…and the patient often doesn’t go.” (MDP-10)

GPs understood psychiatrists’ reluctance to initiate medications for cardiometabolic risks but criticised a lack of non-pharmacological interventions (e.g., referrals to dieticians), and expected GPs would undertake these. GPs also noted that psychiatrists rarely made APM switches to ameliorate cardiometabolic risks, their focus being on addressing psychiatric issues:

“There is…mention in some letters about us helping the patient control lifestyle factors… What I don’t [see] is any evidence in letters that those referrals have been made by the psychiatric teams themselves.” (GP-11)

“Your focus tends to be on mental health…when you’re seeing someone in their 20s [with] acute psychotic illness and their life is coming apart—you’re focusing on that, and you are thinking ‘they might die of heart disease when they’re 60? If I get them to 60, I’ve done really well!’ “(PSY-01).

“I think the GP can recommend or prescribe exercise as well…I’ve never done it…when I came here, I was [told] ’you ask the GP to do that’.” (PSY-08)

Respondents suggested integrating GPs into mental health teams, particularly for inpatient settings, would overcome psychiatrists’ reticence regarding physical health, and ensure that inpatients had physical health needs met before discharge. Others proposed that support workers to co-ordinate physical health monitoring would help in community psychiatric teams:

“Either we make primary care accessible to that group of people or we embed generalists within mental health… it’s going to be probably easier to embed people with good general physical health… intervention skills within mental health, because we know that our group of patients… wouldn’t necessarily present to a GP”. (MDP-06)

Subtheme 1c: Gaps for HCPs in postgraduate and post-speciality training.

HCPs reported inadequate training to manage both psychiatric and cardiometabolic aspects of APMs. While all but two GPs interviewed had undertaken postgraduate psychiatric training, no psychiatrist interviewed had postgraduate experience in general practice (Table 1). This impaired understanding of each other’s specialties: some psychiatrists thought that all GPs undertook psychiatric postgraduate placements, and this drove expectations they could manage APMs. Psychiatrists confirmed postgraduate GP training did not cover APM management:

“I think [GP trainees] were… treated differently [to psychiatric trainees]. It was felt that they didn’t need that sort of in-depth knowledge [around APM management].” (PSY-05)

“GPs would have all had to have done some training in [psychiatry]… am I wrong in that? [informed <50% of GPs have psychiatric placements] … I’m actually shocked…. I had the impression that they [all] had to do… psychiatry.” (PSY-04)

GPs were concerned that stakeholders wanted them to manage more patients on APM without appreciating the volume of specialist care being transferred to GPs:

“Special interest groups are saying, ’Well, actually, this is not complicated… if you do some online teaching for an hour then the GP should know enough’…. It’s not possible, because we can’t keep up to date with all the different antipsychotics… as well as keeping up to date with all the different specialities and their specialist medications.” (GP-11)

Psychiatrists reported they had little training on cardiometabolic risks of APM, and MDPs involved in training confirmed this gap in the psychiatric curriculum. One MDP (former director of postgraduate psychiatric training) suggested that psychiatric trainees should have opportunities to work alongside GPs to improve their physical health skills and learn how primary care functions:

“It doesn’t seem to be built into the curriculum. I don’t directly influence what’s going on in the [Royal College of Psychiatrists] anymore… I don’t know what it says in terms of speaking to physical health… . for adult psychiatry trainees… . [we need] to give them more experience of working in… . primary care.” (MDP-01)

There was a concern by GPs and psychiatrists that psychiatric training placements for GPs were often unsuitable to gain relevant experience (e.g., GP trainees placed in forensic hospitals) and both groups said there was little recognition by their Royal Colleges (who oversee postgraduate training) that management of APM was increasingly transferred to GPs. They suggested this should be addressed by curriculum co-ordination between the Royal College of General Practitioners (RCGP) and Royal College of Psychiatrists (RCPsych). Others suggested changes within the RCPsych were needed to accept that physical health concerns arising from APMs was their responsibility::

If it’s a sequelae from their medications, I think they should be training on looking at ECGs and looking for QTc abnormalities, management of diabetes and [cardiovascular risk assessment]… . (MDP-05)

GPs reported training sessions with psychiatrists were needed, to look at integrated care of patients on APMs, reflecting the need for both specialities to develop joint strategies to improve integrated care:

“I would love to see our [training] sessions return to…group-based multidisciplinary sessions… It’s a brilliant opportunity that we’ve got to develop beyond primary care.” (MDP-09]

Subtheme 2a: Limited psychology provision.

Respondents expressed that limited psychology provision drove APM prescribing as a ‘stop-gap’ which was not good practice:

“What do you do when someone is presenting as severely anxious, mood difficulties, not sleeping, incredibly chaotic: wait 18 months for therapy?… Do you simply adhere to NICE recommendations and say… ‘there’s nothing I can do for you, you’re going to have to wait 18 months, it doesn’t matter how distressed you are?” (PSY-08)

One respondent suggested assistant psychologists could help manage psychological need, as so few fully trained clinical psychologists were available:

“Some of these newer roles—the Clinical Associate in Applied Psychology… they can work with people in the psychological model under supervision. They can do the psychology, the formulations, they can deliver the interventions with support…” (MDP-01)

Subtheme 2b: Pressure to discharge patients to primary care.

Psychiatrists reported pressure from management to discharge patients on APM, including those with SMI if stable, and especially patients without psychosis. As a result of this transfer of care, GPs were concerned patients would be unlikely to ever stop taking APM:

“There was a lot of pressure a few years ago on caseload cleansing…. the only ones we [were told to keep] were the ‘complex and unstable’…. this is ridiculous… if I discharged [the other patients] to primary care, they’d be back in within two weeks.” (PSY-01)

Many psychiatrists were also uncomfortable with discharging these patients, and suggested patients with SMI should remain under their care to have annual reviews. Psychiatrists and GPs often found it difficult to manage cardiometabolic risk, due to lack of resources to undertake monitoring and interventions–a lack of time, clinic space, or clinical equipment were reported as barriers:

‘Where I work, we don’t have any ECG machine, so I’m not able to just get on and do it myself, or train up the staff…’ (PSY-02)

Respondents suggested many potential facilitators to reduce pressure to discharge patients to primary care. Managers proposed removal of numerical targets imposed by governments as a measure of efficiency–the preference being to measure quality of outcomes. GPs wanted SCPs for antipsychotic prescribing, with discharge from psychiatry only undertaken with mutual agreement:

“Secondary care often seems to think they can then just discharge patients [on APM] without any agreement… the problem is that [they] don’t tend to attach any funding to it… I think the main difficulty is getting proper [SCPs] in place, with the funding… and [then] you’ve then got the resources to do it properly.” (MDP-05)

Subtheme 2c: Difficulty to get psychiatric review for patients with cardiometabolic symptoms.

GPs reported difficulty obtaining psychiatric review when cardiometabolic risks developed in patients taking APM discharged to primary care. Psychiatrists often advised ‘no APM change’ due to pressure on appointments rather than see them again, so opportunities to address cardiometabolic risk (e.g., switching APM to ameliorate risk of weight gain) were missed due to resource limitations:

“There’s time pressure -if I’ve got someone [psychiatrically] stable and want to switch their antipsychotic, then I’ll have to give them more clinic appointments.” (PSY-02)

As an alternative to formal SCPs, some respondents suggested 5-yearly comprehensive reviews of patients taking APM in primary care. There was some difference of opinion amongst respondents as to whom would be best placed to undertake reviews. Suggestions including training GPs with an interest in mental health, psychiatric nurses, or pharmacists. Psychiatrists however, suggested that it was unlikely other professionals would have the confidence to withdraw APM, so they should undertake them:

“It would need to be done by the person with the most well-developed sense of judgment of risk… . [there is] a strong case to argue for it being a psychiatrist doing it… . You could get somebody else doing it, but if they were less confident, taking somebody off [antipsychotic] medication is always a bit of a scary thing to do. And it is always kind of tempting not to, because…you know what risks there are…” (PSY-03)

Subtheme 3a: Inadequate information in written handover.

HCPs reported inadequate information in psychiatrist’s letters on APM indication, duration, and monitoring; GPs were often unaware when APMs were prescribed ‘off-label’. GPs reported written advice was usually when to increase APM doses to avoid referral back to psychiatry. This left GPs with little confidence to optimise APM prescribing:

“As someone who completes discharge summaries, I’m going to hold my hand up and say, we don’t always include that… GPs get patients discharged on an antipsychotic when they’re 23 and they’re still on the same antipsychotic at 43” (PSY-01)

“One case that I saw very recently, which was an elderly gentleman… . his psychiatry team said he’s stable enough to reduce his [APM] and discharge… but didn’t then give any sort of plan to reduce it.” (GP-07)

Psychiatrists reported referral letters from GPs lacked detail; lack of personal knowledge of the patient in referrals inhibited care, often only being a computer-generated summary:

“Referral quality can be variable depending on the experience of the GP, and their interest in mental health… sometimes we [have to] go back and ask for more information.” (PSY-05)

Most respondents suggested psychiatrists having standardised letter templates that provided clear information on indication, intended duration, and plans for switching, weaning and reduction, would help support GPs to manage APM. Many noted that the only advisee was on dose titration, and this was insufficient:

“It would be useful if the [psychiatrists] said they’re on this drug, which requires [this] monitoring, and we would expect them to stay on the drug for [this] length of time. And I think they should say what the indication is and that it’s being used off-[label].” (GP-10)

Subtheme 3b: Difficulties in verbal communication between primary and secondary care.

GPs reported difficulties getting to speak to psychiatrists, with responses often from other professionals unable to advise on APM use; psychiatrists were concerned GPs did not often know patients well enough to provide any useful context when they called to find out more about the patient:

“You often find—no disrespect -… queries that we raise are dealt with by health care workers way below the level of training of a consultant psychiatrist.” (GP-11)

“Because of the nature of general practice, you [often cannot] talk to a GP that knows the patient personally… information that comes with the familiarity… can be difficult to access.” (PSY-07)

Some respondents suggested services such as ‘Consultant Connect’ [42] were helpful, where a GP could speak to a psychiatrist for advice, but because they could be located anywhere in the UK and did not have access to the EHR, their value was limited regarding advice on APM. Others suggested that a ‘consultant of the day’ rota providing advice to GPs would improve care, as they would have EHR access to guide management more effectively. Psychiatrists also wanted direct telephone access to GPs to improve communication. An indirect communication benefit from joint training was also proposed—teams would develop closer links to improve mutual trust, problem-solving, and communication:

“We developed a ’psychiatrist of the day’ who would simply take calls from GP’s, and it was amazing: the upskilling that results from that. The value of a local connection is twofold: One is, as a GP, I can seek advice about altering some of these medications, or whether or not they need referral?… Two, also the ’psychiatrist of the day’ gets to pick up what are the issues going on out there… ‘Do we need an education event, or a change to a pathway?’” (MDP-09)

Subtheme 3c: Poor integration of IT systems used in health services.

Respondents stated that suboptimal IT systems inhibited ability to manage patients taking APM, due to different EHR systems being commissioned by primary and secondary care. HCPs often reported inability to view EHRs, wasting time when seeking information:

“The hospital will have one electronic system, and the GP will have a second electronic system. And then psychiatry has a third, even more separate, difficult to access system, which some people have viewable access to, but not editable access.” (GP-07)

All respondents wanted improved access and ability to write into a common EHR to avoid duplication of effort and aid integrated care planning. Respondents recognised with widening access that patient confidentiality was a concern, but some suggested that an overemphasis on patient confidentiality was blocking vital access, and having multiple EHR systems within services, led to fragmentation of care:

“That kind of holy grail of the shared care record, it would sort it all out, it would solve it all.” (GP-08)

Subtheme 5a: Contractual divisions between primary and secondary care.

Respondents expressed concern that the UK General Medical Services (GMS) GP contract inhibited integrated care:

“The GMS contractual issues… that constant argument around "I’m not going to do this unless [we GPs] get paid for it". Those sorts of issues really need to be addressed… sometimes [GPs] forget there’s a patient at the end of all these decisions.” (MDP-08)

The Quality and Outcomes Framework (QOF) in the GMS contract incentivises GPs to monitor physical health risks for patients with SMI, but incentives have been largely abolished in contract revisions in some regions; GPs predicted this would reduce cardiometabolic risk monitoring without earmarked funding. GPs are not expected to provide specialist psychiatric care in their contract and complained services discharging patients with SMI or on APM to them to manage was an unfunded transfer of care. Many were concerned the QOF ‘mental health register’ criteria that drives monitoring, being focussed exclusively on psychotic illnesses, no longer captured all patients prescribed APM and was not fit for purpose, with a risk many patients were not recalled for monitoring. GPs suggested that APM use, not diagnosis, should trigger QOF funding for risk monitoring and payment in their QOF contract, rather than being limited to patients with psychotic illnesses:

“In England, we still have the [QOF] mental health register…. but it doesn’t pick up people who’ve got a personality disorder [taking APM].” (GP-04)

Many respondents suggested a need for more collaborative working between Royal Colleges, medical unions, and service providers to identify barriers to integrated care, and amend contracts to overcome these, but felt organisational protectionism impaired progress. Primary and secondary care often worked in ‘organisational silos’ to create barriers to protect resources, e.g., referral to obesity clinics being restricted to GPs, and service managers needed to redesign and monitor pathways to prevent silos forming. A former RCGP leader reported ‘protectionist’ conflicts of interest even at national levels, where patient needs were secondary to the needs of the organisations competing for resources:

“There is a real tension between being a member’s organization that needs to deliver for its members’ interests, and doing the right thing… I was there representing [the RCGP]…we can see what the right thing is to do, but as membership organizations, we have to protect the needs of our members. So, you would not expect the [RCGP] to meet with the [RCPsych] and [say] ‘You have all the money we get for mental health…just sort out everything’…protectionism gets in the way of better care.” (MDP-04)

Some respondents suggested patient pressure groups skewed resource allocation:

“When… you’re taking a massive stack of antipsychotics, with all the negative impact that has on motivation… . those patients are the ones that I feel are most neglected by mental health services… the patient groups that talk the loudest, are [those] who we perhaps have the least value to offer… .” (PSY-07)

MDPs expressed frustration that their efforts to reduce APM overprescribing did not result in savings to reinvest in services such as psychology:

“Prescribing budgets are held in a different part of the [NHS organisation] … I can’t get hold of prescribing budgets, even if I’ve saved on one element of them, to reinvest the savings.” (MDP-06)

Subtheme 5b: Worsening inequality driving APM use.

Respondents suggested APM use was a ‘sticking plaster’ to deal with consequences of socioeconomic inequality and the medicalisation of distress, and many patients primarily needed social interventions regarding finances, housing, or education rather than health treatment:

“Until we’re able to deal with the fact [people] can’t feed their kids, or heat their homes, that schools don’t have the resources to put into troubled young people. [antipsychotic prescribing] is not going to reduce in our medicalized society… I can absolutely see why [antipsychotic prescribing] rates are rising.” (MDP-04)

Many respondents expressed a sense of powerless to address the socioeconomic determinants driving mental distress in patients, which could only be addressed by governments.

Another area of concern was pressure to prescribe APMs to manage challenging behaviours in people with dementia. Respondents said this was due to care home staff lacking the skills to manage patients with behavioural difficulties via non-pharmacological methods. They suggested investment in better training for care home staff would help to reduce APM prescribing:

“Care homes are running on empty. They don’t have people who are skilled…. they have token specialist dementia champions, but they just don’t have the resources to sit with people while their anxiety levels reduce or engage them… [with the] things that we know…reduce the need for antipsychotic use.” (GP-04)

Subtheme 5c: Medicolegal and regulatory fears of HCPs.

HCPs mentioned fears around stopping APMs if a patient subsequently harmed themselves or others; some explained they ‘prescribe to be seen to do something’ due to working in an unforgiving medicolegal, regulatory, and societal culture:

“If I was to stop an antipsychotic…if something adverse happened… I would have a very difficult time justifying that action, even if it’s a relatively safe thing to [do]… those things lead to medication overprescribing… even if it’s the wrong thing to do, it’s almost a sense that having done something is better than doing nothing.” (GP-04)

Psychiatrists reported unrealistic societal expectations towards their speciality that an adverse outcome must ‘always be someone’s fault’, which inhibited their willingness to deprescribe:

“Physicians accept that there’s a certain percentage of COPD patients who will die, that it doesn’t matter [how] much resource you use…they will get worse, and some of those people will die. And then there is a very marked reluctance… [within society] to accept that [psychiatric] conditions also have a morbidity and mortality… which I find frustrating.” (PSY-07)

Many respondents suggested excessive regulation created barriers and encouraged defensive medicine. They mentioned that society, the judiciary and regulators had not recognised this, and wanted a debate around the increasingly adversarial ‘blame culture’ in which they had to practice.

One unintended consequence of overzealous national performance management indicators contributing to increased APM prescribing was close monitoring of benzodiazepine use, often reported down the level of identifiable clinicians, and some reported unease in case this resulted in censure. Some practitioners admitted ’gaming the system’ by using sedating APMs to treat insomnia to reduce their benzodiazepine rates, as, paradoxically this was not monitored at all:

“I’m guessing if we use diazepam as an example—diazepam was the elixir for everything. And we had, going back, a massive uptake in the prescription of diazepam. We are aware of the issue of diazepam now has, in a sense of its addiction… so we just turn to other medication with a similar effect; in this case it is antipsychotics.” (PSY-04)