These practices pay attention to the skill mix of the counsellors they employ, realising that it is too much to ask that a single counsellor can work successfully in all the areas required by the patients who consult them. Counsellors skilled in specialist areas of work such as relationship and psychosexual counselling, family systems, phobias, HIV, asthma, cardiovascular disorders, chronic disability of all kinds, and anxiety and depression, are carefully chosen to cover as many of these areas as possible. Evidence of their proven expertise and experience in these areas is sought by their employers prior to employing them. COST For a trained, experienced counsellor employed by the general practice it is reasonable to base the salary on a social worker's scale and to start at midpoint. In fund holding practices there is a different agenda as the practice focuses on reducing prescibing costs, reducing referrals to mental health and other services, and to offering a service wanted by their patients.
Considerable savings are possible if there are reductions in referrals to mental health services.
If 18 less patients were referred to non-urgent services per annum then the salary costs would be covered by this saving alone. Further savings are possible if the practice employs psychologists on a part-time basis to provide services instead of purchasing them from psychology units. However, it is not just in mental health care that savings can be made. Experience has demonstrated here and in North America that sometimes profound changes in patient behaviour and disease process can occur because of counselling interventions in major disease areas 2 . Outpatient diabetes care is especially responsive to counselling interventions.