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Toolkit for Primary Mental Health Care Development: Research report Authors: Collings S, Mckenzie S, Dowell AC, Currey N, Gandar P, Rees D
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Citation: Collings S, Mckenzie S, Dowell AC, Currey N, Gandar P, Rees D. 2010. Toolkit
for Primary Mental Health Care Development: Report. Wellington: University of
Otago and Synergia Ltd.
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Acknowledgements
The research team would gratefully like to acknowledge and thank our four research
partners: Counties Manukau District Health Board, Hawke’s Bay District Health
Board, Hutt Valley District Health Board and Nelson-Marlborough District Health
Board for their support and commitment to the project. We would especially like to
acknowledge the individuals and agencies ranging from DHB personnel to clinicians
in both primary and secondary mental health care within each research locality that
worked directly with us, gave up their valuable time to meet, and discussed ideas,
problems and solutions.
Core Research team
The core research team comprises the following members:
Associate Professor Sunny Collings, Principal Investigator, University of Otago
Mr Philip Gandar, Synergia
Professor Tony Dowell, University of Otago
Mr David Rees, Synergia
Ms Sarah Mckenzie, University of Otago
Ms Nandika Currey, University of Otago
Contributors
Dr Debbie Peterson, University of Otago
Ms Helen Montgomery, University of Otago
Ms Joni Wang, University of Otago
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Steering Committee
The research team would also like to acknowledge the support and guidance of the
Mental Health Steering Committee:
Professor Mason Durie (Chair); Ms Sharon McCook (Group Manager, Research
Partnerships, HRC), Ms Lucy Todd (Project Manager, HRC, now replaced by Ms
Heather McNeil), Ms Kate Moodabe (Senior Manager, ProCare Health Ltd.), Dr
Monique Faleafa (National Manager Le Va, Te Pou), Dr Judi Clements (CEO, Mental
Health Foundation), Ms Nemu Lallu (Senior Project Manager, Ministry of Health) and
Ms Ana Sokratov (Consumer Consultant).
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Contents
Acknowledgements ............................................................................................... i
Summary .............................................................................................................. iii
Section 1: Introduction ................................................................................... 1
Aim of the study ............................................................................................................................ 1
Study outputs ................................................................................................................................ 1
General background ...................................................................................................................... 1
Role of Steering Committee .......................................................................................................... 3
Research localities and research partners .................................................................................... 3
Purpose of this report ................................................................................................................... 4
Section 2: Context and environment ............................................................... 5
Overview ..................................................................................................................................... 5
What is primary care? ................................................................................................................... 5
The role of primary care in mental health care ............................................................................. 6
The evolution of primary mental health care ............................................................................... 7
Policy context .............................................................................................................................. 15
Whānau Ora ................................................................................................................................ 17
The interface between primary and secondary care .................................................................. 18
Māori mental health ................................................................................................................... 22
Pacific Peoples’ mental health .................................................................................................... 30
Asian peoples’ mental health ...................................................................................................... 37
A focus on the mental health of children and young people ...................................................... 40
Alcohol and drug issues ............................................................................................................... 42
Mental Health Promotion ........................................................................................................... 43
Does a ‘consumer’ perspective differ between primary and secondary mental health care contexts? ................................................................................................................................... 48
Section 3: Framing the research ..................................................................... 67
Introduction ................................................................................................................................ 67
The Primary Mental Health Initiatives ........................................................................................ 67
Case Study Research ................................................................................................................... 70
Participatory action research ...................................................................................................... 71
Diffusion of Innovation in health care ......................................................................................... 74
Developmental Evaluation .......................................................................................................... 81
System Dynamics and Primary Mental Health Care .................................................................... 86
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Section 4: Methods ........................................................................................ 95
Overview ................................................................................................................................... 95
Objectives ................................................................................................................................... 95
Ethics approval ............................................................................................................................ 95
Settings ................................................................................................................................... 96
Participants.................................................................................................................................. 96
Communities of interest .............................................................................................................. 97
Data sources ................................................................................................................................ 97
Choice of partner DHB localities ................................................................................................. 98
Procedures .................................................................................................................................. 99
Cognitive mapping..................................................................................................................... 101
Systems Dynamic modelling ...................................................................................................... 105
Developing Optimal Model II .................................................................................................... 109
Toolkit development ................................................................................................................. 111
Section 5: Results ........................................................................................ 115
Introduction .............................................................................................................................. 115
Sector Workshop ....................................................................................................................... 115
Timeline of partner progress ..................................................................................................... 127
Exploration of the issues ........................................................................................................... 131
Toolkit summary ........................................................................................................................ 186
Section 6: Discussion ................................................................................... 190
Overview ................................................................................................................................. 190
Translational research process .................................................................................................. 190
Challenges ................................................................................................................................. 193
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Summary
The organisation of primary mental health care: The Real Deal
The ‘Real Deal’ represents an integration of the main messages from this project. It is
our view of a philosophy of primary mental health care.
Primary mental health development requires a number of different perspectives and
ways of thinking. We have tried to model this in the Toolkit by including some
generic themes and more specific methods like systems dynamic modelling.
The main findings are:
Primary mental health care is important and in a state of rapid development.
Up to 75% of all mental health problems are addressed wholly or in part
through primary health care services, yet traditional services and funding are
still focused on secondary care and those patients with severe and enduring
disorders. The growth of Primary Mental Health Care (PMHC) has
demonstrated that new ways of working can be developed in primary care
settings and lead to improvements in the standard of care.
There is no single most appropriate model of care. Successful models all
involve a multi-disciplinary response and an acceptance that while there may
be choice that choice cannot be limitless.
Taking a service user perspective ought to be the cornerstone to
development and yet is challenging to build in to routine working and
strategic planning.
Protected time is the key to successful primary mental health care
development and is in very short supply. If nothing else DHBs and PHOs
should look to support time for strategic thinking and critical reflection within
their own organizations and among primary care teams.
Effective teamwork is essential if good ideas and initiatives are to be brought
to fruition. There is a lack of clarity in many areas about who is involved in
primary mental health care and how they should best work together.
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There is insufficient dialogue between primary and secondary care. Dialogue
and discussions are the key to future development and if there has not
already been strategic discussions between primary and secondary mental
health care teams at both planning and clinical levels, these should be a high
priority.
Primary Care has to accept all types of undifferentiated problem and support
patients in their decision making. In all regions of the country this includes a
significant proportion of patients who have problems exacerbated by socio-
economic difficulty and problems with labels such as ‘stress’. To provide
effective responses to these patients it is important that DHB’s and PHO’s
have services that contain a broad range of disciplines and approaches to
care. It is also important that services can be integrated beyond health care
and involve appropriate liaison with social welfare and education.
Information technology systems are isolated from each other and in many
instances not geared to either individual patient or population level
information need. DHBs and PHOs should actively support projects to share
records and information within primary care and across the primary,
secondary interface.
There are a number of areas where there has either been a relative lack of
primary mental health care services or lack of coordination of services. Child
and Adolescent services are an example of the former and alcohol and other
substance use services an example of the latter. We believe that there should
be an increased emphasis on services for child and youth and the elderly. This
is particularly pressing for child and youth, given the growing research
evidence about the impact of early psychological trauma on future adult
development.
New Zealand is an increasingly culturally diverse society. It is important that
primary mental health services are able to respond to that cultural diversity.
As a result of this project we have refined the original Optimal Model for
PMHC and produced Optimal Model II shown below. The first diagram
represents structural elements and the second, the service user pathway.
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Prioritise policy and practice linkages to:
Secondary mental health
Health promotion
Primary prevention
Other secondary care programmes
Workforce
Sufficient staff with appropriate knowledge and skills i.e. new roles of specialists in PMHC
Career path
Protected time for funded professional
development, supervision
Culturally appropriate
services available
Evidence-led constraint to programme variety
Adaptation to local need within clearly articulated constraints led by policy guidance
Philosophy of PMHC service Services for any person with mild-moderate mental health needs
Explicit service provision for Child & Youth; over 65s Clear inclusion/exclusion criteria based on explicit values
Whānau ora based approaches as appropriate and where possible
Elements within PHO/PHO network
Government agencies e.g. WINZ, Education
NGOs e.g. Salvation Army, Foodbanks, self-help groups,
Other services provided by a range of social entrepreneurs
Contracting to be managed to ensure it is not burdensome
and services are experienced as ‘seamless’ by service users
Formalised links with
PMHC is congruent with DHB programmes
District Health Board
Prioritise primary mental health care
Funding: following removal of ring fence of ‘Mason’ protected mental health funding, prioritise primary mental health programmes
Infrastructure
Clinical champion
Workforce development
Mandatory initial training funded by external body
Uniform training across nation
Rolled out in a timely way using existing courses
Interdisciplinary
To be delivered by educators in current clinical and research practice in primary care
To cover evidence-led key competencies for the new roles: technical expertise in diagnosis, management including drugs and psychological treatments in evidence-led models
Train psychological therapists specifically for low intensity brief psychological treatments
Work towards a variety of modified roles in secondary care, oriented to primary care
supports
links
Infrastructure: prioritise linkages
Patient management system
Information technology
platform
Links with community
Continuous Quality
Improve-ment
Links with other primary care programmes including alcohol & drug
Local PHO or PHO grouping primary mental health clinical champion, working within & supported by distributed leadership
Figure 1 Optimal II for Primary Mental Health Care
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Service user identified (through General Practice or other route- e.g. Māori health provider) Initial assessment including clinical indicators and appropriate assessment tool(s) e.g. K10
Inclusion criteria met?
No
Yes
Clinical/social intervention
Clinical coordinator assessment
General Practitioner/ Practice Nurse:
extended consultation
and
or
Treatment interventions
Examples: talking therapy, pharmacological prescription (from GP), lifestyle interventions, self-management
Provide treatment within practice as much as possible
Monitoring and follow-up (over extended period) including appropriate assessment tool
GP/PN/Coordinator: phone, text, email, face-to-face
Select from usual range of GP
interventions e.g. pharmacological
intervention; lifestyle advice
Secondary referral
Referral to other organisations e.g. NGOs
Figure 2 Service user pathways (within the context of figure 1).
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Section 1: Introduction
Aim of the study
The aim of this study, Toolkit for Primary Mental Health Care Development, was to
develop and use a translational research approach to derive an evidence based,
sustainable approach for the development of primary mental health care (PMHC) in
New Zealand.
Study outputs
The project has generated three ‘outputs’ to date. The two ‘hard’ outputs are the
Toolkit itself and this research report. The third is a ‘process’ output. This is the
consultancy expertise and processes that the research participants had access to as
part of the study. There will be additional outputs submitted as articles for the peer-
reviewed literature.
At the outset, the Steering Committee (see below) made it clear that the Toolkit and
research report should be presented in a style accessible to all contributors to PMHC,
at all levels and in all relevant settings. This included policy, District Health Boards
(DHBs), Primary Health Organisations (PHOs) and Non-Governmental Organisations
(NGOs). The research partners expressed a similar view. In addition, the Toolkit
contents were highly influenced by their suggestions about what would be useful. As
part of making the outputs useable, we have tried to ensure that the Toolkit and
research report can stand alone. Alongside this, in order to maximise potential
benefit, we have also tried to indicate useful cross links between components.
General background
This work was a joint initiative funded by the District Health Board Research Fund
(DHBRF) and administered by the Health Research Council (HRC). The objective of
this initiative was to commission research that addresses key knowledge gaps for
DHB’s. The fund intends to support and promote the translation of research findings
into practice in five priority areas including chronic care, cancer, access to services,
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mental health and cardiovascular disease. It is particularly focussed on the principles
of funding projects that can maximise benefit to the health sector, opportunities for
knowledge transfer, ensuring the investments meet national and international
competency, focus on health services and population health including the health
needs of disadvantaged populations and will contribute to improved health service
delivery and outcomes over the short to medium term.
In September 2007 a request for mental health research proposals (RFP) was issued
by the HRC through the DHBRF Mental Health Steering Committee. The contract was
awarded in December 2008. In the period following the application process there
was a series of negotiations regarding the nature and scope of the project, resulting
in a final project specification that was modified from that required by the original
RFP. The study began in February 2009, to be completed within an 18-month time
frame. The investigating team is a partnership between the University of Otago
Wellington and Synergia Ltd, formed specifically to undertake this work. The
investigators are: Associate Professor Sunny Collings, Mr Philip Gandar, Professor
Tony Dowell, Mr David Rees, Ms Sarah McKenzie and Ms Nandika Currey.
A key aspect of the project was recognising and building on the significant amount of
work that had already been done in PMHC development in New Zealand at the time
we began the work. It was important that any use of the Toolkit would build on and
strengthen existing capabilities and capacity. This created an initial tension between
the possibility of describing an ‘ideal’ version of PMHC and the reality of current and
likely future resources, structures and processes. We needed to consider the balance
between an aspirational Toolkit and a pragmatic one.
As the project proceeded, additional complexity arose. Due to participatory method,
the research process itself was inevitably a small part of the dynamic PMHC system.
The project contributed to service developments in the research partnerships to
varying extents, and bore the consequences of additional unpredicted demands and
constraints on DHBs and PHOs due to the high degree of external pressure from both
the incoming government’s imperatives and the economic downturn.
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Role of Steering Committee
As with all five priority areas, the Toolkit project is monitored by a Steering
Committee. The Mental Health Steering Committee comprised: Professor Mason
Durie (Chair); Ms Sharon McCook (Group Manager, Research Partnerships, HRC), Ms
Lucy Todd (Project Manager, HRC, now replaced by Ms Heather McNeil), Ms Kate
Moodabe (Senior Manager, ProCare Health Ltd.), Dr Monique Faleafa (National
Manager Le Va, Te Pou), Dr Judi Clements (CEO, Mental Health Foundation), Ms
Nemu Lallu (Senior Project Manager, Ministry of Health) and Ms Ana Sokratov
(Consumer Consultant).
From the research team’s perspective, and as agreed in early meetings, the role of
the Steering Committee was to monitor progress, give high-level feedback on the
project development and direction, and to help us identify local champions for the
project in our partner District Health Boards (DHBs).
Research localities and research partners
The research took place in four distinct geographical areas, each being the
catchment area for a DHB population. The areas were: Nelson-Marlborough, Hutt
Valley, Hawke’s Bay and Counties-Manukau.
Because As DHBs are responsible for health and disability services in their catchment
areas, and hold the planning and funding role, we needed to work closely with them
as organisations, as well as with primary care providers in each locality. Within each
research locality we worked directly with specific partners – individuals and agencies
ranging from DHB personnel to clinicians in primary and secondary mental health
care. Details of the process of identification and selection of partner localities are
described in the method section.
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Purpose of this report
This report has three main purposes. These are:
1) To describe the process, outcomes and some consequences of the research
project.
2) To provide background information that may be of interest to those using the
Toolkit.
3) To serve as the full and final report to the Steering Committee. This report is
a combination of a technical report, and a report on results, but it must be
borne in mind that the main results are actually the Toolkit. The report sits
alongside the Toolkit: the Toolkit can be used without reading this report.
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Section 2: Context and environment
Overview
This section provides an overview of the historical and contemporary context of the
Toolkit project. First we define primary care, then discuss the general role of primary
care in mental health care and selected aspects of the evolution of primary mental
health care (PMHC) overseas and in New Zealand. This is followed by a summary of
the policy context of PMHC development work and salient pre-existing issues in the
New Zealand mental health system, for specific sub-populations and other key areas
of service provision relevant to PMHC.
What is primary care?
Primary care is the first point of contact with a health practitioner when people are
unwell. It provides entry to the healthcare system for new problems (Starfield, 1998)
or when specialised investigations or interventions are required. Primary care has
been the basis of medical care since the 19th century with specialist services
beginning in the early 1900’s. The majority of New Zealanders have access to such a
service, with 93.3% of adults able to name a specific primary care provider (general
practitioner (GP), nurse clinic or 24-hour accident and emergency clinic) that they
would go to if injured or ill. 81.3% of all adults have seen their GP at least once in a
12-month period (76.3% and 83.7% for Maori men and women respectively)
(Ministry of Health, 2008). The most common reasons for choosing a primary care
practitioner are proximity and personal recommendation (Ministry of Health, 2008).
Primary care is a major contributor to the maintenance and improvement of a
population’s health status because it has the potential to provide links between and
contribute to both population health and individual health care (Neuwelt et al,
2009). This can happen through the translation of an awareness of the social
determinants of health, a commitment to equity in health outcomes and acceptance
of the potential contribution of communities, into the care of individuals. In addition
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the aggregation of the individual episodes of medical and nursing care provided to
individual patients contributes significantly to population health outcomes.
New Zealand’s primary care sector comprises multiple agencies and includes general
practices and Primary Health Organisations (PHOs), non-government organisations
(NGOs), voluntary agencies and informal care. These agencies and functions range in
nature from fully private business models through non-government, non-profit (third
sector) entities to communities and family/whanau. The many formal providers are
grouped together and coordinated by PHOs of varying sizes and configurations.
The role of primary care in mental health care
Doctors have cared for the emotional wellbeing of their patients for hundreds of
years. This carried over into the more complex service arrangements of the last
century, with primary care professionals, mainly GPs, providing what has until
recently been regarded as ‘generalist’ mental health care (McGrath, 2002). In the
past five years, the role of primary care in mental health care has been enhanced by
the provision of dedicated funding. The common mental disorders such as anxiety
and depression that are most often seen in primary care contribute a greater
proportion of the population burden of illness than the kinds of disorders more often
seen in secondary care, simply because of their high prevalence (Andrews and
Henderson, 2000). PMHC is now seen as an opportunity to help close the treatment
gap for mental health problems, enhance access to care for mental disorders,
promote respect for the human rights of people with mental disorders, and to
provide an affordable way of generating good health outcomes (Funk & Ivbijaro,
2008). That is, PMHC is considered, just as Neuwelt et al suggested for primary care
as a whole (Neuwelt et al, 2009), as a critical component of health systems and
population mental health improvement, with social goals as much as clinical service
goals. In New Zealand, PMHC services are predominantly aimed at people with so
called ‘mild to moderate’ mental health problems, although of course people with
severe and enduring mental health problems also use primary care for both physical
and mental health issues. There is also an expectation that PMHC will encompass
mental health promotion activity, provide appropriate treatment and referral, and
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integrate mental health or psychosocial interventions into the management of
physical health problems as appropriate.
The evolution of primary mental health care
The potential of PMHC has been acknowledged in New Zealand only in the past
fifteen years (Bushnell, 1994), although its possibilities have been examined in detail
in the UK and North America for at least two decades. This section of the report
describes selected aspects of the evolution of PMHC. Over the past twenty years a
large international literature has developed covering many aspects of PMHC,
including investigator-led clinical, services and policy research, and commissioned
health services and policy research and reports. We have not attempted an
exhaustive review and synthesis. Instead we present (with illustrative examples) the
themes most salient to the development of PMHC in New Zealand.
The ‘landscape’ of primary care mental health literature
The landscape of the PMHC literature has a number of features of particular
relevance to PMHC in New Zealand. Firstly, there are two main strands, with the
majority of work coming from the UK and North America (mainly the USA). These
strands have developed in distinct ways as they are shaped by the imperatives of
health care funding and professional role organisation in different systems. The
second important feature is that there seemed to be little cross-fertilisation between
the two until the emergence of a focus on integrated care. The third notable feature
is that until relatively recently little of the literature in either system was generated
from primary care itself.
Evolution of primary mental health care in the UK
In the UK the importance of PMHC was signalled in the 1960s, when, following a
cross-sectional community survey of mental illness it was proposed that GPs were
well-placed to monitor the mental health status of the community and to identify
cases of mental illness needing treatment, given the high prevalence of mental
disorders in the general population (Shepherd et al, 1966). The key justifications for
this were summarised by WHO in 1973 as including: the reluctance of people to
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consider they need help for a mental health problem, with presentations often being
for physical complaints; the common co-existence of physical health problems
alongside mental disorders; the familiarity the GP has with the patient and his/her
social milieu; and the continuity of care that can be provided by the GP (WHO, 1973).
This argument was further developed when Goldberg and Huxley described the
possible pathway of a person with a mental illness through services using a model
that related the epidemiology of mental disorders to parts of the health service, (e.g.
primary and secondary care) with filters operating at each level (Goldberg & Huxley,
1980). This is represented in the diagram below.
A = Consult their GP during year B = Episode of psychological distress during year (level 1) C = Identified by their doctor as psychiatrically ill (level 3) D = Referred to mental illness services (level 4) Do not pass 1st filter (ill, but do not consult) Do not pass 2nd filter (illness not recognised by GP) Do not pass 3rd filter (not referred to mental illness services) Venn diagram showing the relationship of disorders at levels 1, 2, 3 and 4. The square represents the population at risk.
A
B
C
D
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Although the idea of stepped care had not been developed at the time, there are
obvious parallels between Goldberg and Huxley’s filter model, and the stepped care
model in vogue at present in PMHC. Although the Goldberg and Huxley model has
been widely used in conceptualising PMHC, it is worth noting that it is to some
extent system specific, in that it assumes the GP is the gatekeeper to secondary
services, which is not the case in all health systems. In the USA for example it is
common for people to access a psychiatrist directly. In addition, the model applies
mainly to common mental disorders. People with psychotic disorders for example
may present via other routes, such as to ED, to secondary care, or even self-refer to
specialist but primary care services such as Early Intervention for people under the
age of 25. Finally, the model is clearly based on the notion of distinct disorder
categories and does not address the problem of sub-threshold syndromes which
commonly present in primary care.
Despite the presence of local evidence supporting the development of PMHC, in the
UK there was not a policy and clinical focus on the area until the 1980s. In the late
1980s and early 1990s there were policy initiatives coupled with new money for
primary care developments, some of which used a research model to develop
services prior to widespread programme and service dissemination (Jenkins, 1992).
An example of this was a trial of the use of non-specialist facilitators (an existing role
for screening and management of hypertension) to establish systems for screening
and early treatment of depression and anxiety, and the identification and support of
those at risk of these disorders (Bashir et al, 2000). Key tasks were to provide:
protocols (what we might now consider as clinical guidelines) for case-finding and
treatment; education for GPs from counsellors, psychologists, psychiatrists and GP
trainers; training for practice nurses in preliminary assessment of people with
depression and monitoring of treatment effects; enhancing cooperation between
primary and secondary services; advice on the employment of counsellors; and
providing resources for patients. Although the practices with the facilitator showed
better recognition of psychiatric illness by GPs, there were no improvements in
clinical management or patient outcome.
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A second example was the parallel evaluation of two uses of a mental health trained
practice nurse in comparison with a ‘standard’ practice (Mann, 1998). The non-
specialist practice nurses were trained in the assessment and management of
depression. In the first intervention the nurses provided a comprehensive psychiatric
assessment followed by specific feedback to the GP about the patient’s clinical
status. In the second intervention the nurses discussed the patient with the GP
following assessment, then followed the patient up for up to eight hours over a four
month period. For both interventions the comparison was with GP treatment as
usual. The four month outcome was no difference in depression scores in either
intervention group as compared with treatment as usual. Post hoc subgroup
analyses revealed no differences by sex, age, presence of social problems or physical
ill health, or prior history of depression.
These studies are good examples of the kind of PMHC research being done in the UK
in the early to mid 1990s. Studies such as this were some of the first attempts to
study complex PMHC interventions in dynamic real-world settings, and they
generated some important findings beyond the answers to the specific research
questions. A key issue for Bashir’s ‘real world’ pragmatic trial was that it occurred at
a time of significant external health system pressure due to major reforms including
changes to contracting arrangements, and it was notable that GP performance on
case detection in the comparison practices actually worsened under these conditions
(Bashir K et al, 2000). Other observations include the fact that such studies at this
time often lacked thorough economic evaluation, which made arguments for
implementation more difficult to sustain. Study designs were also tightly modelled
on traditional secondary care treatment trials for specific disorders in that outcome
measures focussed on symptoms with little attention to functioning.
The two studies used as examples here also both illustrate the collaborative care
approach, one of the two main models for health professional activity in PMHC– the
collaborative and replacement models (Bower, 2002). In the collaborative model, the
GP has primary responsibility for the care and treatment, and an additional
professional with some more specific mental health expertise works alongside,
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providing structured particular elements of the package of care and linking with both
patient and GP. The original version of this was the consultation-liaison model which
involved a process of ‘mutual learning’ between GP and psychiatrist, psychologist or
other person with specialised knowledge and skills. In the replacement model, the
other professional takes full responsibility for providing the specific treatment or
care. Some refinements of the replacement model include: providing simplified
psychological therapies, self-help, and group treatment and education.
From the mid-nineties, there continued to be significant reforms in the National
Health Service that particularly affected primary care, and along with these came a
new focus on integrated care. Integrated care has a variety of meanings, but broadly
speaking includes attempts to bring together organisations and professionals who
work at the same level in the care hierarchy (horizontal integration), and those who
work at different levels in the care hierarchy (vertical integration) (England & Lester,
2005). It also refers to the integration of the different aspects of care of an individual
with multiple health needs, such as both physical and mental health problems,
although the focus in the UK was mainly on integrating primary and secondary care
for people with severe and enduring, and common mental disorders.
The most recent major development in PMHC in the UK was the Improving Access to
Psychological Therapies programme, initiated in 2007 and aimed at providing
evidence-based treatments for people with depression and anxiety disorders. This
programme, to be rolled out over six years, required the training and recruitment of
over 3,000 new therapists and aspires to provide universal equal access to
personalised care offered by efficient and effective services (Department of Health,
2010). IAPT is configured as part of a stepped care model and assumes the existence
of linked support services (considered as offering ‘integrated care’) including
employment support, debt counselling and other social assistance, a link to a local
GP lead and the expectation of a strong connection to primary care for all patients,
bi-directional care pathways with mental health services, and discharge/onward
referral planning for all patients. A new mental health professional role has been
created – that of the Psychological Wellbeing Practitioner (PWP). The core task
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associated with this role is the delivery of evidence-based low-intensity psychological
interventions such as CBT based self-help, psycho-educational groups, and guided
self-help. Competency frameworks and training materials have been developed to
support this role, and practice standards require access to weekly supervision.
Evaluation of this approach is not yet available, but it was clear early on that the
massive increase in numbers of clinical psychologists was unaffordable.
Evolution of primary mental health care in the USA
In the USA (and to some extent Canada), mental health provision in primary care
settings developed somewhat differently largely due to the different arrangements
in service provision. Firstly, the health care system in the USA is highly fragmented
and complex. Secondly, there is no universal provision funded by the public purse
and, for mental health provision, there are major inequities in that health insurers do
not afford the access to mental health care that is the equivalent of access to
medical or surgical services. Thirdly, the widespread practice of mental health
service provision in the community (albeit specialist services) emerged in the US
prior to the UK.
A further key difference is that patients can access specialists directly: the GP, or
family physician, is not the universal gatekeeper to specialist services as in the UK
and New Zealand. Furthermore, because of the healthcare funding environment, the
USA has a longer history of active management of care provision at the level of
funding for treatment for individuals. For example, different professionals may be
funded to provide only specific aspects of care and treatment, and this is under the
control of health insurers and Health Maintenance Organisations (HMOs) who have
long been interested in integrated managed care, and who all offer programmes
with different features. Of interest here, variations of the collaborative care model in
PMHC have been used and studied for longer in the USA, usually in these managed
care settings (Gilbody, 2006).
Finally, the evolution of both mental health care and primary care in the USA has
been quite different to that in the UK and many other parts of the world. Of
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particular note in relation to psychiatry, the traditions of psychodynamic
psychotherapy (based largely on psychoanalysis) continued to be embedded in
mental health practice for longer than was the case in the UK. Possibly related to this
is that some sectors of the public have quite different expectations from mental
health care – for example, it is much more common for people to be in ‘therapy’ of
some sort, and sometimes for quite long periods, for what may be non-specific
problems. A further difference is that mental health care, including substance use
problems, is known as ‘behavioural health care’, and is regarded much more as a
specialist service delivered in specialist settings such as dedicated clinics.
Regarding primary care, in the USA this includes areas that in the UK and New
Zealand would be considered as areas of specialty practice, such as general internal
medicine, paediatrics and obstetrics & gynaecology.
These features of health care in the USA have led to a highly varied picture in current
provision for PMHC, especially at the detailed level. However, the key debate and
development has been around the notions of integrated and collaborative care. A
useful distinction between these is that in integrated care, mental health provision
occurs as part of primary care practice, and in collaborative care mental health is
delivered alongside and in cooperation with primary care (Strosahl, 1998). In the
former, patients experience the mental health care as a routine aspect of their
primary care, whereas in the latter, it would be experienced as receiving a service
from a specialist, even if they are working alongside the primary care clinician.
Integrated care, as interpreted in the USA, relies on four underlying concepts: the
idea of the ‘health care home’; the health care team, stepped care, and clinical
integration (Collins et al, 2010). These principles are interpreted in a variety of ways
among providers, so that there is significant heterogeneity in the actual delivery of
care.
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The World Health Organisation perspective on Primary Mental Health Care provision
The WHO mental health programme offers a useful high-level perspective from
which to consider developments in PMHC. The four core elements, determined in
the early 1990s, are: treatment of mental disorders; prevention of mental disorders
and substance-use problems; mental health promotion and the psychosocial aspects
of general health and development services. Although the programme encompasses
the whole of mental health care, it is clear that there is significant opportunity for
primary care to contribute, and in some regards, primary care is better placed to
deliver than other parts of the healthcare system. For example, primary care is
better placed to deliver mental health promotion than secondary mental health
care. However despite these broad aspirations, it has been observed that the
application of the goals of primary care mental health has become restricted to the
treatment of common mental disorders in many countries (Sartorius, 2009) –
including the UK, the US and arguably New Zealand.
Key points for considering PMHC in New Zealand
Because our system of specific funded provision for PMHC has only recently evolved,
we are in a good position to learn from the experience of other countries and adapt
approaches to our unique health system funding and structural arrangements. In the
past 15 years we have done a quick ‘catch-up’ in terms of producing our own
epidemiological data (from the MaGPIe study and later Te Rau Hinengaro). We are
also able to refer to the evaluated experience of the early PMHC initiatives rolled out
between 2004 and 2006.
Particular points we need to consider include: do we need to choose between
collaborative care and integrated care; given the funding model for NZ general
practice, which probably favours collaborative care, how would we interpret an
integrated care model; what is the breadth of coverage (i.e. clinical problems, extent
of overlap with social services etc.) most appropriate for the NZ setting given
existing service structures; what is our aspiration for the PMHC workforce and how
does that fit with existing health workforce planning; and what is the best balance
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between central prescription of services and local interpretation of high level
policies?
Taking a service user perspective ought to be a cornerstone to the development of
PMHC in New Zealand, as it should be with all health services, yet it is challenging to
build this into routine working and strategic planning for primary care. Possible
reasons for this include: high demands on time at the clinical coalface, lack of clarity
about who can best represent service user views and values in PMHC, and lack of
prioritisation of this in the complex funding environment of primary care services.
It is likely that there will be future developments using both integrated and
collaborative care models. The final configuration is likely to be moderated by
ongoing budgetary constraints. In the NZ context there is unlikely to be any viable
alternatives to having the GP as the focal point of care because existing co-payment
models are likely to remain for the foreseeable future.
Policy context
In the past ten years there has been significant policy activity in New Zealand
focussed on the role of primary care in improving the health of populations. The
Primary Health Care Strategy released in 2001 defined primary care for New Zealand
as a central function of New Zealand’s health system, being universally accessible to
people in their communities for first contact with the health system and inclusive of
community participation. The vision was a ten year evolution in which primary
health care would become better focussed on the health of the population, and
contributed to a reduction in social inequalities in health. Funding was to be based
on population need rather than fees for service. This saw the establishment of
Primary Health Organisations (PHOs) which were new entities intended to enact the
policy vision. The PHOs developed from Independent Practice Associations (IPAs),
not-for-profit organisations such as those linked to Healthcare Aotearoa, and some
smaller organisations, some of which were iwi-based. One consequence of this
diversity has been marked variation in philosophical approaches, rates of
development, and mental health capacity and capability (Dowell et al, 2009).
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In 2003, the Ministry of Health obtained funding for specific provision for primary
mental health care (PMHC). Prior to this funding for mental health and illness had
been directed at those with severe and enduring illnesses, nominally 3% of the
population, with significant funding injections following a major Inquiry in the mid-
1990s. The target population for the new PMHC initiatives was those with ‘mild-
moderate’ mental disorders, a nominal 17% of the population at any time.
The aims of these new initiatives were to: develop prevention, early intervention and
treatment activities that would reduce the prevalence of common mental disorders;
develop PMHC workforce capacity and capability; and build effective links with other
mental health care providers, especially but not solely secondary care, so that
primary care could become an effective coordinator of care for people with enduring
disorders.
In 2004, Counties-Manukau DHB was contracted by the Ministry of Health to develop
a Toolkit to support service development in PMHC (Ministry of Health, 2004). This
Toolkit was intended as a ‘first edition’ focussing on the establishment of new
services, but to our knowledge has not been updated. A number of the new primary
mental health initiatives used this Toolkit in their service development work.
Following the formal evaluation of the first wave of initiatives (Dowell, Garrett,
Collings et al, 2009), PMHC was rolled out across New Zealand supported by funding
of $22.5 million.
In 2005, the New Zealand mental health action plan Te Tahuhu – Improving Mental
Health 2005-2015 highlighted developing PMHC as one of the leading challenges for
mental health care (Ministry of Health, 2005a).
The emergence of the ‘Better, Sooner, More Convenient Primary Care’ as part of the
new Government’s health priorities means expectations for more devolution of care
to primary care settings, stronger support for self-care, and better integration
between primary and secondary services. This new environment provides important
opportunities as well as challenges for the enhancement and improved reach of
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PMHC, for example, to include substance use problems and younger and older
people. The report Towards optimal primary mental health care in the new primary
care environment: a draft guidance paper (Ministry of Health, 2009) sets out thirteen
key areas of focus for ongoing PMHC development, some of which have emerged
from sector experience in rolling out the initiatives.
A recent paper produced by the National Health Board, Trends in service designs and
new models of care: a review (Ministry of Health, 2010) identifies key pressures
affecting health systems in New Zealand and worldwide. It suggests that trends
towards home-based service delivery, improved integration between parts of the
health sector and strengthening primary care will be more widely adopted in New
Zealand. If this re-orientation of health services skilfully includes consideration of
mental health, it represents a major opportunity to further refine PMHC.
Whānau Ora
In June 2009, the Whānau Ora Taskforce was established with the aim of developing
a policy framework for multiple government agencies to work together with whānau
and families to achieve better outcomes. Whānau Ora focuses on whānau identifying
their own strengths and priorities, and actively participating in the process to solve
the issues that they have identified (Te Puni Kōkiri, 2010). The framework is
underpinned by six goals – whānau are: “self-managing; living healthy lifestyles;
participating fully in society; confidently participating in Te Ao Māori; economically
secure and successfully involved in wealth creation; and cohesive, resilient and
nurturing (Durie et al, 2010, p. 7).
At the time of writing, 130 expressions of interest had been received from 350
providers from around New Zealand (Te Puni Kōkiri, 2010). Of these, forty percent
were from collectives comprising national and regional providers. The providers
were a mix of Māori, Pacific, disability and refugee and migrant organisations.
Chosen providers will work to develop a Programme of Action, which addresses the
“infrastructure needs; workforce training and development needs; a process for
integrating contracts; the development of an outcomes framework and an agreed
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action research, evaluation and monitoring plan” required to provide whānau-
centred services (Te Puni Kōkiri, 2010, p. 2). Further development work will occur in
2011 with the providers implementing priority plans, building relationships and
aiming to achieve the best outcomes for whānau and families in need (Te Puni Kōkiri,
2010).
As specific Whānau Ora programmes are yet to be rolled out, at this stage, we are
unable to provide more detail about this. However, it is clearly a potentially
important development of major scale and high relevance to PMHC for Māori and, in
some cases, non-Māori. One of the key attributes of the Whānau Ora programme is
that it puts the social context of the person and their whānau in the foreground of
consideration of their issues. Giving priority to the relevance of context is an
important aspect of mental health practice which is commonly neglected as services
come under increasing pressure. Whānau Ora programmes are an opportunity to
embed this into PMHC practice so that it becomes the norm. This approach is
entirely consistent with the general philosophy of primary health care.
The interface between primary and secondary care
History and context
In the past, the Western model for health systems was constructed around a distinct
boundary between primary and secondary care. Where primary care was the first
point of contact with health services, it was also very clearly the ‘gate’ to secondary
services, a gate which could be opened or closed by the primary care doctor. In the
early years of the split, secondary care was most commonly offered in hospital. This
boundary also delineated a difference between medical practitioners, whereby
primary care doctors were ‘general practitioners’ and secondary care doctors were
experts in a particular area of work (‘specialists’). In earlier times this was mostly
related to specific skills especially those required for surgical procedures. This strict
approach to boundaries was also reflected in very rigid role demarcation between
other health professionals, particularly medical practitioners and nurses. In this
context, primary care has always addressed common mental health problems, as
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part of the continuity of care that made a therapeutic doctor-patient relationship
possible.
In mental health, specialist care in the community in the form of psychiatric
outpatient clinics to ensure people continued with treatments to reduce the
liklihood of relapse, was offered as early as the 18th century in the UK (which system
was the origin of the New Zealand mental health service). By the beginning of the
20th century, one of the main purposes of this service was to triage cases for eligiblity
to receive treatment in one of the many asylums that were being developed at that
time (Killaspy, 2006), and mental health care was becoming synonymous with what
psychiatrists did. From the 1960s onwards, it was becoming clear that the main
purpose of psychiatric outpatient clinics was again to provide care for people with
severe and enduring mental illnesses such as schizophrenia, and also to assess (but
not necessarily treat) people with common mental disorders, as referrrals from GPs
(Killaspy, 2006).
Strategies to improve links between primary and secondary mental health care were
well under way in the UK by the 1970s, with the establishment of primary care
liaison clinics (Strathdee & Williams, 1984) varying in form from a ‘shifted outpatient’
model, consultation/liaison, to ‘shared care’ and clinical collaboration. Apart from
the genuine clinical collaboration approach, these have generally been described in
another context as ‘divided functions’ models (Bateman & Tyrer; 2004) where the
psychiatrist or other mental health professional provided the mental health care and
the GP oversaw physical health issues. In New Zealand these changes were slower to
evolve, partly because there was no financial compensation for the additional time
required in primary care to provide for people with mental health problems (MaGPIe
Research Group, 2005).
The current situation
Currently, community mental health teams across New Zealand offer a variety of
forms of liason and collaboration with primary care, for the care of both people with
severe and enduring mental disorders and those with common mental disorders. For
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most people with severe and enduring mental disorders the predominant approach
is the divided functions model, and although there is an increasing degree of
collboration, with psychiatrists doing clinics in GP surgeries for example, this
collaboration is still largely based on the assumption that the transfer of specialist
knowledge is the critical element. For the common mental disorders, although
services can now be accessed via primary care mental health services, the mental
health care is still most often provided by a ‘specialist’ (i.e counsellor or therapist) in
the community but outside the practice and to whom the service user has to be
referred (Dowell, Garrett, Collings et al, 2009). The earlier strict boundary between
primary and secondary provision has been further blurred by services such as ‘Youth
one-stop-shops’ and early intervention services that are primary care (i.e. first point
of entry to the health system) but offer specialist expertise.
Until relatively recently, the boundary between primary and secondary mental
health care was to a large extent accepted as a ‘given’, even where professionals
were working side-by-side from time to time. In the New Zealand setting this
acceptance was driven by factors on both sides. Like all professional groupings,
psychiatry had a vested interest in maintaining its status as the ‘specialty’ holder of
the important knowledge and skills (Hafferty & Light, 1995)1, and primary care had
no incentive to enhance its knowledge and skill and expand its activity in the area
because there was no mechanism for adquate payment for the work. Alongside this,
many primary care practitioners had stigmatising attitudes towards people with
mental disorders (Handiside, 2004; Peterson, Pere et al, 2004). Systemic issues such
as the difficulty in accessing specialist services in a timely way, poor or no
communication back to the GP, the tendency of secondary services to accumulate
patients and hold them in the service for long periods (Dew et al, 2005; Killaspy,
2006) and a progressive ‘deskilling’ effect on GPs all contributed to the divide. In
addition clinicians of any kind tend to be reluctant to change from their familiar
models of working (Niroshan Siriwardena, 2009).
1 Also see earlier discussion of the development of primary mental health care
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In New Zealand, the increase in interaction between secondary mental health
services and primary care was initially driven by the need to reduce the burden on
secondary care. This has converged with our greatly improved understanding of the
nature and extent of mental health problems present in primary care practice,
(MaGPIe Research Group, 2003, 2004, 2005, 2006; Collings et al, 2005), the public
demand for access to evidence-based treatment for common mental disorders
which has followed from improved mental health literacy in the population, and,
despite the dearth of New Zealand research on the topic, the urgency with which we
must address the problem of the poor physical healthcare often experienced by
people with mental health problems (Miller et al, 2006).
The nature of the boundary
Although the boundary has been defined by service structures and funding
arrangements, its maintenance was, logically, entirely driven by professionals –at
clinical, managerial and policy levels. The existence of the boundary over a significant
period of time meant that the cultures of psychiatric and general practice evolved
independently and without opportunity or desire for communication or cross-
fertilisation. Until recently, the belief that GPs knew little about mental health
problems, and commonly failed to diagnose and treat them, was pervasive, and
propagated by both psychiatric research literature (MaGPIe Research Group, 2005a)
and some GPs themselves. The stronger this belief, the less there appeared a need
for either party to get to know the perspective of the opposite group of
professionals.
The implication of this is that because the boundary is largely maintained by the
historical patterns of relationships, supported by accepted scopes of professional
practice, funding and organisational structures, then the existing boundaries are not
immutable, transforming the interface is possible; with the right incentives, policy
support and opportunities to develop new working relationships and new ways of
working.
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Māori mental health
Uia mai koe, he aha te mea nui o te ao? Maku e kii atu, he tangata!
"You ask, what is the most important thing in the world? My response is people!"
Māori health
Having optimal health status has been described a state of complete physical,
mental and social wellbeing, rather than just being free of illness (WHO, 1978). In the
case of Māori, the indigenous people or tangata whenua of Aotearoa, New Zealand,
this means achieving highest health and wellbeing in all facets of life (Durie, 1998).
The 2006 Census recorded 565,329 people self-identifying as Māori (Statistics New
Zealand, 2007). In the past 15 years, the Māori population in New Zealand has
increased by 30% (Statistics New Zealand, 2007). About 53% of the total Māori
population identified Māori as their sole ethnicity; of the remainder 42.2% identified
with European ethic groups, 7% with Pacific ethic groups, 1.5% with Asian ethnic
groups and 2.3% listed New Zealander as one of their ethnic groups (Statistics New
Zealand, 2007).
Historically, Māori have been exposed to the effects of colonisation which resulted in
a wide range of negative effects (Reid, 2007). They have also gained sovereignty
after the signing of the Treaty of Waitangi in 1840 by a number of tribal leaders and
representatives of Queen Victoria (Dyall, 1997). The Treaty was designed to “provide
protection and to promote the wellbeing of tangata whenua” by according “rights
and responsibilities to Māori, both individually and collectively, and to the Crown
(Dyall, 1997, p.85). Underlying the Treaty are three key principles; namely,
participation, protection and partnership which are crucial when working with
Māori.
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Māori mental health context
Until recently, there has been a paucity of data on the prevalence of mental health
disorders among Māori. The first national mental health epidemiological study, Te
Rau Hinengaro, The New Zealand Mental Health Survey has provided reliable
estimates of the mental illness prevalence rates for Māori and other ethnic groups in
New Zealand (Ministry of Health, 2008).
Te Rau Hinengaro sampled 2,595 Māori from a wide range of demographic, social,
economic and cultural backgrounds (Baxter et al, 2006). Analysis of Te Rau
Hinengaro data revealed that the prevalence of mental disorders in Māori was 50.7%
over their lifetime (Baxter et al, 2006). The most common lifetime disorders among
Māori were anxiety disorders (31.3%) followed by substance use disorders (26.5%)
and mood disorders (24.3%) (Baxter et al, 2006). Māori aged 25-44 had the highest
lifetime prevalence of any disorder while the lowest was in those aged 65 and over
(Baxter et al, 2006).
For Māori diagnosed with any 12-month disorder, about 33% had had some contact
with health service providers: about 15% had seen mental health specialist services,
20% had visited general medical services and the remaining 9% had had contact with
non-healthcare providers (Baxter et al, 2006). Māori were more likely to present to
health services when their illness has progressed to more advanced stages; nearly
50% of Māori diagnosed with serious disorder had had some contact with services
compared to about 25% of those with moderate and 15% with mild disorders (Baxter
et al, 2006).
The state of Māori mental health as it currently stands is summarised by Durie (1999,
p. 6):
“[In 1897] tuberculosis, pneumonia, malnutrition were the substantive causes
of suffering and death. Today, cancer, motor-vehicle accidents and heart
disease fill similar roles. But there is also evidence that, although loss of life is
less dramatic, the greatest threat to good health for Māori is now poor
mental health.”
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Therefore, while the availability of robust data has generated more reliable
prevalence rates and a better understanding of Māori mental health status, there
still exists the next question: what should be done, and how should it be done? To
answer these questions, we need to look at how mental health is viewed by Māori
and what factors need to be considered when working with Māori with experiences
of mental illness.
Māori perspectives on mental health and wellbeing
Maori are a diverse people and individuals’ cultural identity is expressed in a range of
ways in day-to-day life. This diversity extends to understandings of mental health
and illness, and the preferences of Maori regarding support and treatment for
mental health problems.
Culture and ethnicity play key roles in the way Māori view health and Māori
wellbeing is inextricably linked to historical, economic, social, spiritual and cultural
factors (Dyall, 1997; Durie, 1998). For Māori, secure cultural identity is dependent on
not only being able to identify as Māori but also having effective access to
participation in society, e.g. taking part in activities with whānau and on the marae,
access to ancestral lands and contact with other Māori (Durie, 1997). Cultural
identity also requires being able to express one’s culture safely and having it
endorsed within institutions such as health services (Durie, 2001).
Maori mental health & primary care
To address the increasing prevalence of mental disorders, the Primary Mental Health
Initiatives (PMHI) were developed (Dowell et al, 2009). The initiatives were intended
to be demonstration projects, and in recognition of the limited funding available and
disparities in access to care, they were targeted at known high-needs groups with a
focus on Māori, Pacific and low-income populations (Dowell et al, 2009).
The PMHI were evaluated between June 2005 and November 2007 (Dowell et al,
2009). One of its main aims was to identify the effectiveness of mental health
services to Māori and gain a better understanding of the experiences and needs of
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Māori service users using the PMHIs (Dowell et al, 2009). The evaluation found that
Māori service users had been involved with multiple services and most were
uncertain about how they initially made contact with the PMHI (Dowell et al, 2009).
This included not knowing who referred them and the main reasons for them
interacting with the PMHI (Dowell et al, 2009). Referrals to the PMHI were either
directly or indirectly through a GP although most Māori service users did not report
having a strong supportive relationship with their GP (Dowell et al, 2009).
At time of initial contact with the PMHI, Māori service users experienced multiple
stressors such as death in the whānau, co-morbidity and sexual abuse, which meant
they required considerable support and access to holistic services (Dowell et al,
2009). This raised significant implications for the needs of the service users versus
the way the services were funded and delivered (Dowell et al, 2009). The evaluation
found that despite receiving siloed-style funding, the Māori mental health service
providers delivered holistic services which met the needs of the services users
(Dowell et al, 2009).
The service users felt it was important that Māori service providers had a Māori
understanding of health and wellbeing; was tikanga-based; and worked with whānau
(Dowell et al, 2009). This helped them heal holistically, and build stronger
relationships and gain a better understanding of issues (Dowell et al, 2009). The
evaluation found that while the Māori service users were in contact with the PMHIs,
they did not use any secondary mental health services or specialists.
Kaupapa Māori-informed models
Several models have been proposed by health experts that aim to capture Māori
holistic perspectives on mental health and well being. These include the ‘Te Whare
Tapa Wha’ model (Durie, 1998). It ascribes good health to the four cornerstones of a
house: te taha tinana (physical wellbeing), te taha wairua (spiritual wellbeing), te
taha hinengaro (mental wellbeing) and te taha whānau (family wellbeing) (Durie,
1998).
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The evaluation of Primary Mental Health Initiatives (PMHI) included a revealed that
the ‘Te Whare Tapa Wha’ model was the main kaupapa Māori-based framework
used by mental health services. This was followed by the Dynamic of
whanaungatanga model, which focuses on supporting whānau and the Tikanga
model, which is regarded as the binding essence of the conduct of daily life (Dowell
et al, 2009).
Each of these models consists of fundamental elements which combined, ensure
optimal health and wellbeing. A weakness in one or more of these components is
believed to result in illness. To work effectively with Māori, health professionals
need to understand and apply such models when developing interventions and
treatment plans. Support for such models and a holistic approach has been
repeatedly demonstrated by Māori services users and whānau alike (e.g. Fenton &
Koutua, 2000).
Pictorial development of Te Whare Tapa Whā
Figure 2.2 The wharenui provides the foundations for Māori health (adapted from:
Ministry of Health, 2003, p.17).
Rangatiratanga
Whānau ngatanga Manaakitanga
Whakamana
Tangata Whenua Taurahere
Mana
Kotahitanga
Kaupapa Māori
Wairuatanga
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Position on the wharenui:
Ātea Whānau /hapū Family, extended family unit
Amo Tangata whenua
Taurahere
Local people, tribal members
Those who whakapapa to
other areas
Maihi Manaakitanga
Whakamana
Rangatiratanga
Whānau ngatanga
Value, respect, accept,
support, guide, motivate,
deliver and host
Enable, empower, build
confidence
and understanding
Lead with confidence and
integrity
Partnering, networking,
information sharing, service
co-ordination and shared
kaupapa
Pouporuru Kaupapa Māori
Wairuatanga
Tikanga, Māori values,
Māori for Māori
Cosmic principles and
spirituality
Tekoteko Mana Transparency, integrity and
professionalism
Tāhuhu Kotahitanga Working together, holistic in
nature, shared kaupapa,
unified approaches
Wisdom and knowledge of
the tupuna lies in this part of
the marae
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Factors critical to Māori mental health
The following factors have been identified as recovery aids and barriers for Māori
mental health (adapted from Fenton & Kautua, 2000, Malo, 2000 & Ministry of
Health, 2004).
Recovery aides Barriers
Family/community understanding of mental illness and support
Lack of understanding by communities and families
Being treated with dignity and respect
Discrimination
Involvement of Māori clients and families in design and delivery of interventions
Lack of knowledge within whānau of mental health
Faith and spirituality
Cultural stigma of having mental illness
Personal strength to overcome adversity of mental health experience
Lack of self-help information, especially in early stages of illness
Effective strategies for overcoming language and cultural barriers
Cultural inequality and misunderstanding
Community-oriented services
Ineffective and uninspiring services
Supportive staff who are invested in their clients’ recovery
Lack of care and support from staff
Kaupapa Māori services Authoritarian services that reinforce dependence
Māori mental health workforce
Staff prejudice and stereotyping of Māori
Correct medications and treatments Side-effects of medication and/or ineffective, damaging therapies
Ability to work in the mental health sector as a consumer advisor etc without discrimination
Exclusion by whānau and community
Kotahitanga
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Addressing significant issues for Māori in mental health
There are a range of significant issues for Māori when it comes to mental health
(Fenton, 2000; Malo, 2000; Ministry of Health, 2004). To address these issues and
achieve better outcomes for Māori we need to:
Ensure Māori can effectively access the services they need without fear of
stigma and discrimination. This may help Māori present earlier to health
services so that mental disorders can be treated before becoming severe.
Ensure that there are processes, care planning, and treatment protocols in
use for Māori, which meet their cultural requirements and incorporate the
components of Māori models of health at each step of the clinical pathway,
namely, referral; assessment; treatment planning; treatment intervention;
discharge; and follow-up. This will improve the likelihood of Māori adhering
to their treatment plans.
Practice whānau ngatanga, so that whānau are included in the decision-
making process from assessment through to discharge planning. Whānau
are regarded as the foundation of wellbeing and the main source of
“strength, support, security and identity” (Ministry of Health, 2002). As one
of the cornerstones of a person's health, whānau need to be an integral
part of the person's journey towards recovery.
Work to the principles of the Treaty by forging sustainable links with Māori,
iwi and health providers in their regions.
Ensure that Māori can safely participate in service planning, development,
and monitoring processes such that this participation is encouraged,
supported, and incorporated into decision making for Māori clients.
Implement a continuous quality improvement strategy which includes
measures and tools developed by and administered by Māori and that
there are viable targets set for improvement of Māori and whānau
satisfaction.
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Pacific Peoples’ mental health
New Zealand’s “Pacific Peoples”
The Pacific population is one of the fastest growing sub-groups in New Zealand
(Cook, 1999). The 2006 Census recorded 265,974 people of Pacific ethnicity in New
Zealand, comprising 6.9% of the population (Statistics New Zealand, 2006). Of this,
Samoans comprised the largest group at 49%, Cook Island Maori at 22%, Tongans at
19%, Niueans at 8%, Fijians at 4%, Tokelauans at 3% and Tuvaluans at 1% (Statistics
New Zealand, 2006). Each ethnic group is distinct in language, culture and customs.
Originally, people from the Pacific Islands identified themselves with reference to
their connections with their extended family, village, atoll or island (Asiaisiga,
Falanitule, Tu’itahi, & Guttenbeil, undated). The term “Pacific peoples” was ascribed
to Pacific Islanders when they arrived in New Zealand. It was coined through the use
of a pan identity group construct to acknowledge and emphasize the multitude of
ethnic groups represented in the Pacific Islands (Asiaisiga et al, undated; Anae, 1998;
Health Research Council, 2005).
The popularity of New Zealand as a destination grew in the 1960s due to its
proximity to the Pacific Islands and the high demands for labour following substantial
economic growth (Meleisea, 1998; Bedford, 2001). However, despite these
economic opportunities, Pacific peoples have remained disadvantaged in their
socioeconomic status and over-represented in several negative social and health
outcomes (Bathgate et al, 1994; Statistics New Zealand, 2002). They have also been
identified as the population group most at-risk of adverse health and social
outcomes in New Zealand (Koloto, 2005). One of these outcomes is in the area of
mental health.
Pacific mental health in NZ
Historically, there has been a paucity of data on the prevalence of mental health
disorders in Pacific peoples based in New Zealand. The sample of Pacific peoples in
the mental health surveys carried out in New Zealand prior to 2006 was too small.
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Consequently, it was difficult to generate reliable prevalence estimates (Oakley
Browne et al, 1989). One particular avenue that provided some statistical
information was mental health institutions; however these tended to underestimate
the prevalence of mental health issues in Pacific peoples (Ministry of Health, 1997).
Another avenue was using Pacific admission rates to mental health services to
determine prevalence. This however, was also a poor measure since ethnicity was
not recorded sufficiently well enough, resulting in undercounting (Ministry of Health
2008). A further consequence of this was the perception that Pacific peoples use
mental health services much less compared to other ethnic groups (Ministry of
Health, 2008).
When compared nationally, these statistics suggested that the prevalence rates of
mental illness in Pacific populations were mostly low (Allen, 1997; Ministry of Health,
2005). These findings had repercussions for Pacific peoples – it reinforced existing
views that compared to other ethnic groups, Pacific peoples experienced much lower
rates of mental illness, and Pacific peoples may be resistant to the effects of multiple
stress factors that act as precursors to mental illness (Graves, 1985; Ministry of
Health, 2005).
It wasn’t until the first national mental health epidemiological study, Te Rau
Hinengaro, was conducted that reliable estimates of the mental illness prevalence
rates for Pacific peoples and other ethnic groups were identified (Ministry of Health,
2008). To ensure more robust data was obtained, Pacific peoples were significantly
oversampled (Oakley Browne et al, 2006). Based on the findings from Te Rau
Hinengaro, many of the historical assumptions made about Pacific mental health
prevalence were proven incorrect.
The Pacific Mental Health Context
Analysis of the Te Rau Hinengaro data revealed that the burden of mental health
disorders was high in Pacific peoples, with 25% Pacific peoples experiencing mental
health disorders compared to 20.7% of the general population (Foliaki et al, 2006;
Suaalii-Sauni et al, 2009). Nearly half of Pacific peoples (46.5%) had had some
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experience of mental illness in their lifetime (Foliaki et al, 2006). Further, only 25% of
Pacific peoples who had been diagnosed with a serious mental illness accessed
mental health services (Foliaki et al, 2006).
Suicide and suicidal behaviours are of growing concern in Pacific peoples, particularly
those aged 16-24 years (Ministry of Health, 2008). This age group has been identified
as having highest rates of suicide planning and suicidal attempts (Oakley Browne et
al, 2006). Rates of completed suicides have been somewhat difficult to study given
statistically small numbers (Ministry of Health, 2008). There is some evidence
however, that the rate for completed suicides for Pacific populations in New Zealand
is 8.3 per 100,000 compared to New Zealand’s overall rate of 14 per 100,000
(Ministry of Health 2006). Again of particular concern are the Pacific youth aged 15-
19 years, whose suicide completion rates are 16 per 100,000 compared to 8.3 per
100,000 for Pacific peoples of all ages (Ministry of Health 2005b).
Studies investigating the breakdown of major mental disorders among Pacific
peoples have identified that Pacific peoples suffer from high rates of schizophrenia,
paranoia and acute psychotic disorders, which account for 66% of episodes
compared to 48% of the overall population (Pulotu-Endemann et al, 2004). Pacific
peoples have also been found to have the highest average cost of adult inpatient and
community episodes; being 25% above the national average for inpatient episodes
and 44% above the national average for community episodes (Pulotu-Endemann et
al, 2004). Additionally, although Pacific peoples comprise 6.9% of the population in
New Zealand, they make up 12% of all involuntary inpatient mental health users
(Pulotu-Endemann, 2004).
The state of Pacific mental health as it currently stands is summarised by Mila-Schaaf
& Hudson (2009, p. 10):
“The combination of having a higher burden of mental illness, particularly in
the area of serious mental illness, with high rates of involuntary, forensic and
acute admissions, low or late presentation to services which – once accessed –
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involve the longest and most costly stays - establishes a fairly bleak vista of
the state of Pacific peoples’ mental health in New Zealand”.
Therefore, while the availability of robust data have allowed more reliable
prevalence rates and a better understanding of Pacific peoples’ mental health, there
still exists the next question: what should be done, and how should it be done. To
answer these questions, we need to look at how mental health is viewed by Pacific
peoples and what factors need to be considered when working with Pacific peoples
with experiences of mental illness.
Pacific perspectives on mental health and wellbeing
Mental health is viewed by Pacific peoples as being inherently bound to their holistic
view of health (Bathgate, 1997). Traditionally, mental illness has been considered by
Pacific peoples to be a spiritual possession caused by some breach of the sacred
covenant between the person and their ancestral spirits or god (Agnew et al, 2004).
Consequently, traditional healers are approached to restore the spiritual balance
(Suaalii-Sauni et al, 2009).
Several models of care have been proposed by Pacific health experts that aim to
capture Pacific peoples’ holistic perspectives on mental health and well being
(Agnew et al, 2004). These include: the Fonofale model, which uses a Samoan fale or
house framework (Pulotu-Endeman, 2004); the Pandanus Mat model, which revolves
around the concept of inter-weaving the key elements of a person’s life together to
achieve good health (Agnew et al, 2004); and the traditional healing treatment
model, which refers to the work of traditional healers and its link to ancestral spirits
(Agnew et al, 2004). Each of these models consists of fundamental elements which
combined, ensure optimal health and wellbeing. Mental illness is believed to occur
when one or more of these basic elements are out of balance.
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Factors critical to Pacific mental health
The table below summarises the environmental risk and protective factors that have
been identified for mental health
(adapted from Bathgate & Pulotu-Endemann, 1997, p.109).
Protective factors Risk factors
Support networks and cultural expression Weakened support networks and cultural expression
Family support Lack of family support
Community (culture bound support) Lack of community support
Awareness and esteem of own culture Lack of awareness and esteem
Involvement in activities of own culture Lack of involvement in own culture
Self-esteem and lack of discrimination Lack of self-esteem and presence of
discrimination
Exercise of authority, leadership & decisions
being recognised
Lack of strong leadership or recognition of
authority
Parenting – two parents and extended family
life
Parenting – solo and/or no extended family
support
Parenting supportive and confident of
transition to or balance of Western and
traditional perspectives
Parenting is not supportive or confident
about negotiating Western and traditional
perspectives and expectations
Safe and secure environment Insecure – violence in the home (physical,
verbal)
Successful adaptation and co-existence
between Western and traditional culture,
mores and behaviours
Confusion about acceptable and appropriate
cultural mores and behaviours. Discomfort
with bicultural environment.
Economic security Economic insecurity
Adequate housing Overcrowding, poor quality housing
Satisfactory employment Unemployment or lack of satisfactory job
Adequate income to support family and
meet church and social obligations
Inadequate income to support family and
meet church and social obligations
Absence of substance use Presence of substance abuse
Nil or minimal use of alcohol Excessive use of alcohol
Avoidance of illicit drugs Use of illicit drugs
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Role of families
For Pacific peoples, families and communities play a unique and important role in
their lives. In traditional Pacific Island communities, the family forms “the most
important social unit” (Cribb, 1999). Unlike the ‘typical’ European way of living,
emphasis is placed on the extended family and there is a significant amount of
interaction between family members (Davey, 1993). The family is viewed as a
cohesive unit whose strength depends on the collective efforts of all members rather
than the efforts of an individual (Baker et al, 1986).
In New Zealand, Pacific Island migrants have had to forge new relationships and
reshape existing ones (Mitaera, 1997, as cited in Asiaisiga et al, undated). In doing so,
they try and retain their connection with their place of origin and act as a link to their
cultural traditions for children born and raised in New Zealand. Consequently, the
perceptions of these children of life “back home” are based largely on the
interpretations of their migrant family (Asiaisiga et al, undated).
Family and community support have been identified as perhaps the most crucial to
help the recovery of Pacific peoples from mental illness (Malo, 2000). For example,
the presence of both parents and the extended family are regarded as protective
environmental factors for the mental health of Pacific peoples since it can allow
individuals to experience supportive parenting and find a balance between
traditional and Western perspectives. Solo parenting and/or lack of family support is
believed to elicit the opposite results (Bathgate, 1997).
Access to mental health services
A number of reasons have been identified for Pacific peoples’ poor access to mental
health services (Ministry of Health, 2004). These include:
• Affordability, given the cost of services
• Transportation difficulties, especially for low income populations
• Language barriers, particularly communicating and understanding medical
concepts if English is a second language
• Unmet needs, despite visiting a health provider
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• Lack of knowledge of where mental health services are located
• Lack of clear pathways for access to GP or PHO mental health services
• Perceived and real stigma and discrimination associated with mental illness
• Culturally insensitive/inappropriate mental health services
To address such issues, there is a clear need to ensure sound links are established
between primary and secondary mental health services. Despite this linking,
however, Pacific peoples may still present late to mental health services and be in
acute or crisis stages (Ministry of Health, 2004). Alternatively, their presentation to
health services may be for non-mental health chronic conditions (e.g. diabetes),
where their mental illness is not identified (Ministry of Health, 2004). To overcome
these types of challenges, Pacific mental health organisations, run by Pacific staff
may be highly beneficial. Consultation with Pacific peoples has found that they more
easily identify with culturally competent Pacific staff and find it more comfortable
and easier to communicate in their own language when explaining mental health
issues (Malo, 2000; Ministry of Health, 2004).
Addressing significant issues for Pacific peoples in mental health
There are a range of significant issues for Pacific peoples when it comes to mental
health (Malo, 2000; Ministry of Health, 2004; Pulotu-Endemann, 2004). To address
these issues and achieve better outcomes for Pacific peoples we need to:
Address the range of barriers to Pacific peoples accessing mental health
services. These could include establishing and maintaining better links
between primary and secondary mental health services, developing new
access points such as churches and community health groups, and working
with Pacific families to provide mental health care, where appropriate.
Work closely with Pacific communities to promote mental health and de-
stigmatise mental health issues. Pacific peoples have identified that they
experience stigma within their communities plus find that there is a lack of
understanding within mental health services.
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Ensure mental health staff are culturally aware that they understand the link
between mental health and cultural identity, and are able to effectively use
holistic Pacific models of care. Ongoing training may need to be organised
with input from Pacific cultural advisors.
Provide a choice of services for Pacific peoples where possible. Pacific
peoples have indicated that they prefer dealing with Pacific health workers or
those who are culturally competent. Working with existing Pacific mental
health providers will help tap into existing professional Pacific health
expertise. Ensuring adequate workforce development opportunities are
provided to Pacific staff will also help retain and also up skill the existing
knowledge base and experience.
Undertake robust research to improve the service responsiveness of Pacific
mental health services to meet the needs of Pacific populations. This area is
currently under-researched and the existing tools, approaches, roles, policies
and frameworks have not been empirically validated, supported or improved.
There is an imminent need to identify the factors critical to achieving
successful, responsive mental health services for Pacific peoples.
Asian peoples’ mental health
Asian people, mainly of Indian and Chinese heritage, have immigrated in significant
numbers since the early days of European settlement, but over the past twenty years
the rate and diversity has increased enormously. Asian people made up 10% of the
population in 2006 with a projection for 13% in 2016 and 16.6% in 2026, with the
increase made up mainly by inwards migration. Using the Statistics New Zealand
definition, they are a very diverse group, comprising at least 30 ethnic groups from
as far West as Afghanistan, and as far East as Japan (Rasanathan et al, 2006;
Statistics New Zealand, 2010). Among the ‘Indian’ group, itself diverse, 23% were
born in New Zealand, and among the Chinese group, 22% were born here. Many of
these people are 5th and 6th generation New Zealanders.
As an example of the diversity of those of Indian ethnic background, a significant
proportion of this group were born in Fiji. In addition to being a highly diverse group,
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the New Zealand Asian population is also highly mobile, with 58% of people of any
Asian background reporting moving within New Zealand in the previous five years
(Statistics New Zealand, 2010). Unlike other growing population groups such as
Maori and Pacific people, those of Asian background have lower fertility than the
whole-population average. In terms of socio-economic status, Asian people as a
group are evenly distributed across the spectrum as measured by the NZDep Index
(Salmond et al, 2004). Most Asian people live in one of the five main urban areas of
New Zealand (Ho et al, 2003).
In terms of general indicators of health status, too, the Asian population as a group
apparently fares well, with mortality rates on a par with the New Zealand population
as a whole (Ministry of Health, 2006b). However, there is significant variation in
health status within the group, with people of Indian background, for example,
having the highest rates in New Zealand for cardiovascular disease (Ministry of
Health, 2006). Asian people also use primary care services less than other population
groups (Scragg et al, 2005; Rasanathan et al, 2006; Ministry of Health 2006).
These population characteristics mean specific challenges for the provision of health
services, and mental health services in particular. Frequent moving means people
are more likely to have to find a new general practitioner and establish a trusting
relationship. Asian people who move face the additional burden of getting to know a
new neighbourhood, community and its resources. This is likely to be especially
difficult for those for whom English is a second language (Ho et al, 2000).
Within the population there are groups whose risk of mental health problems is
increased due to chronic physical illness such as cardiovascular disease and diabetes.
An additional challenge is that despite the growing population, the specific yet
diverse needs of Asian people are not yet a focus of interest for most health
professionals (Rasanathan et al, 2006) especially outside Auckland. Asian people face
other challenges too, such as labour market discrimination, with the associated
negative effects on mental health status (Wilson et al, 2005; Harris et al, 2006).
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Although there is huge diversity in the Asian group in terms of languages, religious
beliefs, social practices and understanding of health and illness, in regards to mental
health there are some broad commonalities that are shared to some extent within
and outside the ‘Asian’ grouping. These include: adaptation problems and difficulties;
barriers to mental health service utilisation; family separation and the importance of
traditional healing practices (Ho et al, 2000).
In addition, some have suffered traumatic experiences prior to or as part of the
immigration process, which can mean people suffer post-traumatic stress disorder,
depression or psychosomatic problems on or soon after arrival (Cheung, 1993, 1994).
People from some Asian cultures are more likely to express their psychological distress
via physical symptoms (Hsu & Folstein, 1997) - open displays of emotion may not be
socially acceptable as the need for family and social harmony outweighs the need of the
individual to express feelings.
Regarding adaptation, integration (taking on the new culture’s values while retaining
original ‘heritage identity’) is associated with the best mental health outcomes (Cheung
& Spears, 1995a&b), compared to marginalisation (loss of own culture with rejection by
dominant culture), assimilation (rejection of own culture) and separation (rejection of
the dominant culture) (Berry, 1997).
Usually the specific issues arising are shaped by particular practices and beliefs. Stigma is
an important barrier to accessing mental health services in both primary and secondary
care, because mental illness may bring shame to the family, but the specific beliefs
about mental illness that are associated with the stigma will vary: it may be that mental
illness is contagious, or that it is a punishment for wrongdoing.
Factors that make poor mental health more likely among Asian people coming to New
Zealand include: a drop in socio-economic status, inability to speak English, separation
from family, lack of warm and welcoming reception by the people living nearby or with
whom the person has to interact, isolation from people of a similar background, being a
teen or older person at the time of migration, and experiencing trauma before
migration. Conversely, protective factors include: family support, friendships, having
opportunities to speak the language of origin, and a perception of being welcome.
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One of the main barriers to health service use is inability to understand English, which
means that Asian people simply cannot find out about services. If family or community
members are used to interpret, there can be problems with privacy and perceptions of
appropriateness within the social hierarchy. Another barrier is that health professionals
may not have sufficient specific knowledge of the kinds of clinical presentations, modes
of communication and what behaviours are ‘normal’ or ‘abnormal’, for the particular
ethnic group the service user is from (Ngai, Latimer & Cheung, 2001).
Clearly the Asian grouping in New Zealand is so diverse that highly specific
recommendations for improving access to PMHC cannot be made. However, DHBs and
PHOs are able to become familiar with the Asian communities in their localities and
ensure that health professionals are supported to have the appropriate knowledge and
skills. Where possible interpreters should be made available; information provided in the
appropriate languages and systematic outreach made to local community agencies that
work with the groups, and to the communities themselves.
A focus on the mental health of children and young people
“E aku rangatira, he aha te mea nui o tenei ao? Maku e kii atu, he tamariki, he
tamariki, a taatou, tamariki.
Leaders, where does our future lie? In our children.” Dame Anne Salmond
The future health and well being of any country is dependent on the well being of its
children and young people. In New Zealand we have an image of children enjoying
good health and young people growing to mature and responsible adulthood. While
for a lot of families there is truth to this picture of ourselves, there is an alarming gap
to the reality for many children. New Zealand fares poorly in international child
health statistics with mental health issues being of particular concern. In youth and
adolescence, high levels of psychological disorders, suicide, teenage pregnancy and
substance abuse are creating a context in which many young people are unable to
reach adult life with security and confidence.
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Consideration of Child and Youth mental health should be one of the most important
elements in DHB and PHO strategic thinking and planning. Some reasons for this are:
The prevalence of child and youth mental health problems is high and
underestimated.
Recent developments in neuro-developmental research highlight the
importance of early psychological impacts on long term outcomes , both
psychological and physical
There is a strong long term economic argument for investing in child and
youth mental health in terms of future productivity.
These imperatives should translate into action and activities at primary care team
level. There is a good case for example to be made for routine enquiry about
psychological problems in adolescent consultations, due to the high prevalence of
disorder, associated serious morbidity such as attempted and completed suicide, and
evidence about the effectiveness of ‘screening’. Students report high levels of
suicidal thoughts (males 16.9%, females 29.2%), suicide attempts (males 4.7%,
females 10.6%), and depressive symptoms (males 8.9%, females 18.3%). 6. 12.4% of
young drinkers consume large amounts of alcohol at least once a week 7 and more
than one quarter of students (males 27.2%, females 27.6%) report riding in a car
driven by a potentially intoxicated driver within the last four weeks. Two thirds of
those suffering from depression also have further mental health morbidity. The use
of a structured "teenage consultation" using the HEADDSS mnemonic (Home,
Education / Employment/ Alcohol/ Drugs / Depression/ Smoking/ Sex) or something
similar can be challenging within a busy surgery, but may yield significant results.
There are evidenced based case finding tools which could help to further discussion
about mental health problems with children, adolescents and care givers following
initial cues within the consultation. The use of these tools such as the Strengths and
Difficulties Questionnaire (SDQ) 9 may be appropriate for paediatric use in the same
way that scales such as the Kessler K10 or PHQ can be used in adult practice.
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At the other end of the child age spectrum there is increasing evidence that the
greatest heath gains are to be made from improving health outcomes in the pre nine
months to three year age range. Ensuring that there is integration of maternity
services with primary mental health is important and a focus on early attachment
disorders and family mental health problems can improve mental health outcomes
in the pre-school years.
The development of better screening processes and identification tools for children
at the primary health care level will gain little if there are not also appropriate care
pathways available for referral and management. Currently secondary service
responses, particularly for child mental health and child/family attachment disorder
problems, are extremely limited in many parts of New Zealand. Better screening and
identification will come to very little without response and action.
Alcohol and drug issues
Substance use disorders and sub-threshold substance misuse are major problems in
New Zealand. Our society has had a high tolerance for the health and social risks
associated with alcohol consumption in particular. Te Rau Hinengaro revealed that
alcohol had been used in the previous 12 months by 79.1% of people, and other
drugs by 13.7%. Of those who had used alcohol, 1.6% were dependent and 3.3%
reported alcohol abuse as defined by the DSM system of diagnosis (Oakley-Browne
et al, 2006). These figures are probably underestimates associated with survey
design issues. They also do not acknowledge the significant health and social harms
caused by alcohol intoxication in particular, with a UK study showing that 23% of
adults used alcohol in a harmful way (Drummond et al, 2004). Of particular concerns
is the fact that in New Zealand, 75% of people who have a substance use disorder
will have it by the age of 24 (Wells et al, 2006). Furthermore, co-morbidity between
substance use problems and other mental health problems is high, with 40% of
people with substance use disorders also experiencing anxiety disorders, and 29%
having mood disorders (Oakley-Browne et al, 2006).
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In the evaluation of the primary mental health initiatives, we showed that only 5.2%
of service users were diagnosed with alcohol or substance use problems, which is
very likely to be an underestimate (Dowell, Garrett, Collings et al, 2009). Currently
Government is considering a series of changes to the regulations around supply and
availability of alcohol, and it appears that public attitudes towards our use of alcohol
are changing. This may lead to an increase in demand for treatment for alcohol and
drug-use problems in primary care. However, many GPs feel uncomfortable with the
topic of substance use in the clinical encounter, and often do not take the
opportunity to detect problems, give advice or use brief interventions, more
commonly changing topic or using humour to keep the service user ‘on side’
(Moriarty et al, 2009). It has been known for some time that brief interventions such
as screening and Motivational Interviewing in primary care settings can reduce levels
of drinking, and that this is effective across population groups (Fleming & Manwell,
1999). Much of this work would be initiated during the course of routine
consultations for other problems. Significant investment in workforce development
is required to equip the primary care workforce (not just the PMHC workforce) to
identify and intervene with mild-moderate substance use disorders.
Mental Health Promotion
What is mental health promotion?
Any activity that has among its consequences the enhancement of people’s
psychological and emotional resources, resilience and strengths, and life
competencies that are linked with social health and community participation, can be
considered as mental health promotion. Attempts to prevent the onset of
diagnosable mental disorders and their risk factors are also a domain of mental
health promotion.
As with general health promotion, mental health promotion encompasses many
activities ranging from policy and legislation to opportunistic work with individuals.
In the New Zealand setting an example of a legislative action that supports mental
health promotion is the requirement for employers to provide workplaces where
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employees are not subject to undue psychological stresses such as bullying and
unreasonable work demands. Opportunistic mental health promotion work with
individuals includes such things as a GP working with a person to improve the
amount and quality of sleep he or she is getting. Between these there is a wide range
of activities that take place at programmatic level, such as school-based programmes
and more global programmes such as anti-stigma and mental health literacy
campaigns. Some programmes at this level also have what is essentially an
opportunistic benefit for mental health, for example the green prescription
programme, which aims to increase people’s levels of physical activity, may also
benefit mental health status. Social programmes can also benefit the mental health
status of participants, such as government programmes to increase workforce
participation.
Although mental health promotion has sometimes been presented as aiming at
people who do not have a mental illness, this makes little sense, as people with
mental disorders stand to gain as much from mental health promotion as anybody,
and in some instances (such as anti-stigma and other social inclusion programmes)
arguably more. People with mental illnesses can also benefit greatly from some of
the opportunistic mental health promotion activities that have physical health as the
primary target. Clearly mental health promotion includes activities that enhance
psychological and social wellbeing and community participation for people with
mental disorders, just as for the rest of the population.
Many of the ideas underpinning mental health promotion are consistent with
positive psychology, an emerging branch of psychology that focuses on researching,
understanding and fostering positive emotions, individual strengths and virtues, and
positive institutions (Seligman & Csikszentmihaly, 2000).
Why is mental health promotion important?
Good mental health status is just as important a resource for the successful
management of day-to-day life as good physical health status. This is why the
protection and promotion of mental health is important as an end in itself, not
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simply as a strategy to prevent mental illness. The argument for the importance of
mental health promotion has several components. Firstly, mental health problems
are common. 39.5 % of New Zealanders will suffer a diagnosable mental disorder at
some stage in their lives (Oakley-Browne, 2006). Second, poor mental health is
causally associated with poor physical health. For example, people with depression
are at four times the risk of heart disease as people who are not depressed, and
depression is also a risk factor for stroke (Hiplsey-Cox, 1998; Jonas & Mussulino,
2000). Third, poor mental health is associated with social inequalities, as both a
cause and a consequence. People with mental illnesses are more likely to experience
unstable housing tenure and labour force status, and they are more likely to have
low incomes. Being socially marginalised is bad for mental health status: poverty and
unemployment increase the duration of common mental disorders (Weich & Lewis,
1998). A further example of this is the evidence that the experience of racism is
associated with poor mental health (Harris et al, 2006). Fourth, poor mental health
status (and therefore the burden of increased risk of poorer physical health) is
passed on between generations. Children whose parents have mental health
problems are more likely to have mental health problems themselves, and mental
health issues in childhood are strongly predictive of poorer mental health in
adulthood (Kim-Cohen et al, 2003). Finally, poor mental health status is associated
with personal suffering, and it is consistent with the values of our society that efforts
are made to reduce suffering where possible.
What is happening in mental health promotion in New Zealand?
Over the past fifteen years New Zealand has had a rich and wide-ranging programme
of mental health promotion activity. At the population level, we have seen one of
the world’s leading anti-stigma and social inclusion programmes in the Like Minds,
Like Mine campaign. This state-of-the-art programme had several facets. The nation-
wide media campaign featuring well-known New Zealanders had a long term
strategy to move from portrayals of people with more noticeable problems or
greater levels of disability to portrayals of ‘the person in the street’ who just happens
to have a mental illness. This was accompanied by local delivery of programmes,
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sometimes led by mental health consumers, direct to communities. Another major
mental health promotion programme is the depression awareness campaign using
All Black John Kirwan. This is a good example of a programme designed to have
several areas of effect: it is educational, aimed at increasing mental health literacy
around depression; there is an anti-stigma effect in that the social unacceptability of
having and being treated for depression is reduced; and it was supported by free
telephone help-lines for the public and by improved guidance for primary care
clinicians on the detection of common mental disorders and the management of
depression in primary care. It is also now linked to an online self-help option for the
treatment of depression. Other national-level programmes, such as the anti-
domestic violence campaign, also have benefits for improved mental health status.
At a local level activity is more varied in kind and extent. In some areas, Public Health
Units have staff focused on mental health promotion who work in schools and with
community groups. NGOs and other community agencies such as Plunket are also
involved in mental health promotion activities in a more ad-hoc way often in
association with activities with a separate prime focus. For example, positive
parenting programmes can be seen as essentially mental health promotion
programmes for parents and children, although they may not be publicised as such.
Campaigns to increase parental involvement in their children’s sport, if effective, will
likely have positive effects on parental and child mental health.
The place of mental health promotion in primary care
General health promotion activities are commonly undertaken within the context of
primary care clinical practice, as it is an ideal setting for doing so and achieving
relatively good direct reach into the population (Neuwelt et al, 2009). For several
reasons, primary care is also an ideal setting in which to practice opportunistic or
planned mental health promotion. The high prevalence of mental disorders of any
severity among those presenting in primary care means it is more possible to reach
people with mental disorders with mental health promotion messages. Primary care
is also an ideal setting in which to reach people with chronic physical disorders, who
are at increased risk of developing mental disorders. Primary care offers
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opportunities to do simple mental health promotion work with parents (although
usually mothers) and their children, as part of routine practice. Presentations with
medically unexplained physical symptoms are common in primary care and
practitioners frequently do not make a clear distinction between these and
psychological issues. The pragmatic management approaches GPs often use with
these may include elements of mental health promotion. Evidence is mounting that
some simple lifestyle changes such as increasing exercise and ensuring adequate and
good quality sleep are beneficial for both mental health and physical health. This
means that some aspects of mental health promotion have been introduced into
primary care practice already. One area of mental health promotion that is
particularly challenging in primary care in New Zealand is around moderating alcohol
consumption (Moriarty et al, 2009). One reason for this is that excess alcohol use is
endemic in New Zealand society due to pricing, ease of availability and the collective
attitude to public and private drunkenness as being socially acceptable. Many of the
concepts underpinning mental health promotion fit well with positive psychology, an
emerging branch of psychology that focuses on researching, understanding and fostering
positive emotions, individual strengths and virtues, and positive institutions (ref). This
philosophy has been recently incorporated into the Mental Health Foundation’s activities
and is beginning to gain traction in New Zealand (Seligman et al, 2000).
What this means for primary mental health care development in New Zealand
Most of the ideas behind mental health promotion are entirely congruent with
primary care philosophy and practice, and a good deal of mental health promotion
already occurs in routine practice. This will usually be occurring following the kind of
prioritising process that GPs and other primary care clinicians use to determine
which issue they will deal with in a given clinical encounter, and often as part of the
management of another problem. However, primary care practitioners do not
necessarily consider these activities as ‘mental health promotion’. The term is not
one used in primary care and is regarded as belonging in public health. For this
reason, attempts to encourage primary care practitioners to increase their focus on
mental health promotion at the individual level will require a re-framing of the
activity so they see it as congruent with and enhancing what they already do. As
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practices amalgamate into larger entities that include a wider range of health
professionals, it will be possible for primary care to take on more responsibility for
mental health promotion in local communities, such as supporting classroom-based
programmes in schools. However, these activities will have to be funded.
Does a ‘consumer’ perspective differ between primary and secondary mental health care contexts?
People using primary mental health care (PMHC) are diverse. Because primary care is
the first point of contact for health care, all primary care users are potential users of
PMHC. Likewise, all users of secondary and tertiary mental health services are users
of primary care and therefore may receive mental health care in that setting to
varying extents, in addition to receiving physical health care.
People who use PMHC can be divided into four main groups based on pattern of
service use. These are those who:
1. currently use secondary/tertiary mental health services, and who use primary
care for physical health needs.
2. use both primary and secondary/tertiary services for their mental health
needs.
3. have used secondary/tertiary mental health services but now only use
primary services for their mental health needs.
4. only ever use only primary care for their mental health care needs.
We have used these distinctions because, although there are many commonalities
between the groups, there are also important differences in respect of the kinds of
clinical problems encountered and therefore the kinds of responses primary care
needs to make. Groups 1-3 have been addressed quite distinctly in the mental health
service literature, for example in discussions of shared care and in material on the
consumer movement and consumer perspectives but there has been relatively little
attention to the fourth group, i.e. those who only ever use primary care for their
mental health needs. In this brief section we focus on this group in order to highlight
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possible questions about how their needs are best met in the primary care service
context.
PMHC in New Zealand has developed with some influence from secondary care
approaches, and, we suggest, with insufficient critical thinking about how
transferable some of those approaches are. For example, there has been a general
assumption that users of PMHC and users of secondary mental health services have
the same needs and aspirations, the same desires for representation and
participation, and the same goals for recovery.2 We contend that while the mental
health consumer movement has made vital contributions to improving
secondary/tertiary services and modes of practice, a blanket assumption that the
primary care context would prompt the same drivers of consumer concern may be
flawed, for several reasons.
Firstly, the origins and makeup of the traditional mental health consumer movement
are perhaps unique among consumers of health services. Secondly, the historical and
current relationships differ between primary care users and health professionals,
and between secondary care users and mental health professionals. Thirdly, the
notion of recovery may hold different meanings for these two groups, and lastly,
stigma and discrimination may be experienced differently by them. We will examine
each of these possibilities in turn.
The mental health consumer movement
To understand why the issues for those who use secondary mental health services
may differ from those who use primary mental health services, we first need to
examine the history of the mental health consumer movement.
Internationally, mental health consumer movements have their origins in the 18th
century and earlier (U.S. Department of Health and Human Services 1999; Tomes
2 For example Te Kokiri: The mental health and addiction action plan 2006-2015 Ministry of Health
(2006) encourages the engagement of service users in the planning and development of primary mental health and addiction services, but does not distinguish between primary and secondary service users.
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2006). Then, people wrote about their experiences of institutions and what they
thought needed to happen to improve conditions for people being treated for
mental illness. By the 1970s, buoyed by civil rights movements, a fully fledged
movement was growing internationally. People began questioning issues such as
their treatment in psychiatric hospitals, compulsory treatment and the dominance of
the medical model in the treatment of mental illness. New Zealand was also
positively influenced by the growing consumer movement, and in many ways was at
the forefront of it. A brief account of the increasing role of service users in New
Zealand’s mental health sector is presented in Te Haererenga mo te Whakaoranga
1996‐2006 (Mental Health Commission 2007). Needless to say, the voices of those
who have used or are using, mental health services are being increasingly heard.
The influence of the consumer movement on mental health services and policy in
New Zealand has been enormous. The perspectives which have informed both the
international and New Zealand based consumer movements have tended, however,
to be from people who have used secondary/tertiary mental health services. They
may have been hospitalised in psychiatric hospitals, been treated by psychiatrists
and other mental health professionals, and may have been treated without their
consent. They may have had severe or complex illnesses or illnesses of long duration.
Most of these experiences are not shared by people using only primary mental
health services.
The relationship between GP and patient
Another way in which those seeking help for mental health issues only in primary
care may differ to those using secondary services is in the relationship between the
service provider (often the GP) and the service user. The first issue here relates to
the nature of primary care. People most commonly attend with undifferentiated
problems and it is the GP/primary care practitioner’s task to determine their nature.
When people attend mental health services there is already acknowledgment that
the problem is, or is likely to be, a mental health problem. Unlike in secondary care,
the main reason for a visit to a primary care practitioner may not be a mental health
issue. For example, the person may seek help for a physical health problem, which
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the practitioner then attributes to a mental health issue. Alternatively, a mental
health issue may be raised incidentally as part of the consultation. Having made a
diagnosis, the GP may or may not tell the person it is mental illness or a mental
health problem. The GP may explain the treatment in terms of a physical problem,
such as lack of sleep, rather than as a psychological problem. If the GP does frame
the issue as a mental health problem, and the person is experiencing physical
symptoms, the person may feel frustrated that the concerns about their physical
health are not being taken seriously. On the other hand the person may be reluctant
to accept that a problem is psychological in nature. Sometimes the GP reasons that if
there are multiple problems they should be dealt with in order of urgency or
acceptability to the person presenting, and may discuss the mental health
component in follow-up appointments.
A second issue is that of stigma. Although there is less stigma associated with mental
illness today than in the past, stigma and discrimination are still present in New
Zealand society. As a society we are not yet completely comfortable with the idea
that mental illnesses are common and not shameful. The person seeking help may
recognise that they have a mental health problem, and want help with it, but not
want to be labelled as having a mental illness. Having such a diagnosis in general
medical records may result in discrimination from insurance companies and health
providers (Dew, Dowell et al. 2005), and for this reason the GP may feel just as
uncomfortable about giving the diagnosis as the person is receiving it. Both parties
may perceive that a diagnosis of mental disorder is more appropriate for those using
secondary services rather than for someone who may be experiencing mild,
self‐limiting problems. Recognition of the risk of stigma and discrimination may lead
either party to talk in more general terms (e.g. feeling a bit ‘down’), rather than
using specific terms such as ‘depression’.
Some users of PMHC may perceive primary care as a context in which coercion is less
likely to be used than in secondary services. This may be because the use of the
Mental Health Act is less prominent in primary care.
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These examples illustrate some of the possible perspectives on the primary care
professional/service user relationship. In contrast for those using secondary
services, the agenda is usually specifically about mental illness and this is known to
both parties prior to meeting.
The notion of recovery
Recovery is a concept playing a critical role in secondary mental health services, the
application of which may differ in PMHC. In New Zealand, ‘recovery’ has become one
of the cornerstones of mental health policy. All secondary mental health services are
expected to be ‘recovery oriented’, highlighted by the Mental Health Commission’s
publication of recovery competencies for mental health workers (Mental Health
Commission 2001). The Ministry of Health has stated that one of its key expected
outcomes for people using mental health services is that they “experience
recovery‐focused mental health services that provide choice, promote
independence, and are effective, efficient, responsive and timely.” (Ministry of
Health 2005, p4).
At the surface, the idea of recovery may seem obvious – that people who experience
mental illness get better. However, in mental health services, the prevailing attitude
for many years was that, for those with ‘serious’ mental illness, the course of illness
would be unremitting, chronic and deteriorating. There is good evidence that this is
not the case, and that many people diagnosed with mental illness become
completely symptom-free and resume their lives with little disruption (Slade 2009).
However, some still do not, and for those with this experience, many people
associated with the consumer movement argue that recovery is more than just
getting better. It is about “living well in the presence or absence of (their) mental
illness” (Mental Health Commission 1998 p1).
The key difference between a clinical definition of recovery and a consumer
definition is that, for many consumers, recovery is regarded as a process, rather than
an outcome (Mulligan 2003; Resnick, Rosenheck et al, 2004; Davidson, O'Connell et
al, 2006; Ramon, Shera et al. 2009). Using a consumer definition (sometimes referred
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to as personal recovery in the literature (Slade 2009), most people who experience
mental illness, no matter how severe or protracted, are capable of recovery. In fact,
people with mental illness may continue to take medication or receive other
treatment, experience symptoms, and live with aspects of mental illness that others
may see as disabling, yet still consider themselves to be in recovery.
How relevant is this recovery concept to primary mental health care? This needs to
be considered at the level of the service user, and at the level of policy and service
provision. At the service user level, many people with new mental health issues who
approach their primary healthcare provider will do so with trepidation. They may not
realise that the problems they are experiencing are mental illness or even mental
health related. They may be experiencing self‐stigma and be fearful that their
symptoms and distress will get a lot worse and matters may be taken out of their
control. They are likely to have the same perceptions of people with experience of
mental illness as other members of the general public and may have no wish to have
those stereotypes associated with them. Because they are not fluent in the jargon of
mental health services, they are unlikely to have heard of the idea of “recovery” and
may not realise that they may be able to “live well in the presence or absence of
their mental illness” (Mental Health Commission 1998 p1). Most people seeking help
from primary care providers are experiencing mental illness at the mild to moderate
end of the spectrum, and a reasonable expectation in most cases is that the episode
will end and life will be taken up again with little change. Even if they do identify as
having a mental illness, they may not consider themselves to have anything in
common with someone with a different sort of problem, such as schizophrenia, for
example. The message that they may live well in the presence or absence of their
depression, may not be as acceptable as hearing that they will be cured of their
depression.
Some of these arguments also apply at the service provider and policy level. As
stated earlier in this report, primary care services have been providing care for
people with mental health problems for many decades, regardless of whether it has
been recognised or funded as a core service component. Expecting successful direct
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transfer (or imposition) of a construct derived from experience of secondary care
may be unrealistic. While many of the values of recovery are completely compatible
with primary care philosophies, their packaging into this particular construct may not
be. Examples of the values that are a good fit include: the giving of hope, and
providing interventions and support that help the person live the life they choose to
live. It would be preferable for primary care as a discipline to consider the elements
of the recovery concept and adopt a version of it that is a good fit with the
aspirations of PMHC users.
The consequence of these issues is that while the philosophy of recovery is just as
important for people with the mild to moderate common mental health problems
presenting in primary care as for anyone else with a mental illness or mental health
problem, there may be little utility in articulating the concept in the same way as it is
expressed in secondary and tertiary mental health services. We accept that some
people will see our suggestions as debatable, and we think that further discussion of
these ideas is important. Perhaps unsurprisingly, there is as yet no research in this
area, but it will be a fruitful domain for future work.
Stigma and discrimination
Internalised or self‐stigma is an issue for many people using secondary mental health
services (Peterson, Barnes et al. 2008; Peterson and Gordon 2010). A person seeking
help from primary care for mental health issues may also experience self‐stigma.
They may worry that others will think less of them if it is known that they have a
mental illness or mental health problem. All the stereotypes they have about people
with mental illness now apply to them. They may choose to distance themselves
more from those using secondary services, thinking that their experiences do not
warrant such labelling, in order to avoid experiencing an increase in self‐stigma.
The experience of discrimination is probably one of the features that unite those
using secondary services. For those accessing primary care for mental health issues,
it may be easier to escape some of the discrimination than those using secondary
services experience. Because they are not explicitly using mental health services,
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they may be more able to keep the reason for their use of primary care confidential.
If their condition is recognised as relating to their mental health, there may be a
perception that their condition is not as serious as those using secondary services.
Nevertheless, discrimination associated with mental illness does exist in primary
care. Earlier in this section we gave an example of how societal discrimination and
stigma may contribute to various practices such as a GP avoiding a diagnosis of
mental illness due to a fear of discrimination against their patient. The attitudes of
some primary health care providers may contribute to people who use their services
feeling discriminated against. The service user may feel their physical health
concerns are dismissed, their mental health concerns downplayed, or that their GP
does not feel comfortable discussing mental illness.
However, the extent of discrimination and the stigma associated with mental illness
may be changing. This is indicated by the success of two of the Ministry of Health’s
campaigns ‐ the depression awareness campaign fronted by ex‐All Black John Kirwan,
and the Like Minds, Like Mine programme to counter stigma and discrimination
associated with mental illness. The Like Minds campaign has been running
successfully now for more than thirteen years (Wyllie, Cameron et al, 2008;
Vaithianathan and Pram 2010). These campaigns may be encouraging more people
to seek help for mental health issues from primary providers, thus making the use of
these more socially acceptable.
Implications
The similarities and differences between those using secondary and primary mental
health services have various implications. Firstly, more research is needed to
understand the place that the current notion of recovery has in PMHC, and whether
it is a useful concept in this setting.
Secondly, discrimination and self‐stigma are major elements of the experience of
most people who use mental health services. There are, however, likely to be
differences in the experiences of those using primary mental health services
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compared to those using secondary services. We need new research to uncover
what these are and find out any implications for PMHC.
Finally, there are implications for how best to represent the viewpoints of those
seeking help from primary mental health services, and how to encourage the
participation of these users in their own care. These are important for people using
secondary services, and are issues that the consumer movement has traditionally
focused on from the perspectives of secondary service users. Because of the
differences between the users of primary and secondary services it is likely that one
group cannot adequately represent the other. There has been little consultation to
date with users of primary mental health services to determine whether this is, in
fact, the case, let alone whether these issues are as important to primary mental
health users as they are to those using secondary services. Future service and policy
development should include consideration of such consultation.
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Section 3: Framing the research
Introduction
This project was informed by two methods and three theories or frameworks. In this
section we discuss the key methods and theories that we used. Firstly, we give a
brief overview of the Evaluation of the Primary Mental Health Initiatives which were
used to explore the research queries and assumptions during early engagement with
the research partners. Next we discuss the main methodological approaches that
informed the emergent method used in this project, which include case study and
participatory action research (PAR). Finally, we discuss the different lenses used to
frame this work, which have informed the entire research process. These include
Diffusion of Innovation theory, Developmental Evaluation and Systems theory.
The Primary Mental Health Initiatives
The development of the primary mental health initiatives (PMHI)
In April 2004 the Ministry of Health sent out requests to Primary health
Organisations (PHOs) for proposals for primary mental health care. By November
2004 the proposals had been assessed and funding was provided for initiatives
proposed by 42 PHOs and distributed to 256 different groupings. The PMHI
programme in PHOs was seen as being part of a package of initiatives being
undertaken to develop PHOs and support the implementation of the Primary Health
Care Strategy. The principal target population for these initiatives was those with
mild to moderate mental health.
Other than the provision of ‘usual’ GP-delivered primary mental health care, the
majority of the PHOS involved in the initiatives did not have any formalised primary
mental health programmes prior to the implementation of this new funding stream.
Until the introduction of the PMHIs there had been no central funding to specifically
support primary mental health care, with this kind of activity limited to a small
number of PHOs or DHB projects. As a result, the Ministry of Health recognised that
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particular attention should be given to the development of primary mental health
services in New Zealand.
The evaluation of the Primary Mental Health Initiatives
In March 2005 a request for proposals for an evaluation of the initiatives was
advertised and awarded in June 2005 to the Department of Primary Health Care and
General Practice, University of Otago, Wellington. The evaluation of the initiatives
was intended to have a strong formative component and to provide resources for
the further development of primary mental health initiatives. The final report
described the evaluation of the PMHIs which was conducted between June 2005 and
November 2007.
One of the main outcomes of the evaluation was the Optimal Model for PMHC in
New Zealand, shown in the diagram on the next page. This was used as a basis for
the current project. A revised version of Optimal Model II is one of the key products
of this current project.
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An optimal model for a Primary Mental Health Initiative
This model has now been superceded by Optimal Model II which is shown on page
50 of the Knowledge Bank in the Toolkit documentation.
Figure 3.1: Optimal model for Primary Mental Health Initiative. (Source: Dowell et al.
2009. Evaluation of the Primary Mental Health Initiatives; Summary Report).
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Case Study Research
Background
Case study research uses the uniqueness of the case or a small number of cases to
investigate a phenomenon in its real life context (Yin, 1994; Simons, 2009). It is
commonly used in health services, policy and organisational research. This approach
produces an in-depth understanding of what is studied, in order to generate
knowledge that may be transferrable to other contexts, and/or to inform policy or
practice development. Case study research can use both quantitative and qualitative
methods, making it ideal for studies of implementation processes in organisations
(Greenhalgh, 2005). Case studies are ideal for answering ‘how’ or ‘why’ questions in
complex and dynamic situations where investigators have little control over events
(Yin, 1994). Case study research was the approach of choice for this research
because DHBs are dynamic organisations in a complex fast-moving environment.
The case study approach also readily generates outputs that are accessible to a
range of audiences, which is important if our findings are to be applied.
The contextual element of case study was of particular relevance to this study for
two reasons. Firstly, because the main output was to be a Toolkit that could be
applied in contexts similar to those we were studying, it was critical that we
developed an in depth understanding of the context of primary mental health care
delivery. For this project, the particular elements of context that we were especially
interested in were: the processes around primary mental health care planning and
provision, and the organisational context. The second reason the contextual element
was especially relevant to this work was to allow us to move beyond Optimal Model I
as was produced by the Primary Mental Health Evaluation (Dowell, Garrett, Collings
et al, 2009). Optimal Model I was derived from work describing what was observed
when new services were designed and introduced. In that work, apart from the
purely evaluative components, we defined a typology of primary mental health care
as it was being provided by funded initiatives in New Zealand at that time. We also
described the observed features of primary mental health care in the unusual
context at that time. The context was unusual because it was created by the sudden
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availability of new money for this specific purpose. Using a case study framework for
the present study meant we were able to consider primary mental health care as a
more established social phenomenon and map the range of elements and
dimensions within it (Ritchie, 2003). It also gave us a framework within which to
draw together the multiple perspectives we were required to consider in the project.
The way we drew together aspects of participatory action research and case study as
the work proceeded, is described in more detail in the Methods section of this
report.
Participatory action research
Background
In the 21st century participatory action research (PAR) is increasingly used in health
research. Initially PAR was mainly used in low income countries for needs
assessment and planning and evaluating health services (Baum, 2006). Recently, PAR
has been used more frequently in rich countries. In mental health research PAR has
been used in response to the survivors’ movement and demands for a voice in
planning and running services and to stimulate choices and alternative forms of
treatment (Weaver, 2001).
PAR is a method of research that both seeks to gain more knowledge and aims to
change people’s circumstances for the better by engaging them in the research
process. There are numerous approaches to action research (Meyer, 2006). Stringer
(Stringer, 1996) that the common themes which emerge from the diverse
approaches to action research “all acknowledge fundamental investment in
processes that:
Are rigorously empirical and reflective (or interpretive)
Engage people as active participants in the research process; and
Results in some practical outcome related to the lives or work of the
participants”.
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Action research is known by many other names including participatory action
research, collaborative inquiry, emancipatory research and action learning. Put
simply, action research is “learning by doing”.
At a time when there is increasing concern that research evidence is not sufficiently
influencing practice development, action research is gaining credibility in health care
settings (Meyer, 2000, 2006; Baum, 2006; Braithwaite, Westbrook et al, 2007; Kerr,
Penney et al, 2010). Waterman proposes three principals of action research in health
care settings (Waterman, 2007).
1. Participation
2. Critical reflection
3. To improve practice and the experience and outcome of patient care.
Participation
Participation is fundamental to action research: it is an approach which demands
that participant’s perceive the need to change and are willing to play an active part
in the research and the change process (Baum, 2006; Meyer 2000, 2006). A
partnership between researchers and participants is seen as equitable and liberating
in action research (Stringer, 1996; Baum, 2006). Compared to other more traditional
research approaches where participants play a passive role in that they do not
determine the research questions or affect practice, participants in action research
are active (Wallerstein & Duran 2003; Kemmis & McTaggart, 2000). However, the
level of participation can vary between projects and may vary within a project.
Within each of the four research partners we facilitated the formation of a ‘coalition’
representing key actors in the system including DHBs, PHOs, primary care practices,
PMH support services, Māori providers and community organisations. Through the
principals of action research we aimed to encourage bi-directional feedback and
enable reflection to stimulate productive change and improvement in a participatory
environment in order to bring about profound culture change in the way health
professionals work together to deliver services.
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Improving practice through critical reflection
Action research is particularly suited to identifying problems in clinical practice and
helping develop potential solutions in order to improve practice. Action research
aims to assist both health professional and patients to understand their problems
better and to enlighten and inform them so that then can decide on action. The
research moves beyond describing the ‘status quo’ as in traditional research to
speculating on what might or ought to be’, introducing changes and assessing the
results (Waterman, 2007; Meyer, 2006). Critical reflection is a form of analysis that
not only explores how and why things happened but identifies the assumptions
underpinning that analysis. It binds together all the activities associated with the
research process and leads to empowerment and action. In practice, critical
reflection in a group setting refers to the process of identifying and examining
assumptions that underpin daily activity, and asking whether the ideologies and
attitudes that influence practice are those that best serve the interest of patients
and staff (Waterman, 2007; Meyer, 2006).
Throughout this research we have examined professional values and assumptions
about mental health service delivery in our four areas and explored the relationships
between and within professional groups. We have gathered and explored the
different perspectives on problems that exist in PMHC and our partners have shared
their experiences with us, the research team. By drawing on the experiences and
integrating these with other types of evidence, we have been able to draw
conclusion about how, and why, practice could be changed.
Role of the research team
The main role of the research team in action research is to implement the methods
in such a manner as to produce a mutually agreeable outcome for all participants,
with the process being maintained by them afterwards. To accomplish this requires
the adoption of many different roles, at various stages of the process, by the
research team in order to act as a catalyst to assist stakeholder in defining their
problems clearly and to support them as they work toward effective solutions to the
issues that concern them (Stringer, 1996; Meyer, 2000). These roles include those of
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observer, listener, teacher, consultant, leader, catalyser, facilitator and reporter.
The researcher’s main role however is to nurture local leaders to the point where
they can take responsibility for the process. Normally the point is reach when they
understand the methods and are able to carry on in when the researchers leave. As
this research was of a predetermined duration, this point was not reached for some
of the research partners.
Reasons for choosing action research as a method
There were three main reasons for choosing this method in the current work and
they reflect the strengths of action research in health care research. Firstly, it can
lead to contextually relevant changes or innovations in practices that will have a
positive effect on patient experiences and the outcome of health care interventions.
Secondly, the knowledge and theory are directly relevant for action. Third,
participants are helped to take responsibility for their own circumstances
(Waterman, 2007; Baum, 2006; Meyer, 2000, 2006).
Diffusion of Innovation in health care
Background
Bridging the knowledge-to-practice gap in health care is an important issue that has
gained interest in recent years and is a major concern in many countries.
Implementing new methods, guidelines or tools into routine care, however is a slow
and unpredictable process (Berwick, 2003), and the factors that play a role in the
change process are not yet fully understood (Glasgow, 2004).
The health care sector worldwide has experienced a proliferation of innovation
aimed at improving life expectancy, quality of life, diagnostic and treatment options.
Innovations in healthcare organisations also continue to be a driving force in the
quest to balance cost containment and cost effectiveness with health care quality.
From the organisation perspective these innovations are typically new services, new
ways of working and/or new technologies (Lansisalmi, 2006). From the patients
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perspective the intended benefits are with improved health or reduced suffering due
to illness. Despite the surge in innovation, theoretical research on the art and science
of healthcare innovation has been limited (Omachonu, 2010).
Much of the current literature on innovations in health care has largely been driven
by the UK (Greenhalgh, 2005; Williams, 2009). Although research from Europe
(Fleuren, 2004; Carlfjord, 2010) and the US (Rye, 2007) in on the increase.
What is innovation?
Defining innovation is difficult given the multiple definitions employed in the
literature. It is generally agreed that the term innovation is, or at least requires, a
form of change. It is not just invention but also implementation (or adoption) i.e. the
uptake of new ideas or moving from one state to another. Innovation is a process
and an outcome, represents newness and involves discontinuous change
(Greenhalgh, 2005; Rogers, 1995). It can be defined as ‘the intentional introduction
and application within a role, group, or organisation, of ideas, process, products or
procedures, new to the relevant unit of adoption, designed to significantly benefit
the individual, the group or wider society (West & Farr, 1990). This definition
captures the three most important characteristics of innovation: novelty, application
and intended benefit (Lansisalmi, 2006).
Greenhalgh et al (2005) define innovation in service delivery within health
organisations as ‘a set of behaviours, routines, and ways of working, along with any
associated administrative technologies and systems, which are:
perceived as new by a proportion of key stakeholders;
linked to the provision or support of health care
discontinuous with previous practices
directed at improving health outcomes, administrative efficiency, cost-
effectiveness, or user experience; and
implemented by means of planned and coordinated action by individuals,
teams or organisations.
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Innovations in health care can be product (introduction of a good or serves that is
new or significantly improved), process (implementation of a new or significantly
improved production or delivery method) or structural (implementation of a new
organisation methods in the organisation practices, workplace organisation or
external relations) (Omachonu, 2010; Varkey, 2008). More specifically healthcare
innovation can be defined as the introduction of a new concept, idea, services,
process, or product aimed at improving treatment, diagnoses, education, outreach,
prevention and research, and with the long term goals of improving quality, safety,
outcomes, efficiency and costs (Omachonu, 2010).
Adoption, diffusion and dissemination of innovations
Rogers defines adoption as ‘the decision to make full use of the innovation as the
best course of action available’ (Rogers, 1995). People and organisations choose
rationally to adopt innovations because of some actual or perceived advantage.
However the adoption of advantageous innovations often fails to take place, likewise
adoption of disadvantageous innovations is sadly very common (Greenhalgh et al,
2005). Diffusion is the ‘process by which innovation is communicated through certain
channels over time among members of social change’ (Greenhalgh et al, 2005;
Haider, 2004; Rogers, 1995). The study of diffusion of innovations (DOI) has a long
history in social science and is a term that means different things to different
scholars. Classical diffusion on innovations research, as set out by Rogers (Rogers,
1995) is a body of knowledge built around empirical work that demonstrated a
consistent pattern of adoption of news ideas over time by people in a social system
(Moseley, 2004). There are a wide range of conceptual and theoretical models for
the adoption, diffusion, dissemination, implementation and sustainability of
innovations have been proposed and test in a diverse field of disciplines. Greenhalgh
et al. in their systematic review of the literature failed to find an all-encompassing
theoretical framework to underpin the diffusion of innovations as applied to health
service organisations, which is consistent with previous attempts to review similar
bodies of literature (Greenhalgh, 2005).
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There are three main clusters of influence on the dissemination/diffusion of
innovation which are focussed on in the literature. These influences or determinants
of the diffusion of innovation correlate with the rate of spread of a change and
include: the characteristics of the innovation; the characteristics of the people who
adopt the innovation or fail to do so and contextual factors.
Characteristics of the innovation:
Innovations in health have defining characteristics or attributes that affect and help
to explain their differential rate of adoption. These are relative advantage,
compatibility, complexity, trialability and observability (Greenhalgh, 2005; Haider,
2004; Rogers, 1995). The optimisation of these five qualities will allow an innovation
to be adopted more rapidly than other innovations that lack them. The more
knowledge individuals can gain about the expected consequences on an innovation,
the more likely they are to adopt it (Rogers, 1995).
Characteristics of the adopting individuals:
The classic diffusion of innovation model categorises individuals by their readiness
for adopting an innovation. People may be innovators (venturesome information
seekers with wide social networks who can cope with a higher degree of
uncertainty); early adopters (open to ideas and active experimenters who tend to
seek information, are self-sufficient and respond well to printed information); early
and late majority (require a large amount of personalised information and support
before adopting, but are often influential with peers); or ‘laggards’ (low social status,
sparse social networks and learn about innovations from interpersonal channels)
(Rogers, 1995). These categories are however, simplistic and certainly value-laden
(Greenhalgh, 2005).
Contextual factors (characteristics of the organisation and of the broader environment).
The importance of the organisational context is highlighted in the literature (Berwick,
2003; Greenhalgh, 2004). A number of key aspects of communication and influences
have been identified such as decision making structures; the presence of opinion
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leaders/champions; characteristics of the organisation such as its size, maturity,
complexity and extent of decentralisation; leadership; resources such as the nature
of supporting technologies; foci of professional knowledge within the organisation;
capacity to take on new knowledge; openness to change and skill mix. The broader
environment is also crucial. The socio-political climate, external incentives and
mandates, and the role of external agencies and change agents who influence the
direction of innovation-decisions are all important (Greenhalgh, 2005; Haider, 2004;
Meyer, 1997; Rogers, 1995; Howell, 1990).
Greenhalgh et al (2005) developed a conceptual model (see figure 3.2) based on the
empirical findings of their systematic review which attempts to depict their main
findings diagrammatically. This model has informed our work through helping us to
gain a theoretical understanding of innovation, spread and sustainably in health care
organisations. It has also helped to frame our thinking in the context of the bigger
picture and to consider the influences of both the inner and outer context of health
services organisations.
Figure 3.2 Greenhalghs’ conceptual model of diffusion and dissemination of
innovation (Source Greenhalgh T et al. 2005. Diffusions of Innovations in Health Service
Organisations. Oxford).
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Application of the DOI framework
The Diffusion of Innovation (DOI) framework has proven to be flexible enough to
conceptualise many kinds of social change, including change through processes of
public dialogue and participation, change within organisations, as well as change
though public agenda setting and media effects (Moseley, 2004; Haider, 2004). Some
of the challenges in applying DOI theory include determining how to speed up the
decision-making process, identifying appropriate change agents optimised for
reaching different target population, building assurance for funding and ensuring
prospective rather than retrospective assessments of how different people respond
to innovations (Haider, 2004). This may involved finding sound innovations, finding
and support “innovators”, investing in “early adopters;, making early adopter activity
observable , trusting and enabling reinvention, creating slacks for change and leading
by example (Berwick, 2003).
Greenhalgh et al take a whole systems approach to researching the diffusion of
innovation. Innovations are seen as emerging, evolving and diffusing through a
complex interplay of the external and internal system context (Greenhalgh, 2005;
Haider, 2004). In this approach, the research considers the dynamic interaction
between components of an organisation. They suggest a two-stage framework for
applying the model in a service context. The first stage is to consider the individual
components of the model in turn e.g. the attributes of the innovation; the
characteristics and behaviours of individuals; the structural and cultural
determinants of organisational innovativeness and so on. The second stage is to
consider the interaction between these components with particular reference to
local context, setting and timing. Whereas the first stage is largely a question of
applying a literature-derived checklist and many questions can be addressed almost
as a paper exercise, the second stage requires a high degree of practical wisdom,
local knowledge and consultation, all of which have occurred through our research
process. This research has particularly focussed on the inner and outer context
within a primary mental health care setting and the interaction between these two
components.
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Inner context
The inner (organisational) context influences the adoption, spread and sustainability
of innovations. The “inner context’ comprises both the visible organisational
structure and the culture and ways of working, both of which vary enormously
between organisations. A number of features of organisation (both structural and
cultural) have been shown to influence the likelihood that an innovation will be
successfully adopted by all relevant individuals and incorporated into ‘business as
usual’ (Greenhalgh, 2004). These include (1) structural determinants such as size of
organisation, decentralisation and resources (2) the absorptive capacity got new
knowledge such as pre-existing knowledge/skills base and ability to integrated new
knowledge (3) receptive context for change such as leadership and vision and good
managerial relationships.
In applying this to our own thinking we have explored the infrastructure and
relationships within the research partners we have worked with. We have observed
issues around the primary/secondary interface and the alignment between the
diverse viewpoints across primary and specialist services; issues around workforce
and its capacity to absorb new knowledge combined with lack of protective time;
and issues in developing cross-sector leadership.
Outer context
An organisation’s decision to adopt an innovation, and its effort to implement and
sustain it, depends on some key external influences. Firstly, are informal
organisational networks because a key influence on an organisation’s adoption
decision is whether a threshold proportion of comparable (homophilous)
organisations have done so or plan to do so. An organisation that is well networked
will be more amenable to this influence. These networks can also serve to warn
organisations of innovations that have no perceived advantages. Secondly, the socio-
political climate is key. A ‘policy’ push occurring at the early stage of implementation
of an innovation initiative can increase its chances of success, perhaps most crucially
by making a dedicated funding stream available. Thirdly, external mandates (political
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must-dos) can increase the motivation but not the capacity of an organisation to
adopt and innovation.
Through this work we have explored issues relevant to the outer context of PMHC in
New Zealand. Currently, broader primary health care is under stress, capacity
constraint and time stress. Although a number of different Primary Mental Health
initiatives have enabled some relief with the burden of that they have are not
necessarily sustainable going forward because of variations in how they are
configured and the funding that is going into them. The current policy environment
and the strive for Better, Sooner, More, Convenient health care (National
Government, 2009) is a key driver in the current outer context of mental health care
in New Zealand.
Developmental Evaluation
Background
Organised primary mental health care (PMHC), in the form of structure services and
programmes, is a relative new-comer to health services with a range of issues and
challenges in its development. It has emerged largely since the establishment of the
Primary Mental Health Initiatives (PMHIs) which are examples of innovative
interventions, often in highly dynamic environments. Those involved in the initiatives
were, in a sense, engaged in ongoing trial and error experimentation, figuring out
what works, learning lessons and adapting to changes circumstances. In this type if
innovative setting where goals are emergent and changing rather than
predetermined and fixed, developmental evaluation (DE) is an ideal approach to
evaluation (Patton, 2008). The purpose of DE is organisational development and
rapid response to emergent realities in highly dynamic and complex systems, often
under conditions of great uncertainty (Patton, 1994, 2008).
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What is developmental evaluation?
DE was conceptualised by Michael Patton as an alternative to formative and
summative evaluations3. Why? Because Patton realised that in innovative
interventions, the environment is often highly dynamic, and those involved are
engaged in ongoing trial and error experimentation, figuring out what works,
learning lessons and adapting to changed circumstances and are often committed to
ongoing development. They never expect to arrive at a fixed, static, and stable model
and therefore doing summative or formative evaluations is not appropriate (Patton,
2008). DE supports the process of innovation within an organisation and in its
activities by bringing data to bear to inform and guide emergent choice. Initiatives
that are innovation are often in a state of continuous developmental and adaptation,
and they frequently unfold in a changing and unpredictable environment. Much
therefore is in flux; the framing of the issue can change, how the problem is
conceptualised evolved and various approaches are likely to be tested. Adaptations
are largely driven by new learning and by changes in participants, partners and
context.
Within DE there is a natural progression of steps from problem to solution in a linear
and logical way. The researchers move methodically from assessing the situation to
gathering and analysing the data, formulating a solution and then implementing the
solution. This is illustrated in the figure below from Gamble (2008).
3 Formative evaluation assists with working through implementation problems of a program in order
that is ready for a summative assessment. Summative evaluation is conducted after the completion of
a program for the benefit of a decision maker to determine whether to continue, expand or
disseminate the program evaluation (Patton, 2008).
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Figure 3.3 The progression of step in developmental evaluation (Source Gamble, J.,
A Developmental Evaluation Primer. 2008, The J.W. McConnell Family Foundation)
However, a major challenge is that not all problems are straightforward with optimal
solutions. These kinds of problems are complex or “wicked”, difficult to define, with
no immediate solutions and one where every wicked problem can be considered to
be a symptom of another problem (Petticrew, 2009). This is the place where
innovators often find themselves. When innovating within a complex system, it is
difficult to understand the ramifications of changes. The dynamics of a complex
system have a high degree of connectivity and interdependence. There are diverse
elements whose intersections create unpredictable, emergent results. Thus instead
of logical steps (outlined in previous figure) the experience of innovating often looks
more like figure 3.4- rapidly moving back and forth between problem and solution.
Ultimately DE is about rigorous inquiry for development. It is about using your data
in a meaningful way that informs the innovation which in progress.
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Figure 3.4 The experience of innovating moves rapidly between problem and
solution over time. (Source Gamble, J., A Developmental Evaluation Primer. 2008, The J.W.
McConnell Family Foundation)
How does developmental evaluation differ from tradition evaluation?
The table on the following page from Patton (2008) provides some general
characteristics involved in taking a developmental approach (on the right hand side
of the table) as opposed to a more traditional approach to evaluation (on the left
hand side).
Table of the general characteristics of a developmental approach to evaluation in
comparison to traditional evaluation.
Traditional evaluations Developmental Evaluations
Measure success against pre-
determined goals
Develop new measures and monitoring mechanism as
goals emerge and evolve
Design the evaluation based on linear
cause-and-effect modelling
Based on complex systems thinking, nonlinear,
emergent dynamics, and interdependent
interconnections
Render definitive judgements of
success or failure
Provide rapid feedback, generate learnings, support
direction, or affirm changes in direction
Position the evaluator outside to Position the evaluator as a design team members
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assure independence and objectivity integrated into developmental decision making
Aim to provide generalisable findings
so that effective practices can be
applied elsewhere
Aim to produce context-specific understandings that
inform ongoing innovation; innovate principles are
generalisable
Accountability focuses on and directed
to external authorities and funders
Accountability centred on the innovators deep sense
of fundamental values and commitment
Accountability aimed at control and
locating source of failures
Learning to respond to lack of control and staying in
touch with what’s unfolding and thereby responding
strategically
Evaluation is often a compliance
function delighted down within the
organisations
Evaluation is a leadership function : reality testing,
results focused and learning –oriented leadership
Evaluator determines the design based
on the evaluators perspective about
what is important. The evaluator
controls the evaluation
Evaluator collaborate with those engage in the
change effort to design an evaluation process that
matched the innovation philosophically and
organisationally
Evaluation results in opinion of success
or failure
Evaluation supports ongoing learning
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System Dynamics and Primary Mental Health Care
Background
Our contemporary understanding and treatment of mental health focuses on trying
to understand the ‘whole person’ and, wherever possible, ensuring that their various
needs are met by and within the community, balancing therapeutic interventions
with interventions that meet their social, cultural and spiritual needs. Such an
approach forces us to try and understand the context within which mental health
conditions develop. Furthermore, there is a strong commitment to understand how
the broader social and cultural context affects peoples’ lives and to incorporate this
understanding into how we respond to those with mental health conditions.
However, the tools we have available to understand this context are limited and
tend to focus on one aspect at a time, rather than the context as a whole, Whether it
be cultural appropriateness, models of care, links between primary and secondary
care, or the skills of those providing the service, for example, we are often forced to
treat each in isolation. There is little that helps us understand the interdependencies
among the real-world processes that exist in this context.
With rare exceptions the overall system dynamics…[of the mental health
system]… have not been directly addressed; the focus has been on policy
initiatives rather than on the context within which policy is developed, and on
countless explanatory variables that do not fit together coherently to allow
for explanation rather than description (McCubbin & Cohen, 1999).
What is needed are better tools that provide us with insight into how each part
relates to the whole, and to each other, and how these relationships determine
system change. In any significant change there are several "moving parts", and a
static or linear process, by itself, is insufficient for anticipating many of the pitfalls
and undesirable side effects that could easily undermine any change efforts over
time.
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Throughout the Toolkit, and described specifically in the ‘Systems Planning Guide’,
we have tried to capture the ‘whole system’ by focusing on key intervention points
and how each relates to the other. The following sections describe the approach we
have taken.
Systems, Primary Mental Health Care Systems and System Dynamics
A system is a functional whole made up of elements that are coupled together in a
way that may not be apparent from a study of each individual element. As it is a
functional whole it cannot be split into parts and be expected to provide two smaller
parts. This differentiates ‘systems’ from ‘piles’. Split a pile of sand in two and you
have two smaller piles of sand. Split a cow in two and…. Also, if you split your
Primary Mental Health Care (PMHC) system in two you don’t end up with two
smaller PMHC systems. What you end up with is fundamentally different. Thus
looking at the world through a systems lens means focusing on the relationships that
bind the system together; as it is these relationships that give the system its distinct
characteristics. Each PMHC system throughout the country has similar elements. For
example, people with mental health conditions, GPs, mental health nurses, mental
health specialist and some level of funding. How they relate to each other however,
how information is passed between them, how they work together, where and how
the funding is allocated will be different in different places and as a result each PMH
system will be unique to the context within which it sits. Thus change is brought
about by changes to the key elements, for example an increase in the funding,
and/or changes to the relationships in the system, for example, changing how the
funding is allocated. Thus a systems perspective is concerned with understanding
how parts of the systems are related together and what ‘rules’ determine these
relationships as it is these relationships’ that determine its dynamics, how it will
evolve over time. To capture these relationships a systems approach makes
extensive use of qualitative and quantitative modelling. The Planning Guide, within
this toolkit is our understanding of the key linkages within the system and how they
affect any interventions you may wish to take.
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Models and Modelling
There is a well-known cliché that says, ‘all models are wrong, but some are useful’.
The point is that a model is one way of exploring a system. It is a hypothesis of how
the system works. A good model can reveal new insights. Models are about helping
people gain insight and understanding not about accurately predicting an exact
future situation. ‘Knowing’ that the number of people with mental health conditions
predicted by a model is likely to rise above 30,000 in your region is less useful than
understanding how the system is working and how the parts of the system connect
together to produce that increase. Whether the number turns out to be 33, 000 or
38,000 is far less relevant.
What are the characteristics of useful models?
Models are tools that help us grasp the complexity of the world we live in. They help
us by creating a virtual world, with certain characteristics, that enable us to reflect
on and better understand the real world.
The first characteristic of effective models is that they are simplifications of the real
world, scaled down versions of the real thing; scaled down in terms of size and
complexity (Beer, 1994). Models are like sketches; not drawn to show all of the
subject’s many facets, but to highlight salient points. They give us a sense of the
whole as well as of the important aspects that the artist wants us to focus on. They
leave out much of what is there; and their impact upon our understanding of
complicated systems is gained by providing us with a simplified representation of
reality.
A second characteristic of a good model is that it is representative. That is, the real
parts of the real systems are represented, in their relevant positions, within the
model.
Because of these first two characteristics useful models are ‘workable’. They can, in
principle, work like the real thing. For example, a model of an emergency
department can ‘overflow’ with patients if there is excess demand due to an
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accident or winter flu, and a model of PMHC can show a growth in unmet need, if
services are not developed to meet it.
Finally, a model is useful if it is appropriate. The simplification and the
representation of the real world enable the model to provide information on aspects
of the real system that are of interest. While an emergency department model may
meet the first three criteria it is unlikely to meet the needs of someone concerned
with, for example, the impact of housing on childhood asthma. It will certainly not
meet the needs of people trying to come to grips with issues in PMHC.
So, rather than merely simplifying the real world useful models gain their usefulness
by forcing us to develop a coherent set of propositions that say something important
about the system we are investigating. A powerful model has a clear set of logical
propositions in which the logic and the assumptions underlying it are clear.
From this perspective models are ‘tools for thinking’. “Just as hand and power tools
add to the physical power and aptitude of humans, so these *....modelling…+ tools for
thinking may be used to add leverage to human thought and analysis” (Pidd, 1996).
Above all models are reflective tools, or as one writer put it:
“One can create a computer model of a forest ecosystem, consisting of a
group of assumptions and information in the form of computer language
commands and numbers. By operating the model, the computer faithfully
demonstrates the implications of our assumptions and our information. It
forces us to see the implications, true or false, wise or foolish, of the
assumptions we have made. It is not so much that we want to believe
everything that the computer tells us, but that we want a tool to confront us
with the implications of what we think we know” (Botkin, 1977).
We don’t, to paraphrase Daniel Botkin, want to ‘believe’ any model, but we do want
a tool that challenges our thinking; that helps us surface and test our assumptions
and test alternative perspectives. So, our models of PMHC, in this toolkit are not
accurate representations’ of all that may be involved in PMHC. They are attempts to
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focus on and capture salient aspects of the system to help people think through local
issues. It is through the modelling process that we discuss the information and the
assumptions that inform our thinking. It is through the modelling process that we are
able to explore the implications of our assumptions and reflect upon the things we
consider important.
System Dynamics Modelling
System Dynamics Modelling (SD) is one approach to building models. It focuses on i)
mapping the structure of the system by describing the causal links between key
factors and then ii) modelling the system to explore how it evolves over time
(Sterman, 2000). The mapping process is important in helping people understand the
complex and interconnected nature of the system they are dealing with. It can help
highlight the key causal connections and the unintended consequences and possible
side effects of their decisions (Homer & Oliva 2001). It is also an approach that has
been used extensively in New Zealand (Cavana & Tobias, 2006; Rees & Orr-Walker,
2006) and overseas (Dangerfield, 1999; Homer & Hirsch, 2006) to model key health
issues.
The value of SD as an approach is that it provides a way of mapping and modelling
complex systems so that the forces of change and their influence on each other can
be better understood and the overall direction of the system can be better
influenced. SD provides a way of bringing the best evidence available to bear on a
problem in a way that facilitates wide ranging engagement. Its ability to support
engagement is a key reason why it is becoming increasingly used to solve complex
health problems. Getting useful answers to complex questions requires people right
across the system to work together. The problems of health can no longer be solved
by the doctor alone, working with his or her patient. Nor can they be solved by the
planner, the accountant or any single health discipline. To work effectively in today’s
environment health professionals need tools that enable them to apply the best
knowledge available, in a way that brings together all the relevant people to work on
the problem. SD is helpful here as it provides a common language for discussion and
debate from across all these professions and disciplines. Too often when people get
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together to discuss important issues they come with their own language. The
language of accountants, of planners, of doctors, of nurses, and of managers is
spoken in different dialects and misunderstanding is common. SD provides a neutral
mapping language which can be used to ensure all relevant interests are mapped
and understood. Mapping, using the language of SD delivers a rich view of the
system that is relevant and understandable.
The visual nature of SD modelling also makes it a powerful communication tool,
enabling people to inform and educate others’ about the system, showing where
they fit in and how their actions influence the whole.
Toolkit Models
The most explicit use of the systems approach in the toolkit is the Planning Guide
and the simulation model, designed to help translate national data into data useful
at a regional and local level. Both use the SD approach described above. The
Planning Guide limits it’s modelling to a qualitative approach, describing key
elements within PMHC and how they are linked together. The simulation model
takes the national data from Te Rau Hinengaro: The New Zealand Mental Health
Survey and uses SD software to provide a model that provides some insight into the
implication of the National survey for local populations.
Throughout the toolkit however we have tried to take a systems perspective and
provide material that points to the importance of local context and understanding
the relationships that are at play within any system of PMHC.
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Beer S. 1994. Brain of the Firm, 2nd Edition. Chichester, John Wiley and Sons.
Berwick D.M. 2003. Disseminating Innovations in Health Care. Journal of the American Medical Association 289(15):1969-1975
Botkin D. 1977. Life and Death in the Forest: The computer as an Aid to Understanding, in: C. Hall and J. Day (eds.) Ecosystem Modelling in Theory and Practice: An Introduction With Case Studies, John Wiley and Sons, New York, p.217.
Braithwaite J, Westbrook J et al. 2007. An action research protocol to strengthen system-wide inter-professional learning and practice. BMC Health Services Research 7(1): 144.
Cavana R. Y & Tobias M. 2006. Integrated System Dynamics: Analysis of Policy Options for Tobacco Control in New Zealand. International Systems Dynamics Conference. Nijmegen.
Carlfjord S et al. 2010. Key factors in influencing adoption of innovation in primary health care: a qualitative study based on implementation theory. BMC Family Practice 11(60).
Dangerfield B. C. 1999. System dynamics applications to European health care issues. Journal of the Operational Research Society 50: 345-353.
Dowell A, Garrett S, Collings S, McBain L, Mckinlay E, Stanley J. 2009. Evaluation of the primary mental health initiatives: summary report 2008. Wellington: University of Otago and Ministry of Health.
Glasgow RE, Klesges LM, Dzewaltowski DA, Bull SS, Estabrooks P. 2004. The future of health behaviour change research: what is needed to improve translation of research in health promotion practice? Ann Behavioural Medicine 27: 3-12.
Greenhalgh T, et al. 2005. Diffusions of Innovations in Health Service Organisations. 2005, Oxford: Blackwell Publishing.
Haider M & Kreps GL. 2004. Forty Years of Diffusion of Innovations: Utility and Value in Public Health. Journal of Health Communication 9: 3-11
Homer J & Oliva R. 2001. Maps and models in system dynamics: a response to Coyle. System Dynamics Review 17(4): 347-355.
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Homer J & Hirsch G. 2006. System Dynamics Modeling for Public Health: Background and Opportunities. American Journal of Public Health 96(3):452-458.
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Kerr S, Penney L et al. 2010. Kaupapa Maori Action Research to improve heart disease services in Aotearoa, New Zealand. Ethnicity & Health 15(1): 15-31.
Kemmis S & McTaggart R. 2000. Participatory action research. In Denzin N & Lincoln Y (eds). Handbook of Qualitative Research. 2nd edition, Sage, California, 567-605.
Länsisalmi H et al. 2006. Innovation in Healthcare: A Systematic Review of Recent Research. Nursing Science Quarterly 19(1):66-72.
McCubbin M & Cohen D. 1999. A Systemic and Value-Based Approach to Strategic Reform of the Mental Health system. Health Care Analysis 7: 57-77.
Meyer J. 2000. Using qualitative methods in health related action research. British Medical Journal 320: 178-181.
Meyer J. 2006. Action Research. In Pope C & Mays N (eds). Qualitative Research in health care. 3rd edition. Blackwell Publishing, BMJ Books. Oxford
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Ritchie J. 2003 The applications of qualitative methods to social research. In: Qualitative research practice: a guide for social science students and researchers. Eds: Ritchie J & Lewis J. London: Sage (p27).
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Section 4: Methods
Overview
This chapter gives a general non-technical description of the methods used in the
project.
The 18-month translational research project, which aimed to answer the research
queries:
What do DHBs, PHOs, NGOs and other organisations need to do to provide quality,
appropriate primary mental health care (PMHC) ranging from mental health
promotion to treatment of disorders? and,
What are the critical contextual factors that will enable them to do this?
in order to produce a resource that would enable the sustainable enhancement and
further development of PMHC in New Zealand.
We developed a qualitative method that was a synthesis of Participatory Action
Research (PAR) and Case Study research, and was informed by an understanding of
the diffusion of innovation in healthcare, developmental evaluation, and system
dynamics.
Objectives
The key objectives were to produce the Toolkit for Primary Mental Health Care
Development, a ‘process’ output (the action research with the partners, see below),
and a research report.
Ethics approval
Ethics approval was granted by the Multi-region Ethics Committee on 3 August 2009
(MEC/09/56/EXP).
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Settings
The project was conducted in multiple specific settings in four districts described by
DHB service catchment areas. Specific settings included primary care, NGO, planning
and funding, PHO and secondary care locations. Gaining a strong understanding of
the specific settings was a critical element of the project, therefore we invested
signficant effort in ensuring members of the research team were present at the
locations where the research partners were doing their routine work. We also
conducted interviews by telephone and held meetings with participants by
teleconference, and held two hui in Wellington, one for the wider sector, at the
beginning of the project, and one for the research partners at the close of the action
research part of the project.
Participants
The participants were all stakeholders in PMHC in the four geographical localities.
They included service users, general practitioners, primary care nurses, PHO
adminstrative and management staff, DHB funding and planning staff. The four DHB
localities were: Hutt Valley, Hawke’s Bay, Counties Manukau and Nelson DHBs. We
refer to these as our ‘research partners’, and as the project progressed, in each
locality the partnership came to be represented by a small group of people, the
composition of which varied signficantly across localities.
In reporting the results we have not identified participants, either as individuals or in
relation to their specific organisational affiliation or DHB locality. At times we have
had to include some information that makes it possible to to identify the DHB
locality, for example, where the service has unique features. However, it is important
to remember that the nature of the project was to uncover commonalities and to
use observed differences to illuminate these. We have taken the perspective that the
system in each locality is uniquely and perfectly adapted to its particular
circumstances. Focussing unduly on single instances or exceptions may prompt a
‘league table’ type attitude, with either criticisim and blaming or unwarranted
praise. In our work on the Primary Mental Health Evaluation we came under
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signficant pressure (from the funder and a small number of participants) to identify
the ‘best’ service. That was not the spirit within which participants engaged in the
project, and in order to maximise the benefit from this ‘Toolkit’ project, we have
continued with this philosophy. We have been fortunate that as a consequence we
have been privileged to be in a position of trust with participants, who have been
generous with their time, stories and ideas.
Communities of interest
This project was also reliant on individuals and groups we have called ‘communities
of interest’. This comprises several kinds of people. Firstly, because we restricted the
size of the research team (in relation to the request in the RFP) in order to make it
manageable, we needed to ensure that all relevant constituencies could contribute.
As this was a PAR research model, and we considered that the research partners had
the best knowledge of their important stakeholders, our approach was to engage
with these stakeholders as part of the routine work development work the partners
were doing in association with the project. The aim was also to use the PAR process
to foster and maybe enhance the local use of these networks to problem-solve as
part of PMHC development. Other communities of interest also supported and
contributed to the project by sharing information formally and informally. This
included staff at the Ministry of Health, the Mental Health Commission and Public
Health Units.
Data sources
We used multiple sources of observational data, and a small amount of generated
data. The observational data was as close to naturally-occurring as could be achieved
given the participatory nature of the project, and was based on our meetings,
interviews and discussion with participants, telephone calls and emails, and
documents (some internal and some publicly available) provided by the partners or
sought by us. The data we generated purposefully was derived from a series of key-
informant interviews designed to elicit information that was not arising through the
planned work with the research partners. In some cases these interviews were
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individual interviews with people already engaged in the project who wished to
express views they did not feel they could express in workplace groups. In addition,
we used published data from the MaGPIe studies, Te Rau Hinengaro and the Primary
Mental Health Initiatives Evaluation.
All meetings and key informant interviews were audio-recorded and transcribed
verbatim. Some interviews and discussions were impromptu – as a result of ad hoc
phone calls for example, to organise meetings or for us to respond to a query from a
research partner. For these, written notes were kept. As the project evolved, the
researchers developed working relationships with the research partners around their
specific work-streams and an increasing number of brief ‘naturally occurring’
communications emerged. While we strove to record these, it was challenging to do
so, as for example, phone calls might be taken in airport lounges or while engaged in
other work. Significant communications and developments were briefly recorded
and shared with the wider research team at research meetings.
All recorded data is recorded in an archive and backed up electronically at the
University of Otago Wellington.
Choice of partner DHB localities
Potential partner DHB localities had been identified prior to commencement of the
project. While any DHB locality in New Zealand was eligible, the final choice of
partners was shaped by a number of factors including:
Aiming for a spread across a range of levels of PMHC provision ‘maturity’
The desire to include provision across urban and rural areas
Coverage of a range of populations (ethnicity, age and socio-demographic mix)
Capacity and readiness to participate
Existing relationships with key personnel in relevant DHB locality organisations
Geographical spread of partners across New Zealand
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Although the DHB Research Fund Steering Group had undertaken to facilitate our
work with the DHB locality partners by helping us to identify ‘project champions’,
this was not required.
The final selection was: Nelson, Hawke’s Bay, Counties-Manukau and Hutt Valley
DHBs.
Procedures
The project was heavily based around face-to-face meetings with the research
partners. Initially the meetings and topics were prompted by us and the focus was
establishing working relationships, identifying the key people, supporting the
partners to identify the key challenges in their planning and provision for PMHC, and
developing a joint work-stream that was consistent with partners’ current goals and
met the needs of the project. For the first four months, all research team members
attended all partner meetings. This was very time-intensive but was necessary to
ensure that we all developed familiarity with all partners and the partners had the
opportunity to engage fully with the research team. Following this, the core research
team (Collings, Gandar, Dowell and Rees) assorted into four unique pairs with one
pair ‘allocated’ to each DHB partner. The assortment was based on a combination of
the emergent needs of each partner’s work-stream, ensuring each pair contained an
academic and a consultant, and, pragmatically, on geographical proximity.
As the project proceeded, we gave strong prompts for the partners to develop their
own agendas for the work with us, in essence using us as a free consultancy service,
which we would participate in and observe. All partners put us under pressure at
some time to provide them with an agenda for developing their PMHC services.
Although they were very busy solving day-to-day problems in their PMHC provision,
such as how to manage an unexpected opportunity for additional funding, they were
less ready to engage in strategic issues. In keeping with the PAR approach, we acted
as a resource and a prompt but did not engage in directing partners’ agendas. Our
commitment to working at the partners’ pace and to their agenda meant that at
times progress (from a research point of view) with one or two of the partners was
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considerably slower than we had hoped. This was a direct reflection of the capacity
of the research partners to engage in any activity that was outside their immediate
urgent priorities.
At two time-points we requested meetings with the partners to further our own
research-specific agenda. These were to get feedback on our issues mapping
(relatively early in the process, with exact timing dependent on partner progress)
and input into the Toolkit development (later in the process).
As previously discussed, we planned for project engagement with communities of
interest to emerge from the working relationships between partners and their
relevant communities. At about six months, we recognised that this strategy was not
working as well as we had hoped, and we began to prompt this more actively. This
did result in a number of meetings between partners and external people relevant to
the partners’ work-stream, although we still chose to complement this data with key
informant interviews.
Key informant interviews were required for the areas of child and youth and alcohol
and other drugs. A relevant key informant was identified in each DHB and a prepared
semi-structured interview recorded and transcribed.
The full research team met on average monthly throughout the project. Most of
these meetings were face-to-face although teleconferencing was used. We had
planned to use teleconferencing more often, however as we needed to be more
proactive with the partners than we had anticipated, we increased the amount of
responsive planning and found that this was easier to achieve face-to-face than in
long teleconferences. The researcher pairs allocated to each partner also met and
communicated by email and phone as required, independently of the larger research
team meetings.
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Cognitive mapping
A key element of the participative action research (PAR) process in this project was
the method of engagement with each of the research partners in order to
understand and shape the issues that would be at the core of the Toolkit. The action
research process required a method that:
1. Supported multi-perspective group inquiry
2. Enabled collaborative cycles of sense making, issue construction and
convergence towards potential action research problems and solutions
3. Efficiently handled rich qualitative data from across the different research
partner contexts
Cognitive Mapping, a process originally developed by Colin Eden (Eden, 1988),
provided a basis for the method used to analyse the problems identified through our
collaborative work with each research partner. Cognitive mapping seeks to support
the social construction process that takes place as ideas and concepts used by
different participants are articulated, connected and constructed within reflective
dialogue. The method belongs to a broader stream of participative modelling theory
and problem structuring methods which have particular value in dealing with
situations of complexity and uncertainty.
‘Participatory modelling methods’ are an approach which aims to support a diverse
collection of actors in addressing a problematic situation of shared concern. The
situation is normally characterized by high levels of complexity and uncertainty,
where differing perspectives and conflicting priorities are the norm rather than the
exception. Typically, the most challenging element in addressing these common
situations is the framing and definition of the critical issues that constitute the
problem, as well as understanding the systemic relationships between these issues.
‘Problem structuring methods’ provide analytical assistance through 'on-the-hoof'
modelling, which are used to foster dialogue, reflection and learning about the
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critical issues, in order to reach shared understanding and joint agreements
regarding these key issues (Shaw et al, 2006).
In this project ‘cognitive mapping’ was used during the initial exploration phase of
the action research process when we wanted to reach a shared understanding and
joint agreement between the research team and the research partners regarding the
issues of concern.
Analysis of notes taken during face-to-face meetings, copies of white board notes
and transcripts of the recording of each meeting was undertaken to explore the
content of the conversation and dialogue taking place between the action research
partners in each of the location. The Decision Explorer software tool
[www.banxia.com] was used to analyse observations, statements and constructs
about the situation, problems and concerns which were noted in the form of very
short statements. Specific attention was given to the causal stories and connections
made during the ebb and flow of the discussions with each partner, the explanations
for why a situation had arisen or the description of the consequences or impact that
made it problematic. Using the software tool these connections were formalised by
linking related concepts in a way that showed the flow of explanation, from an
assumed ‘source’ or ‘cause’ to an ‘issue’ that has some consequence or significance.
An example of the issues and connections made is shown in the diagram on the
following page. It illustrates how short statements (constructed from the
conversations) were joined by connections which reflect the flow of explanations
that arose in the exchanges and dialogue between people with different
perspectives. In general, the story flows from the bottom to the top of the diagram,
describing the various sources of each issue (in this example concern about gaps in
service and inequities for the type of need) and resulting in the conclusion
“somehow we need a debate about how and where we spend our mental health
money”.
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An example of the issues and connections made during cognitive mapping.
focused on depression but in terms of loss of
function a number of other high value
areas
gaps & area's of poor focus, such as
child & youth
we being too focused and anal in
our targeting
in the midst of making cuts in
programmes, concern about equity,
including age equity mismatch between where MH problems start and where we
spend our $
somehow we need a debate about how and where we spend
our MH money
age and stage, further move to
youth the closer to health promotion
our programme very structured, too complicated, need simpler approaches
an 80/20 rule
a youth focus will not be a
disease/condition focus
age and stage; predictable stress
points - transitions into adulthood, relationship
separation, loosing job, retirement
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Each exploration session with the partners generated a considerable volume of
constructs, typically a hundred or more. To handle the complexity of this, clusters of
related constructs were developed using the software tool in order to facilitate
analysis of the meaning and content of each. Typically the clusters of constructs
were never discrete but richly interconnected. In order to preserve this
interconnectedness and the richness of the data but also highlight each of the stories
created by the clusters, a dotted line was looped around each cluster to highlight the
its significance. Along with each cluster a set of summary questions, about what the
cluster potentially represented in terms of issues of concern, were included. The
resulting maps (presented in the results section) were used during the second cycle
of meetings with each of the research partners. The maps were used to generate
further dialogue over the nature of each of the issues and richer, shared
understanding of what each of the specific issues is, what the causes are and any
potential consequences.
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Systems Dynamic modelling
Background
The models within the Toolkit were built using the principles of System Dynamics
(SD). System Dynamics is an approach to modelling that focuses on understanding
how the structure of a system, the key elements and their connections, determines
system performance over time. SD was first developed by Jay Forrester and
described in his book Industrial Dynamics (1961). Rather than focusing on statistical
tools, such as regression analysis, it bases its insights on an assumption that systems,
such as mental health, can usefully be considered as a set of causally linked
elements. By modelling these linkages it is possible to explore the likely
consequences of their interactions, that is, how the system will behave over time.
Technically, a SD model is a linked set of difference equations; differential equations
in a form that can be simulated (Sterman, 2000). These describe a dynamic situation
in terms of the key stocks or accumulations, for example people with depression.
They also describe the inflows and outflows to these stocks, for example people
developing depressive symptoms and those recovering. They also describe the
factors, decisions and activities that affect these flows, for example a television
social marketing campaign that helps people acknowledge and seek help for their
depression and increased access to therapies that increase the numbers recovering.
A simple example showing some of the factors that may affect recovery is shown:
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SD has been applied in a wide range of situations, including business, public policy
and health, where people want to use tools that help unravel complex issues that
have proved intractable to more simple approaches. Within health it has been used
in a number of areas. These include specific clinical areas such as HIV/AIDS
(Dangerfield, 2001), diabetes (Homer, 2005) and mental health (Hovmand, 2010). It
has also been used to look at risk factors such as tobacco (Cavana, 2006), obesity
(Homer, 2006) and cardiovascular disease risk factors (Homer 2008). Other areas
within health include service capacity (Wolstenholme, 2007) and emergency care
(Brailsford, 2004).
The purpose of the SD modelling in this research was firstly to provide an overview
of key elements that impacted upon areas of concern expressed by our research
partners. In developing a qualitative model of the system of mental health we have
been able to provide a framework within which those concerned with developing
more effective provisions of primary mental health care (PMHC) for their regions can
explore a range of issues and options while taking cognizance of the ‘whole system’.
The second purpose was to provide a dynamic tool that would help planners, funders
and managers within regions establish more reliable estimates of the burden of
mental health conditions within their populations.
Model Structure Overview
The figure on the following page provides an overview of the core model structure.
The population stocks are shown as orange rectangles and the flows into and out of
these stocks are shown as think black arrows. The significance of this structure is that
it shows the populations as moving in and out of specific symptom states. This was
agreed early on in our model development process as being reflective of the focus of
primary care, that is, a focus on the symptoms being exhibited by the patient
regardless of the underlying diagnostic category. This focus on symptoms, at an
individual and population level became a central focus throughout the research..
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The rest of the model that was developed around this core structure focused on the
importance of and the links between:
An understanding of your regional population
The impact of this population upon service demand
The service currently being provided
Ways of improving the services being provided
The impact of different models of care
Managing demand through the use of access criteria
Focusing on risk factors for mental illness
The importance of the social context
Data Sources
In obtaining data for the models we looked at two key areas. The first was data on
the structure of the mental health system, that is, what are the key elements and
how they relate to each other.
The first source of data was the work undertaken by the University of Otago
Wellington, who conducted an evaluation of the Primary Mental Health Initiatives
between June 2005 and November 2007 (Dowell et al, 2009). This provided an
overview of the different models of care that have evolved in New Zealand and some
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of the structures behind them. For example, one of the most common structures was
one in which assessment was carried out by phone or by a clinical co-ordinator. This
was followed up, where appropriate, with a package of care involving one or more
services. A second model had a similar approach, except that the assessment was
carried out by a GP. By combining positive features of all the different models, the
evaluation devised a conceptual schema for an effective ‘generic’ optimal model.
This enabled a first draft of our systems model to be developed.
This draft was presented to each of the research partners. The discussions that
followed enabled us to explore their current issues in PMHC, how they related to the
model and how the model could be used to help improve the conversations they
were currently having, by providing a structured inquiry tool. Feedback from the
initial meetings with each of the partners was used to refine the model. These
refinements were further tested and discussed with the research partners
throughout the research project.
During these feedback sessions it became clear that there was very little data that
could provide much insight into the burden of mental health conditions within each
region. The most comprehensive data was provided by Te Rau Hinengaro, the New
Zealand Mental Health Survey completed in 2004 (Oakley Brown et al, 2006).
However, while the survey is very comprehensive it only provides national data for
one specific point in time, with no data provided at the regional level.
To overcome this deficit, and build upon the best data currently available, we built a
SD simulation model that enables any region to gain estimates of regional
prevalence i.e. based on their own populations. The model is designed so that each
region is able to use the data in two ways. The first option allows the user of the
model to accept national assumptions, for example, the percentage of Māori within
the population, and run the model with those assumptions to gain regional
estimates. The second option allows the user to adjust national assumptions, such as
the percentage Māori in their population, the baseline prevalence, or the percentage
of the population for example, living in NZ Deprivation deciles 9 and 10. This
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provides not only a more realistic estimate of prevalence but does so in a way that
provides a tool for improving the level of inquiry and understanding by forcing each
region to develop a basic understanding of their local population. Along with our
focus on symptoms, our push to support a better understanding of population
characteristics has underpinned the models developed in this research.
Developing Optimal Model II
The purpose of Optimal Model II (OM II) was to refine the existing Optimal Model I
(OM I), shown below, in light of the knowledge generated from this project.
Figure 4.1: Optimal model for Primary Mental Health Initiative. (Source: Dowell et al.
2009. Evaluation of the Primary Mental Health Initiatives; Summary Report).
The refined model was strongly informed by the data, our experience of working
with the research partners and also by the emergent policy and health system
context for PMHC provision in New Zealand. This was especially challenging as
government policy and planning in relation to primary care, and including PMHC,
emerged extremely rapidly over the duration of this 18-month project. The latter
was critical as we aimed to ‘future proof’ the new model as much as possible.
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Developing a model that had some enduring properties was a constraint on detail,
although this does also mean that the model is permissive of some degree of local
adaptation. This model has now been superseded by Optimal Model II which is
shown on page 50 of the Knowledge Bank in the Toolkit documentation
Figure 2: Service user pathway (in the context of the structure of Figure 1)
A key difference between OM I and OM II is that OM I is essentially a descriptive
model, based on the positive observed features of the original 25 primary mental
health initiatives. OM II retains the descriptive elements but is more prescriptive for
example in terms of requiring boundary and rationing decisions to be explicit. OM I
has become embedded in New Zealand thinking about PMHC provision, so we
retained the general form so that users can easily transition to its adoption.
Service user identified (through General Practice or other route- e.g. Māori health provider) Initial assessment including clinical indicators and appropriate assessment tool(s) e.g. K10
Inclusion criteria met?
No
Yes
Clinical/social intervention
Clinical coordinator assessment
General Practitioner/ Practice Nurse:
extended consultation
and
or
Treatment interventions
Examples: talking therapy, pharmacological prescription (from GP), lifestyle interventions, self-management
Provide treatment within practice as much as possible
Monitoring and follow-up (over extended period) including appropriate assessment tool
GP/PN/Coordinator: phone, text, email, face-to-face
Select from usual range of GP
interventions e.g.
pharmacological intervention;
lifestyle advice
Secondary referral
Referral to other organisations e.g. NGOs
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Toolkit development
The main purpose of this study was to develop a Toolkit that would support
sustainable PMHC development in a range of general policy and finding climates. We
had multiple audiences (policy to clinical coalface) with multiple agendas, and the
scope of the project as specified in the RFP was very broad. There is a good deal of
material already on PMHC available and simply replicating content and tools that
were already in existence would be pointless.
Furthermore, ‘Toolkits’ have been in vogue recently, and we wanted to produce one
that was different to those already in existence in the New Zealand PMHC setting.
At the beginning of the project we devised a plan to guide us through the Toolkit
development process. Key activities were:
Sourcing and examining a range of Toolkits designed for other purposes
Preparing a list of essential requirements for the Toolkit (based on our
knowledge and experience and emerging data from the research partners)
Working with research partners to determine what their demands of a
Toolkit would be
Drafting and testing key materials and considering the relationships between
the Toolkit elements
Ensuring coherence between the Toolkit elements
Deciding what supporting material would be needed (to be contained in the
Research Report) document
The essential requirements of the Toolkit were that it:
Build on what already exists in the PMHC sector
Be accessible and readily useable in the hands of very busy people
Content areas must be congruent with the key issues facing PMHC planners
and funders at all levels
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Facilitate deliberate and forward-thinking planning (but still be useful for the
urgent reactive work)
Provide the right amount of supporting content (‘Not too heavy, not too
light’)
Partner input and testing essential
Be congruent with what is currently regarded as best practice in PMHC, but
be flexible enough to accommodate emerging clinical knowledge and policy
settings
Throughout the Toolkit development process we tested our ‘product’ against these
basic requirements, and the emergent OM II, in an iterative process that mirrored
the reflective activities commonly seen in quality assurance projects.
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References
Brailsford S, Lattimer V et al. 2004. Emergency and on-demand health care: modelling a large complex system. Journal of the Operational Research Society 55: 34-42.
Cavana R. Y & Tobias M. 2006. Integrated System Dynamics: Analysis of Policy Options for Tobacco Control in New Zealand. International Systems Dynamics Conference. Nijmegen.
Dangerfield BC et al. 2001. Model-based scenarios for the epidemiology of HIV/AIDS: the consequences of highly active antiretroviral therapy. System Dynamics Review 17(2): 119-150.
Dowell AC, Garret S, Collings S, McBain L, Mckinlay E, Stanley J. 2009. Evaluation of the Primary Mental Health Initiatives: Summary report 2008. Wellington: University of Otago and Ministry of health.
Eden C. 1988. Cognitive Mapping. European Journal of Operational Research 36:1-13
Forrester JW. 1961. Industrial Dynamics. Oregon, Productivity Press.
Homer J, Jones A et al. 2005. The CDC's Diabetes Systems Modeling Project: Developing a New Tool for Chronic Disease Prevention and Control. International Systems Dynamics Conference. New York.
Homer J, Milstein B et al. 2006. Obesity Population Dynamics: Exploring Historical Growth and Plausible Futures in the U.S. 24th International System Dynamics Conference. Nijmegan: 1-29.
Homer J, Milstein B et al. 2008. Modeling the Local Dynamics of Cardiovascular Health: Risk Factors, Context and Capacity. Preventing Chronic Disease 5(2): 1-6.
Hovmand PS & Gillespie DF. 2010. Implementation of Evidence-Based Practice and Organizational Performance. Journal of Behavioral Health Services and Research 37(1): 16.
MA Oakley Browne, JE Wells, KM Scott (eds). 2006. Te Rau Hinengaro: The New Zealand Mental Health Survey. Wellington: Ministry of Health.
Shaw D, Franco A. Westcombe M. 2006. Problems structuring methods: new directions in a problematic world. Journal of Operational Research Society 57: 7: 757-758.
Sterman JD. 2000. Business Dynamics: Systems Thinking and Modeling for a Complex World. Boston, The McGraw Hill Companies.
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Weaver Y, Nicholls V. 2001. The Camden “Alternative choices in mental health”. In Winter R, Munn-Giddings C (eds). A handbook for action research in health and social care. London. Routledge.
Wolstenholme E, Monk D, McKelvie D, Arnold S. 2007. Coping but not coping in health and social care. Masking the reality of running organisations beyond safe design capacity. System Dynamics Review 23(4): 371-389.
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Section 5: Results
Introduction
In this section we present the results of the Toolkit project. This includes the findings
from a sector workshop held in the early stages of the project; a timeline of our
meetings with the four research partners; followed by the results of the exploration
of the partners’ key issues for PMHC development. Finally, we present a summary of
the Toolkit itself. The full Toolkit, the main result, is presented separately in an
accompanying document.
Sector Workshop
Although we had many meetings and workshops with the research partners, and
have not reported on these in depth, we have chosen to report details of the sector-
wide workshop held at the beginning of the project because it provided an important
‘scaffold’ for the continuing work, and because it provided us with an opportunity
later on to check the Toolkit was reflective of the original wider stakeholder
perspectives. This was important given that the Toolkit needed to be ‘generalisable’
to the whole sector, yet our focussed work was with only four DHB locality partners.
In early March 2009 invitations were sent to DHBs, PHOs, NGOs, community groups
and secondary care providers with an interest in PMHC to attend a one-day
workshop held at the University of Otago, Wellington. The aims of this workshop
were: to begin to engage the diverse range of providers within the primary mental
health sector; to provide a learning and networking opportunity for the sector (we
provided an update on the primary mental health evaluation); to establish the
project as part of the PMHC landscape for the next eighteen months; to explore early
ideas on what the key challenges were for PMHC and this project at that time; and to
begin to explore some ideas about what aspects should be covered in a Toolkit.
As with all our meetings and workshops, this was audio-recorded and transcribed
verbatim. Although it was not set up as a focus group, as it was too large, we did
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obtain some of the advantages of focus groups as a source of data. Specifically, the
discussion itself illuminated the issue to a significant degree, the group setting
provided a social context within which to explore how stakeholders’ ideas were
shaped and refined through reflection and sharing ideas with others, and for
differences in views to emerge. Although we had a prepared agenda, we gained a lot
by not remaining tied to it, and responding to the group pressure for an opportunity
to work on defining the boundaries of PMHC.
Analysis was done at two levels. Firstly, very soon after the meeting, the research
team read the transcripts and their contemporaneous research notes, and extracted
high-level themes which were sufficient as a platform for the evolving project.
Around thirteen months into the project, SM, who had not yet joined the project at
the time of the meeting, read the transcripts and listened to the recordings and did
an in depth inductive thematic analysis of the discussion content. SM is a non-
clinical Research Fellow who did not have prior experience in PMHC or even in
primary care research. Having her do this in depth analysis freed it from any
particular biases or agendas the original core research team might have introduced,
and provided an important opportunity for us to check that the project direction and
in particular the Toolkit development was consistent with the original sector views. It
is this in-depth analysis that is reported here.
This workshop generated a lot of interest, with 21 participants from around the
country including: clinical coordinators, primary mental health coordinators, PHO
Team leaders, and individuals from Compass Health (formerly the Wellington
Independent Practitioners Association), Richmond (NGO), Pathways (NGO), Platform
(NGO), Te Korowai-Whariki (CCDHB), ProCare, The Royal New Zealand College of
General Practitioners, New Zealand College of Mental Health Nurses, Alcohol
Advisory Council of New Zealand (ALAC), District Health Boards New Zealand
(DHBNZ) and our four research partners.
The problem of definition of PMHC arose early in the discussion. This presented a
better opportunity to ensure the scope of the project was relevant to the sector than
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what we had planned, so we split participants into four groups and gave them the
task of defining ‘primary mental health care’. The results of these discussions and
the later whole-group discussion are presented here.
The fourteen key themes raised by each of the small groups are represented in
summary form in Figure 1, followed by descriptive précis of theme content
supported by verbatim quotations.
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Figure 1: Fourteen key themes from group discussions
Participation, partnership and
protection
Includes the broader
determinants of health
Consumer
focused
For all ages
Integrated and co-ordinated care
Alternative approach to
health Focuses on well
being
Involves primary
care
Community
focused
Uncommon
Provides ongoing care
Accessible
Family and
Whānau focused
Holistic
What is primary mental
health care?
Issues raised by all 4 groups
Issues raised by 3 groups
Issues raised by 2 groups
Issues raised by 1 group
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Workshop theme content
Here we elaborate on the themes identified by three or four of the groups. The
question being answered was ‘What is primary mental health care?’ Participants
were asked to think broadly and to include values, practice context, who it is for, and
nature of tasks. In the following text, verbatim quotes are in italics and in “ ”
quotation marks. ‘ ‘ is used for author’s emphasis.
Involves primary care
Four groups saw PMHC as being strongly anchored in general practice, and as being
represented by “what general practice is doing now”. The distinction between PMHC
and secondary care mental health was important, and in some respects one of the
defining features because of the importance of its non-institutional and less
stigmatising nature. PMHC involved early intervention and was the first point of
contact for health services for most people.
“… first point of contact, GP, helpline, pharmacy, etc., but then concluded that
actually I'd go to psych emergency as my first point of contact. So it's not too
broad. And it’s used a lot that term, we’d consider it’s not the right term.
What we did agree is it’s not secondary. Because in a sense it's not the
hospital, I mean it's the antithesis of the hospital, that’s the whole
philosophy”.
“The hospital tends to deal with mental illness and primary care focuses on
wellness, prevention and other dimensions. We got into community care and
the word community, and in general we ranged across that debate and it
ranged from its too broad and actually the hospital is part of our community.
When I go to hospital, I come out of hospital, I'm not actually leaving the
community, I'm not getting in a spaceship and leaving the planet, it just so
happens that in mental health, particularly as opposed to other health areas,
it’s not seen. When you go into the hospital you’re not seen as part of the
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community so we then talked about political aspects and stigma associated
with hospitals here”.
The importance of continuity of care, and the possibility for PMHC to reach out to
those who do not have a trusted and established provider, was also a defining
feature.
“In many cases people … have pre-established relationships with their general
practice teams and that’s fine, that helps the delivery of primary mental
health when you are working with people you know and you’ve seen those
people for a long time and they’re a known and trusted practitioner. But
there are actually a large group of people out there without those established
relationships, with any health care works. So the service, it has to be known
that there is help out there for people who don’t have established
relationships”.
Continuity of care was an advantage for some clinical problems:
“It has to be longitudinal because mental illness is … something that, well
there are often remissions so it’s not often a one-off issue, so you have to
have something that is going to be managing them on an ongoing basis”.
If there were effective links with the local community such outreach would be more
possible and probably more effective. However, it was acknowledged that many
practices do not operate on this sort of model but are more focussed on the small
business framework where work could not be done if there was no compensation or
if it was not part of an identified and reported work-stream. This was not necessarily
a deficiency but a reality – practices that operated on a business model could still
provide excellent PMHC and in some cases subsidised community outreach activities
from other funding streams.
It was notable that all four groups felt the need to establish that PMHC was related
to primary care and general practice. The term ‘general practice’ was used
frequently and appeared to signify the importance of the relationship with the
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doctor. This was balanced by the used of terms such as ‘general practice team’, but
no other professional groups were mentioned (e.g. practice nurse or counsellor).
Other professionals were only specifically named when they were outside the
general practice setting (e.g. pharmacist). The importance of naming general practice
may also have been a balance to shift the focus away from other ‘first point of
contact’ services such as help-lines and emergency departments. One participant
spoke of “any door [being the] right door [for mental health]” in the context of
broadening out from a focus on the GP although this was in the context of
accessibility (see below).
Includes the broader determinants of health
This was the second theme generated by all groups. The broader determinants of
mental health were discussed by many participants. These were issues not
necessarily always identified as being associated with mental health, such as social
connectedness and domestic violence or abuse.
“We would … be thinking of issues like bullying and family violence and abuse
and the impact that those things have on your mental health and wellbeing”.
“There’s just people who are lonely and isolated and …you might have a
chance to notice and do something as part of something else you’re doing like
diabetic care.”
The whole-of-life approach was important. There was reluctance to focus on some
age groups and leave others out, but there was support for the general idea of
targeting to high need, which was variously constructed as socio-economic
deprivation and ethnicity.
“We had a big discussion around ages and risk and target groups and we
decided that it would be important to take a whole of life approach, but also
to target where we know there is poor access and where people are not
getting the assistance that they do need.”
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“…have to ask what’s the point if you don’t include young people. That’s
where it all starts and that’s where it’s hardest to get any help from anywhere
else unless they’re really on the edge.”
“It’s all one life and the thing about primary care is you can get that
continuity and really know someone…you might be able to achieve a lot with
not too much if you already have that history and that relationship”.
The social context of people with mental health problems was acknowledged as
critical, regardless of ethnic background.
“… informed by cultural values and we would want to see a paradigm shift
where there’s a greater focus on an individual in the context of the whānau
and the community irrespective of your ethnicity.”
Several participants noted that ethnicity was not the only way social inequalities in
mental health were defined, and that the contributions of Maori and Pacific
frameworks for understanding mental health were acknowledged as making an
important contribution to thinking about mental health and mental illness in New
Zealand.
“There are lots of way to be unequal in your mental health… maybe ethnicity
is more important for some aspects of physical health but take men for
example and their suicide rates which is really just dying of depression that
no-one’s noticing or treating.”
Integrated and coordinated care
This arose from the discussions of three groups. Participants believed that PMHC
should be coordinated across District Health Boards (DHBs), Primary Health
Organisations (PHOs) and non-governmental organisations (NGOs) and provide a
broad and comprehensive range of services. Narrowly focused funding streams and
contracts were seen as having potential to create gaps that service users could fall
into, and a tremendous amount of time could be used up trying to bridge these gaps
on a case-by-case basis at the primary care level.
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“In some ways it’s a bit piecemeal, things have grown up because there was
an opportunity but it’s not well organised across organisations and the strain
of that is borne by the small ones and the NGOs”
“I’m not sure what integrated means until I find there’s a gap between
services and someone’s going to fall into it. Somehow it’s always someone
else’s responsibility”
“It’s got to be coordinated, so this thing here is about coordinated before you
get to the person who can help you. This is about once you’ve accessed the
service, how that service can then coordinate with other services to help the
patient”.
The idea of coordinated care overlapped with that of what is called in the USA the
‘healthcare home’, that is, the locus from where care is coordinated, access to other
services is brokered, and all the key information is held. One participant referred to
this as a ‘hub’:
“…it’s about the coordination hub for all [the] bits of you that need mental
health stuff; facilitation, coordination, intervention. Could be a hospital, GP,
NGO. So that’s definitely a hub role…”
The positioning of NGOs in relation to this ‘hub’ was noted by several participants to
be somewhat (and perhaps increasingly) anomalous in the emerging PMHC
environment.
“NGOs have a historical association with secondary care services and they
tend to be in kind of an outer space, no-mans-land because they’re locked into
the contract frameworks around secondary mental health services when in
fact they should be anchored probably, based on … with their GP services”.
“We have to refer people to secondary mental health services when they’re
not even eligible probably, just to get access to what an NGO can offer.”
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“We [NGOs] could do a lot for primary mental health care. A lot of these
‘minor’ mental health problems are social issues we can help with. It’s what
we do…but people can’t get access to us because of the contracts”.
One participant acknowledged that although one of the key attributes of
coordinated primary care was comprehensiveness, there would always be some
limitation given that breadth is traded against depth of knowledge in a small area.
“So the more common kind of term you use in general practice as far as
primary care goes is comprehensiveness, a broad range of services, broad
enough to care for all health needs. But acknowledging the limitations that
may be in that so that you have to acknowledge that there are some
uncommon presentations that you’re not going to be able to maintain your
competence”.
Holistic care
This theme also arose from the discussions of three groups. Many participants
considered that PMHC must see the individual as a whole as you cannot separate
physical, mental and spiritual health.
“The whole person being that, this bit is my mental health bit and I have
diabetes and cardiovascular disease and my mother’s just died and whereas
the specialist mental health services focus on this bit, they make pick up that
you’re in grief, but they may not pick up that you have diabetes or whatever”.
This was seen as one of the strengths of PMHC, and one participant linked this back
to the idea of the healthcare hub:
“…it’s that ability to know more about what’s going on for the person… in all
their aspects… because you have got all the information and you can retrieve
it… it could be really efficient from the patient’s perspective and from a
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mental health point of view they might feel that someone knew them well
and understood.”
Accessibility
Accessibility was mentioned by three groups. It was most commonly framed around
self-referral, affordability and ease of access from a practical point of view, and
mentioned as part of a series of descriptors of PMHC without further elaboration.
One participant framed it as also meaning that the service and clinicians were
accessible in the sense that they were willing to discuss mental health issues and
involve the whole whanau i.e. address mental health problems in the way service
users may want them to be addressed, as part of life. This view was supported by
that group and endorsed by the wider group later, especially in regards to the
perceived willingness of primary care clinicians to talk about mental health
problems. Another participant in the same group considered that any primary care
staff member should be able to manage the basics of an enquiry about mental health
care. Although it was not stated, this could potentially even include the receptionist
or any other staff who have contact with the public.
“It started off being equity but really we decided it was more ease of access,
was more where we were coming from. First contact care, which was of
course a more general practice point of view and that was developed into any
door is the right door [for mental health]. So it's saying not just the GP, it's
about whoever you can get access to at the beginning and they will at least
take you in and point you in the right direction”.
“They should be accessible, available by self-referral, that they’re integrated,
holistic, seen as a part of a service that’s offered to the whole whānau or
family, … that any mental health issues are seen as just a normal part of life
and that there’s a supportive team there to help when you’re going through
those issues.”
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Focus on health and wellbeing
Participants from three groups considered that PMHC should focus on supporting
mental well being and sustaining wellness rather than focussing on an illness
perspective. It was seen as being synergistic with general health promotion and
other programmes to improve social wellbeing, and not in a silo of its own. This was
the closest any participant came to speaking of mental health promotion per se.
“Primary mental health care should have a health focus not an illness focus
and be seen in conjunction with all the other health promotion projects that
are going on at the moment, such as HEHA, social consecutiveness issues,
things to do with housing, youth health. It's not isolated from anything.
An illness perspective was seen as having limited utility in the PMHC context, partly
because of the continuity of care, where a clinician will “get to know a person over a
long period through dealing with many health issues”, and also because diagnosis
was seen as having limited utility. PMHC should be about assessment rather than
diagnoses because “what matters is what you do to help, not what you call it and in
any case the diagnoses are not a good fit for primary care problems”.
“I said diagnostic from a general practice point of view but we changed that
to assessment, the emphasis being that it needs to be needs-based…we were
looking at mental wellbeing being one of the focuses to support a person to
get a life and keep a life”.
Finally, seeing mental health issues as being part of the continuum of the “ups and
downs of life” meant that service users may not identify with the service as a specific
mental health service. By extension service users may not identify as ‘mental health
consumers’.
“Many of the people that our team deals with do not identify with the word
mental health. They don’t want to. It’s just they’re having a moment, they're
stressed or they’re not part of the system. So not necessarily identify with
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mental health, which is pretty ironic considering it's the primary mental
health sphere”.
A community focus
Participants in three groups believed that PMHC should “meet the needs of the
community”. However this was poorly defined. It was unclear what ‘community’
meant, and whether or not this was focussed at activities such as mental health
promotion, or whether it was a general aspirational statement. One participant
articulated this as being associated with knowing what resources are available in the
community and drawing these into the plan for treatment and support of the service
user. The responsibility for doing this was seen by this participant as appropriately
belonging to the mental health coordinator.
“The people who are thinking about providing primary mental health care
services need to actually know what the needs of the community are, what’s
already available in the community, how people can work as a virtual team
and this, again, is the sort of thing that primary mental health coordinators,
these new roles that we’ve talked about, have developed. Mental health
coordinators know what’s happening in their community…”
Timeline of partner progress
Here we present a summary of scheduled formal activities with the research
partners over the course of the project from March 2009 through to June 2010. The
purpose of this is to provide a sense of how the project process progressed over the
eighteen months. The project progressed in three phases.
Phase One
This phase had two key tasks: to engage and partners and gain an understanding of
the critical issues facing the PMHC sector, from the sector’s perspective.
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In keeping with the PAR philosophy we began by working at the research partners’
pace. It became evident early on that the preparedness and capacity of the partners
to engage in the research process was variable, despite their willingness to ‘sign up’
to the project at the outset. In retrospect in appeared that what prompted partners
to actively engage in the process with us was an emerging urgent problem to solve
(such as how to make use of a new funding stream that suddenly becomes
available), or a need for medium term planning prompted by a change elsewhere in
the system that had potential to impinge on the PMHC programme. Only one
partner engaged from the outset because the project was relevant to and could
support their strategic planning for their district-wide mental health services.
Another partner did not fully use the opportunity to engage the support for their
current work-plan, although they were very generous with meeting us and providing
data. One partner was undergoing a major management restructure which had a
paralysing effect for several months.
Although this general pattern across all the partners caused us some concern at the
time, it proved to yield very valuable data about the capacity of the PMHC sector to
absorb new activity not explicitly tied to contract deliverables, and the extent of
organisational resilience to internal and external pressures. We had many
conversations with partners about time and capacity and uncovered and can
emphasise the fact that there is little ‘fat’ in the system but a high degree of
willingness to consider new ways of working and to be flexible to ensure that money
is well spent. There is a remarkable degree of commitment to PMHC, which is now
seen by the partners as an absolutely integral part of primary care programmes. The
issue of time being one of the most scarce resources in the PMHC system fed directly
into the Toolkit development process. We used the time in Phase One to thoroughly
investigate and map the issues that partners saw as most challenging in their work,
and where possible, to support them with some immediate problem solving to ‘earn
our stripes’ and demonstrate our commitment to them in the research process.
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Phase Two
In this phase the key task was to support the partners’ work-plans. The challenge
here was not to direct them. From their perspective a key data-gathering phase was
over, we had done some analysis and fed it back to them, and we were now into a
phase of supporting them. For them, this meant requests to us for direction about
what issue they should tackle first, or, if they had defined their issue, directions as to
what would be the best decision. For us, it was a delicate balance between providing
what they asked for and thus bolstering our credibility and further cementing their
commitment, and holding back so we could observe how they went about solving
their problems, and how they used information and prompts for thinking that we fed
in at strategic times in their work process. We made a commitment to the partners
to be as available as they wanted at this stage: they titrated this well with their
needs depending on how engaged they were in their own change and planning
process. They of course had limited time themselves, and it was usually not too
demanding to accommodate.
Phase Three
At the beginning of phase three we considered our progress and decided to become
more active with the partners. Having evaluated the amount of data we had and the
need to begin to direct the project more specifically towards Toolkit development,
we wanted to observe what happened if we were a more active resource. We
introduced this phase and change in approach by reminding them that the project
would be over in five months, and prompting them to consider working on an issue
that had been identified during phase one. One of the partners that had been
supportive but relatively inactive responded very enthusiastically and a period of
intense work dealing with some very challenging issues began. Again, although we
would have anticipated this to be late in the project in terms of utility, it actually
provided an excellent opportunity to test some ideas for the Toolkit.
The diagram on the next page shows the scheduled formal activities with the
partners, indicating the three phases of the project. Note that in addition to these
there were many phone calls, teleconferences and emails.
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Pattern of partner face-to-face and formal meetings March 2009 to June 2010
MARCH (All)
Full meetings with each research partner
Sector engagement
workshop
MAY
Hutt Valley Counties
JUNE
Full meeting or teleconference
with each research partner
PHO meetings NGO meeting Service users
meeting
JULY
Hutt Valley
Ropata PHO
AUGUST
Hutt Valley
OCTOBER
Hutt Valley Nelson
NOVEMBER
Counties Nelson
Hutt Valley
DECEMBER
Full meeting
with each research partner
Hutt Valley Counties Manakau
JANUARY
Counties
FEBRUARY
Counties
MARCH
Counties
APRIL
Full meeting
with each research partner
Child & Youth
MAY JUNE
Counties
Phase 1 – initial exploration of the issues; Phase 2: hands off but available; Phase 3: decision to be more active Immediate problem solving not guiding the research partners
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Exploration of the issues
This section provides the results of the issues exploration with each of the research
partners. For each area the research followed a process of:
1. Creating a framework for engagement
2. Undertaking an initial issues exploration cycle
3. Iterative development of an action research agenda
4. A cycle of dialogue, action and reflection, with a wide range of approaches, depth
and intensity depending on local capacity and time
5. A process reflection to understand what had been useful and how that experience
could contribute to a toolkit of knowledge and resources for the future.
As described, the pathway and timing of the process unfolded according to the capacity and
priorities of each of the partners. For some this was a formalised process with dedicated
resources and a project structure, for others the action research process was chiefly a
reflective learning opportunity – perhaps their only opportunity to stand back from the
busyness of daily activity.
Research Partner 1
The first research locality contained a diverse landscape of primary mental health care
(PMHC) activity, including Chronic Care Management (CCM) Depression programme,
primary mental health coordinators, Service to Improve Access (SIA) funding for people
living in deprivation quintile five, specific services developed by Primary Health
Organisations (PHOs) and practices and more targeted responses for specific populations
e.g. Pacific peoples.
CCM Depression was well established and the largest investment but with some recognised
issues:
It is condition focussed; excludes anxiety for example, although in practice the
limitation to depression may not be as tight as it appears
Questions over the upper and lower age boundaries
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Effectiveness currently limited to less than 50% of those eligible - 3 groups of
people in CCM, 20% non-attenders, (come once then drop out), 47-48% who do
well within 6 months, then nearly a third who stay longer with lower levels of
apparent benefit (questions of additional needs, non-compliance or access to the
right intervention)
Effectiveness of response for Pacific people - usage of CCM Depression by Pacific
people is low despite measured prevalence being similar to other populations, a
pattern also seen in utilisation of other mental health services. By contrast there is
high utilisation by Pacific for other CCM programmes such as diabetes.
Wider CCM questions over how each of the separate programmes are integrated,
e.g. to support those with complex clusters of needs and contribute to capacity for
self-care
After some years of having money to invest in a range of innovative programmes the district
is under financial pressure, leading to increased focus on the results and value of this
investment and how to gain greater coherence, synergies and impact across programmes.
Framework for engagement
At the outset of the participatory action research (PAR) process there was a considerable
period of discussion about how the research could assist the development of primary
mental health. This partner has a standing clinical leadership group that is supported by the
DHB. The decision to participate was treated as a potentially significant investment of
resources in time and money which meant the case for participation required an extensive
process of discussion. This resulted in a working set of issues, proposed by the local
convener that represented some ideas for joint action:
Better recognition and treatment of depression – is the current very structured
programme i.e. CCM Depression the way to go?
How does this approach spread beyond depression to other common MH
conditions such as anxiety and obsessive compulsive disorders?
How do we address the huge issues of substance abuse and unmet need?
Role of psychological interventions in pain management? By whom?
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Role of and access to CBT on a wider basis - how do we make it happen?
Need for Primary Mental Health Workers being based at practice level
(clusters/localities) - what's the evidence of benefit and if its relatively cost-
effective how do we make it happen?.
What is the role of psychological intervention in people with long term conditions?
By psychologist or other worker? If so how do we target the right people? What is
the relative cost-effectiveness compared to other interventions? Is this a
secondary not a primary intervention?
Interface with primary and secondary mental health and social issues - would a
multi-skilled social worker be more effective in reducing resource utilisation in
secondary care!
How to most cost effectively apply best practice and make interventions easily
accessible
First cycle issues exploration
An initial issues exploration working session was held with a local working group to explore
the issues.
Based on session notes and transcripts a draft set of concept maps was prepared by the
research team f as shown on the following pages:
Refocusing CCM Depression
The first theme that emerged centred on the combination of both benefits and limitations
of the CCM Depression approach. The focus on depression enabled utilisation of a strong
evidence base for screening, access criteria and treatment that has generated good
outcomes for those accessing services. It also enabled the utilisation of a wider chronic care
management infrastructure than primary mental health could have afforded on its own.
This infrastructure of systems, people capability and service support tools was seen to be
highly valuable and applicable on a wider scale than those who were eligible for specific
programme funding and services.
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“one of the issues here is that the funding in primary care is tied to programmes…. So
you’re either in or you’re out in terms of funding and I mean it was really nice to find
some way of saying that if you have depression or this mental health or that mental
health this set of supports in programme is there but for these people there’s
funding. So if someone comes in and they’re depressed and for whatever reason they
don’t need to or don’t want to or don’t meet the criteria to go into CCM Depression
or whatever, the rest of it’s still there to support the GP in terms of the, you know the
screening, the IT support and so on. Actually ultimately funding out at whatever
success looks like. If you’re actually funding that at the end as opposed to funding
inputs at the beginning you’re going to have better results.”
However the tight focus on depression was seen as “putting a lot of eggs in one basket”
“90% of our investment is in just one area, depression. Is this right?”
In many respects the desire to broaden the focus of from depression recognised that
presenting mental health issues in primary care frequently do not fit condition based
diagnostic categories and that GPs were already pragmatically broadening the criteria, e.g.
people presenting with moderate anxiety could meet the programme criteria for
depression.
“we know we want to look at different mental health disorders, we want to look at
alcohol and drug. We want to look at anxiety, we want to broaden the age category
as well but we also want to know the risks involved in doing that, the cost of doing
that.”
In summary while CCM Depression represented the major investment it was not the totality
of the primary mental health response in the district. The choices about whether to focus on
improving the effectiveness of the existing CCM programme, widening its scope or
eligibility/age criteria or improving the impact/linkages for people with complex clusters of
need to be considered in the context of the broader ‘primary mental health system’.
There were seen to be potential benefits from shifting from a condition focus to
understanding the common pathways across a range of needs and developing tools to
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manage a range of responses including low cost, brief interventions, problem solving,
forging better connections with self-care.
With a general acceptance of the value of refocusing CCM depression the issue became
framed as;
How could the core programme be extended and widened to better meet need while
retaining the benefits that the depression focus has provided?
Integrating PMHC and wider long term conditions approaches
While structured PMHC in this research partner initially developed as a module within the
Chronic Care programme the relationship between approaches to support mental health
and approaches for long term conditions is still seen to represent substantial questions
about the nature of need and the benefits of integrated approaches. (Note, in part these
questions were being raised from the context of a wider CCM performance and quality
development programme, of which the development of approaches to primary mental
health was part).
From a need perspective the addressing the mental health aspects of people with long term
conditions was seen to be a critical leverage point for more effective self-care, treatment
adherence, better outcomes and potentially lower costs for a population with a high burden
of overall morbidity. Yet at a service level there is no routine screening for mental health
issues as part of disease based chronic care management.
The issue became framed as a question over the role of psychological interventions for
people with long term conditions. Is this part of the focus of a primary mental health service
or is this just part of the core service of a good long term conditions programme? Given
that the brief interventions, motivational development, problem solving and self-care
development approaches were seen as very similar the developmental issue became:
How could we leverage and focus long term conditions management to address
mental health issues directly, drawing on, and contributing to a common capability
with primary mental health?
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Focusing on sustainability, outcomes and value for money in primary mental health
Flowing on from the previous two issues the discussion participants raised a number of
issues about how to manage a shift from an early stage of evolutionary development of
primary mental health into a more mature and sustainable pathway. This was a rich
discussion about how to build on a successful initiative while recognising its weaknesses and
limitations:
“I subjectively compare people I see in one DHB area to another so it’s just a
subjective ballpark thing. My sense is that I see less people [here] who have been
sitting on Fluoxetine for two years and are still depressed than I do across the
boundary. And so I think that the model used here has actually shifted practice
behaviour in a way that it hasn’t occurred in that other environment. But how do you
tap into kind of generating those questions let alone answering them to then inform
how you kind of, the kind of things that might make a difference to outcome.”
Limitations were seen to have arisen through the siloed funding streams, programme
ownership and accountability arrangements inherent in a programmatic approach; framed
as a choice between comprehensive primary care or selective programmes for specific
issues. This led to questions about the relationship of the various disconnected streams of
mental health services and how a coherent view of the role and function of primary mental
health could be developed that would make the best use of all the resources in the system.
“The patients accessing specialist mental health services are not that different in
severity or complexity than those we see in our practices”
“it’s largely been funding that’s restricted us really so that’s, you know it was only the
availability of this national primary mental health initiative funding that even
allowed us to really investigate the possibility of doing what we’ve done”
Through this discussion the need for a framework to guide development and investments in
primary mental health emerged:
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“If we only had 10 million dollars these are our top priorities. If we only have 5
million these are the ones that we want to spend that money on and then plus use
your research and evidence and using evidence based treatments which is the best
sort of programme to put in there”
In particular the value of a framework would be to build a sense of purpose and direction
that the seemed lacking in the programme and initiative funded development of primary
mental health to date.
“…if you’re going to have these conversations don’t let yourselves get hijacked by
where the money comes from”
Choice of focus
From the idea of developing a framework for guiding the development of PMHC the issues
of choice of focus started to emerge in the discussion, as shown in the second concept map.
Here the debate circled around three interwoven themes:
Choice of target population: The existing narrow depression focus raised issues of
exclusion of populations with high levels of need and ability to benefit. The current
programme used hard cut off limits based on age (18 – 65 years) that were seen to
be in equitable. Older patients could equally benefit from primary based mental
health services. The gaps in terms of services targeting child and youth highlighted
a mismatch between where mental health problems start developing and where
the primary mental health money is invested.
Usage of diagnostic categorisation: The discussion raised questions over the value
of continuing with a diagnostic based service design and access criterion or
whether an alternative view based on symptomatic stress, complexity/capacity
and ability to function would provide a better way of understanding mental health
needs as seen in primary care.
Choice of model of mental health: Prevailing thinking and discourse within mental
health was seen to be conditioned by entrenched mental models, while these may
be appropriate for severe and enduring mental health conditions they were not
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necessarily appropriate for primary health. Assumptions about the enduring
nature of mental illness and concepts of recovery drive service models that are not
appropriate to the episodic, short duration response that are effective in primary
settings. Avoiding diagnostic labelling and the consequent drag of services and
resources was seen as a critical part of developing a framework.
From the issues exploration phase it was clear that there was a strong desire to build on the
existing base of services but where and how to evolve PMH in the district was not clear.
However in order to be sustainable the principles behind existing approaches will need to be
maintained; a focus on responding to severity of need, not putting resource against those
who will get better anyway, focus on those who have a much lower rate of spontaneous
remission & evidence for a benefit of intervention, (shorten duration of episode, time to
recovery, reduce risk of reoccurrence).
Addressing disparities e.g. low utilisation of services by Pacific peoples
Of particular concern to the group were unresolved issues of addressing disparities in
service access, utilisation and outcome. Within this research partner, this was clearly seen in
utilisation of services by Pacific peoples. While there had been a substantial investment in
developing Pacific capability, services and organisations that did not seem to be translating
into the expected outcomes. With a variety of views over what drives this gap the
implications for the development of sustainable primary mental health services was unclear
and an unresolved issue.
“..[there is a] stigma of shame within the Pacific population [with regards to mental
ill health]. It’s a cultural character type where you are seen as bubbly and positive on
the outside when in actual fact you are not on the inside. Perhaps it’s about looking
at grass roots, destigmitisation education type stuff via churches mainly and other
community organisations. Doing some work around increasing the understanding
and sensitivity of GPs, practice nurses and front desk staff to the Pacific world view
and view of reality…and see what difference that makes. However although we may
want Pacific to Pacific, that is tricky because there is issues of family contacts and
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knowing people through other networks. It’s not as easy as [offering] Māori to Māori
services. There is something unique about this. Perhaps we just need to try stuff, see
if it works and learn from it”.
Development of the action research agenda
The draft concept maps were bought back to the discussion group for a further cycle of
reflection and review to develop a sense of the priorities for development effort. Based on
the discussions within the local research partnership the research team proposed four
possible candidate areas for joint action research and learning:
1. To develop an understanding of the ‘as-is’ primary mental health system across the
multiple programmes and organisations involved, as a container for design, planning
and improvement conversations with different stakeholders.
2. Within the existing CCM evaluation/redesign develop a framework that can integrate
the programme within a primary mental health system that provides layers of
service with differing intensity, type of response and mix of resource requirements.
Identify tools that facilitate selection of service kind and intensity to match need
with clear inclusion/exclusion guidelines, and criteria that take into account need
and resource or capacity driven constraints. Develop ideas or specifications for the
necessary infrastructure to implement and sustain this within the overall primary
mental health system.
3. Using the locality focus being developed by CMDHB, (e.g. Mangere) facilitate an
action research inquiry with Pacific stakeholders to identify and explore the leverage
points for increasing Pacific access and engagement with the district’s overall
primary mental health responses
4. Explore the linkages between primary mental health, the management of long term
conditions and person centric approaches to developing self-care capacity. How
could better integration improve outcomes and manage limited resources?
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Research Partner 1 cognitive maps from May 2009
Programme Sustainability / CCM Linkages
2 comparing CCMversus some otherway how do we
broaden it to otherthings
3 how would we grow
the PMH workforcewith some priorityso we have the
capacity needed
4 what is the return
on investment ofPMH, what difference
will it make togrowth in acute
medicine?
5 how do we move onfrom initiation tomaintenance &
sustainability, what
do we change
6 what systems &structures to we
have to demonstratewhether we make a
difference
7 how do we know ifwe have made a
difference?
8 what changes will
make a difference? I11 where would we
put additionalresource?
12 potent treatment
effect but a black
box as to what
cuases it
13 choice oftreatment and
intensiveness notclear cut
14 services have
grown organically
15 choice ofintensiveness, 4 or6 makes a huge
difference tonumbers treated &capacity required
16 relativelyhaphazard targeting
and inclusion
17 focused ondepression but interms of loss of
function a number ofother high value
areas
19 benefits offunctionality
widespread but notwell understood
20 health service
utilisation
21 change in
employment status,unhealthy days
22 there is likelyto be no more PMH $
24 depressioneasiest first target
26 focussing andshifting difficult
to do at all levelsof practice and
organisation
28 CCM are we beingtoo focused and anal
in our targeting
29 CCM a lot of eggsin one basket & a
lot of other issuesin PMH that we are
not addressing
33 some how we needa debate about how
and where we spendour MH money
34 metered
investment acrossthe contiuum of
need, how to portraythe pattern of our
response
35 developing steps
in intensiveness,using the all theresources in the
system
36 Patients
accessing SMH notthat different fromthose we see in our
practices
41 can we create
links and synergieswith what is already
happening (LTCinitiatives)
42 overlap between
needs of those
complex end in CCM &
those accessing theseparate CCM
Depression
43 impact of MH onLTC is absolutely
key to makingprogress
44 MH as impedimenton self care
45 serviceefficiency benefits
of links
52 the MH
consequences andopportunities of LTC
53 CCM too
complicated, need
simpler approaches
an 80/20 rule
54 CCM parts don't
interact well witheach other
55 comprehensive
primary care or
selective programesfor specific issues
56 advantages anddiadvantages of
silos in ownership,accountability,
funding streams,
engagement
57 good evidence forthe links between
LTC & MH
58 would it helpleverage and refocus
CCM, eg address MHissues directly
59 move towards a
spectrum approach ofMH & LTC?
60 what should belabelled a MH
problem?
67 level of needbased responses
71 use project to
form core of astream of activity
around CCM
depression, shifttowards outcomes
86 90% of investmentin CCM deppression,
is this right?
Integrating PMH &wider LTC approaches
Refocusing CCMDepression
Focusing on outcomes,sustainability & value formoney in PMH
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Shift of focus – age/stage & mental distress?
17 focused ondepression but interms of loss of
function a number of
other high valueareas
23 gaps & area's of
poor focus, such asyouth
28 CCM are we being
too focused and analin our targeting
31 in the midst ofmaking cuts in
programmes, concernabout equity,
including age equity
32 mismatch between
where MH problemsstart and where we
spend our $
33 some how we need
a debate about howand where we spend
our MH money
38 age and stage,further move to
youth the closer to
health promotion
39 more move towardschild & youth the
less clear theevidence base
53 CCM toocomplicated, needsimpler approaches
an 80/20 rule
60 what should be
labelled a MHproblem?
61 PMH forcompexity/stress
62 but no evidencefor progressiveness
to severe MH
63 strongly heald
beleif structures inMOH and NGO
64 earlypreventative action
theories
65 supports anindustry
66 a youth focus
will not be adisease/condition
focus
83 philosphicalissue aboutchronicity
longrevity vs shortsharp help
84 the recoverymodel thinking asdriver of long term
'dependancy'
85 lebelling andmarketing of CCM
inappropriatemessage for all PMH88 if we could make
stress & its impactsexplicit could be a
different windowinto responding
89 age and stage;
predictable stresspoints -
transitions, intoadulthood, reln
separation, loosingjob, retirement
90 what we need is
access to SRI,electic CBT and a
social worker
91 how can we avoid
diagnostic drag -the label drags
services and
resources
Wider focus on complexity, & age/stage issues?
Avoiding the pitfalls of entrenchedmental models of what mental health support services require
Developing a better understandingabout what outcomes we want in primary mental health
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Action Learning Process
As a result of the second cycle discussion on priorities and purpose and scope was agreed to
by the local steering group to be narrowed down to focus on the development of a planning
framework: (ref CM PMH Working group TOR 2009)
Objectives
1. To develop a coherent planning/service development framework for primary mental
health and addiction services for people with mild to moderate mental health issues.
2. To develop a list of priorities within the framework for new, or enhancements to
existing, services over the next five years.
Scope
The five-year service development plan will include primary mental health and addiction
services that:
Relate to the recognition and management of high prevalence mental health
disorders in primary care
Cover all age ranges of people with mild to moderate mental health conditions
Include early recognition and referral pathways and follow-up of low prevalence,
high acuity disorders
Address the physical health needs of people with severe and enduring mental
health disorders
Address the mental health needs of people with chronic physical health disorders
Address the interface and collaboration with secondary mental health services and
NGO services
Address psycho-social complexities and linkages to other physical co-morbidities
and self-care capacity development
Include pertinent aspects of health promotion and prevention services
Are evidence-based, implementable and affordable i.e. are cognisant of funding
restraints and opportunities
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Are informed by, and support a whānau ora approach.
Excluded from the service plan are:
Secondary and specialist mental health services structures and funding.
A process based on four cycles of research, review and development the basis of the action
learning cycle took place over five months. The first three cycles focused on specific
populations, considering the mental health needs, service gaps and potential benefits for (1)
adults, (2) older adults and those with combined mental health and physical health needs,
(3) child and youth. The fourth cycle sought to integrate the reflections and
recommendations into an overall planning and investment framework.
The working group of eleven members was supported by a clinical leader, a project manager
who also provided research and writing services.
Each cycle was initiated with a set of selected research articles, policy documents and
position papers that formed the core of the group discussion. Formal minutes were
provided from each meeting.
Action learning results
A formal report was produced from the partners’ process with recommendations across a
wide range of areas:
1. Enhancing ‘usual care’
The working Group recognised that the large majority of mental health services provided in
primary settings is part of ‘business as usual’ rather than structured primary care
programmes.
“we’re obsessed with additional, relatively small amounts of money. What we also
want to do is up stand of primary cares usual mental health interactions with
patients which are not going to be funded ever out of additional money but by the
money which is currently in primary care. And we haven’t focussed much on that and
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I actually think there’s a hell of a lot of gain to be done focussed on that interaction
as well as anything you might want to do additionally with additional money….and
we can’t fund usual care, there’s so much of this we can’t fund it with all new
money….. Cause actually most of the funding goes into usual care anyway relatively
so.”
“funding is inferred in usual care anyway and if you look at the cost of the primary
mental health initiatives nationally…here 2.5 million we get from initiatives which is
great, which is wonderful but you’ve got to weigh that up against maybe 85 million
that primary care gets first level services, that’s for their habitation and SIA funding
and everything else. So that’s nothing compared to usual care so that’s why we can’t
ignore what is expected from usual care anyway. And five years ago it wouldn’t have
been 85 million. Probably the same sector would have gotten 5 million, you know it’s
been a massive injection of funding in primary care over the last, since the primary
care strategy”
In recognition of busy primary health teams the group recommended:
Extending primary mental health coordinator roles from the current small base to
achieve a fulltime dedicated Mental Health Practitioner available to every large
primary health practice.
Implementing a comprehensive primary mental health workforce skills
development programme through a mixture of utilisation of existing development
programmes, development of new roles and better utilisation of capacity across
primary, community and secondary services
Expansion of the districts current self-management programme ( a generic peer led
Stanford model) into a programme for people with mental issues and active
promotion of ‘The Journal’ and e-CBT programmes as part of a standard package of
care in general practice. Two related recommendations proposed the development
of local peer support networks and directories of local community services to
enable people to find self-help support in their local area.
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Developing a community pharmacy programme to provide medicines compliance
support for mental health
Development of screening and triage capability for earlier identification of issues
greater access to primary care based support.
2. Structured Care Programmes
The Working Group reviewed the population health needs and service gaps for a range of
populations in the area. It proposed a set of changes to the existing depression focused
programme:
Maintain the current severity thresholds but widening the focus to include
depression, anxiety and addictions
Lifting the age cut-off beyond the current 65 year limit with the inclusion of
screening for cognitive impairment in older adults.
Provide screening and brief motivational and counselling interventions for alcohol
abuse as a core primary mental health service
Provide better physical health care for people with severe and enduring mental
health conditions and physical health co-morbidities
Developing a comprehensive approach to primary care based youth mental health
services that includes actions to increase awareness of youth mental health issues
in primary care, support various forms of youth access and develop cross
organisational linkages and support
The Working Group saw a huge investment potential to initiate wellness
programmes at birth with a focus on identifying and engaging high risk mothers
and families and develop means to intervene effectively.
“Because the biggest thing that has come through since my involvement in primary
mental health over the last seven years is that the key thing for GP’s to have, to
effectively engage with their patients is time, additional time. And every time, every
minute that ticks by somebody’s paying for the heat, light, power that’s happening in
the background okay. And it’s either the patient or it’s the GP themselves or its some
funding agency… So if they are required in terms of good delivery, good general
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practice to offer additional time to a consult that may be around something else that
the patient’s presenting for but they know the deep rooted cause that the person is
there is actually for depression. They actually want to effectively engage, they’re
going to have to commit to additional time either themselves or, so if the toolkit can
allude to the fact that it doesn’t have to be the GP that offers that intervention for
those that are mild perhaps…. And there’s an opportunity to up skill the other
workforce component tree to effectively engage with that patient. Cause basically
the patient, even if the patients rung every second week by the nurse to say how’s
the Fluoxetine going, I mean that’s massive. Now that could be actually cost
effective because the patient doesn’t have to keep coming in and taking up the GP’s
time so. ”
3. Enhancing the interfaces with secondary care
While outside the scope of the Working Group it generated a number of ideas about how to
improve the interface. It recommended that a whole system approach is required using
either process mapping or the patient journey to identify which aspects of the system are
breaking down and why and the extent of the breakdown (requiring detailed analysis of
current patient activities). Every team member in both sectors needs to be involved in this
review process.
“ [mental health] needs to be integrated into the whole practice team and what
we’ve got is a workforce that’s going to be coming through that’s not necessarily
going to be the doctor or the nurse. And actually how can we give them skills and
tools and techniques to be able to, you know have some of those conversations and
deliver some of that…we’ve got a huge amount of community health workers out
there that would have more understanding around the social needs of these patients
than probably anybody in the practice because they’re in the homes that are having
that. So what tools and techniques and skills can we be giving them and developing
them to actually provide some of that intervention, some of that support. Sometimes
it could be as much of just brokering to get them to the GP to have that conversation,
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you know. So I mean you’ve got a workforce that’s going to change over the coming
years.”
Research Partner 2
The 2007 Primary Mental Health Initiatives programme provided the starting point for
structured PMHC with this partner. These were developed by each of the five PHOs in the
district with varying approaches, from an integrated practice based service at one smaller
PHO to a large primary mental health team operating as a referral based primary health
service supporting a number of practices at a large PHO. The services had largely developed
in isolation from each other and from secondary care. Integration at a district planning level
was seen as desirable and part of the reason for participating in the action research process.
Framework for engagement
The energy for engagement in the action research process in this partner came from
secondary services who had undertaken a “Knowing the People Planning” process with their
secondary service consumers that highlighted a need for better functioning across the
primary /secondary boundary.
The action research project was seen to be aligned with planned work of secondary services
to improve the interface and work more effectively with primary mental health services in
this research partner locality. It was seen as an opportunity to improve networks with
colleagues in the primary health sector and explore how available specialist resources could
be better employed to meet the clinical needs of those with mental illness in the regions.
Through the support of DHB Funding and Planning a series of exploratory workshops with
primary, secondary, NGO and consumer representatives provided the framework for
engagement although the primary source of energy and resource for the project remained
with a secondary based clinical leader, service manager and project manager.
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First cycle issues exploration
Five separate issues exploration sessions were held in the area: two with primary care,
together with NGO, consumer and specialist services.
Primary care: Core focus – people with mild to moderate stress
There was a strong representation from both primary health teams that there was a large
gap between the assumptions of the primary health strategy; a continuum of mild,
moderate to severe with primary health expected to address the mild to moderate end of
the spectrum, and the need that presented in primary care. In their view primary health is
providing effective response for a mild to moderate level of need largely arising from a
complex array of life problems only some of which is represented by mental health
disorders. The core business of primary mental health is to address presenting need created
by complex combinations of the effect of stress, complexity, lack of resiliency and loss of
capacity to function. In their view, there is a clear boundary between severity in these terms
and smaller proportion of those with severe psychosis needing specialist treatment and
ongoing social support.
The primary health teams were proud of the results achieved by the PMHI to date but also
acutely aware that their level of resource was limited. This raised a number of issues:
Questions of threshold and intensity for mild to moderate stress. The PMHI model of
brief problem solving interventions is seen as being appropriate but with constrained
funding. The cost of care is heavily influenced by the number of session contracted
per episode. This varies considerably across PHOs. If the funding is to be effectively
utilised there needs to be some rationale and consistency. Options with a lower level
of services intensity were seen as potentially needed to meet the level of demand
that has been exposed by the introduction of the service.
Development of the most effective model of care for those significant stress and
dysfunction but who can most effectively be treated in primary and community
settings
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Options for those with severe needs arising from complex life problems for those
who need a combination of primary care but supported by different form of
specialist assessment, advice and a wider range of support than can be provided
under PMHI funding
“I think this movement into thinking more at a community level population level is
actually really an important thing to think about in this area, I’m thinking about
funding, funding’s always [an issue], things are much more expensive when you have
really intensive one on one engagements, you have to have them, they’re absolutely
crucial but there’s a whole other level that is able to be dealt with where you’re
reaching more people for less money and preventing, so it’s like you focus here
absolutely and you do it right and you also bring in this other dimension…and it’s
much harder to measure and demonstrate.”
“We have now built up expectations in the community, word is out and I feel on a
moral point of view, that we can’t stop it, it has to keep going. I’m just concerned
about how, now that the word has got out, last month we had 30 referrals, that’s a
lot of referrals. We’ve asked our GPs to get engaged, they have engaged, now the
flood gates are open, it’s about how are we going to manage all that in the future
with a limited budget because I think this happens a lot, we have a lot of pilot
programmes and it’s not just this one where you set up an expectation and you get
good feedback, you get engagement at a community level and then you say, actually
we’re going to peer it back or we’re actually going to stop it. And I don’t think this
[particular] programme; we can’t afford to stop it.”
However development of effective responses to these issues was seen to require a more
district wide approach to PMHC. Developing this would be a challenge since there were
severe constraints on primary care leadership, particularly GP time, wide variety in PHO
approach and capacity and no district wide primary mental health strategy or leadership
that could take on this challenge.
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NGO: How will primary mental health and the NGO sector make best use of their
combined resources?
The session exploring NGO perspectives described a combination of appreciation that PMHC
was providing a new and better form of access and a concern that the multiple different
models of primary mental health risked duplication, poor use of NGO existing capacity and
potential competition for limited resources. Identifying how to engage with PHO mental
health services to understand the issues has been difficult:
“PHOs are trying to get people onto their lists and into their services a lot quicker
than what was happening 18 months ago so we see that as quite a positive move for
people in that respect... and you do get that feedback that there is certainly some
PHOs that are actually very good at what they’re putting in place and what’s
happening within their services.”.
“...the way the PHO development and the way that it’s kind of come in, to me it says
it’s very very hard to get your head around you know, people are working different
models and that each, you know under those models, are prepared to offer you
know, more or less kind of services of what they’re operating, what they’re actually
able to give to clients and there been, my concern at the beginning was that there
was going to be some duplication, you know that there were services already
operating that were providing a good service, that had developed the expertise and
that the PHOs were gonna come and kind of start replicating that just because they
didn’t know what already existed... , I’ve invited the local PHO to come on a number
of occasions, it just hasn’t been productive at all, to get someone along.”
Barriers? “Yeah, I was just going to say money, and I think very guarded about their
pot of gold and what we’re really going to do with it and once you’re given it, you
don’t want it taken from you, but it’s not like that at all, it’s not like that at all, you
know they do preventative mental health care, then that’s what they’re doing, you
know lets know about it, except some of our people when they get referred onto
PHOs under the care of that general practitioner, well then let’s know about it, you
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know what are you doing so we can support people on that journey, and vice versa,
we haven’t had any referrals from PHOs and we’re the only service out there.”
NGOs were concerned about how to be effectively involved in the development of the next
stages of a more inclusive model of care incorporating primary, community and secondary
capabilities. Their strengths lie in their capacity to provide a person centred, tailored,
holistic response that includes peer, family and community resources. The lack of effective
engagement of PHOs with the NGO sector created a concern that this may not happen.
“It would be really very good but they [PHOs] don’t really have an established
working relationship with the NGO group that exists within the region and that’s a
concern, and they’ve been invited to you know, sit at the tables…”
Specialist mental health services: How could a more integrated mental health system be
developed to increase service access, improve outcomes and optimise the use of specialist
resources?
Specialist services were enthusiastic about the potential of rethinking their role in a wider
integrated system of mental health. This had been stimulated by a number of factors:
Continued challenges in achieving service goals (3%) and in achieving access for high
needs groups
Concerns over delays and waits for people to be seen
Large case loads, including many with long duration ongoing care, “ours for life”, but
with very low levels of actual specialist service interaction
Variable and in some cases poor physical health care for patients within the service
Cost pressures
DHB planners, service management and clinical leadership were keen to explore if a
different approach, that utilised the combined capability of primary and secondary services
could achieve better outcomes more efficiently. This was seen to require a process of
developing greater levels of integration and shared care between primary and secondary
services.
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“there are people currently in our mental health services that actually could be
managed effectively in primary health care… and there is people that don’t get near
the boundary of secondary services 'cause they’re mild to moderate.”
“We need to provide greater access and that doesn’t necessarily mean GPs referring
to us, it might mean mental health service delivery more happening within primary
care in a partnership, that’s where we want to get to.”
The barriers to this happening included a history of limited relationships between secondary
services and GPs/PHOs, difficulties in developing working relationships with very limited GP
capacity and time with a legacy of suspicions that any approach to greater integration would
be seen as ‘secondary dumping’ its problems on primary care.
“the actual [act of being] physically able to sit down and work out the changed
management of how we work in these services and [for] them then being able to
spare the time to meet with secondary and work out the referral pathways and that
sort of thing, [there is] the time pressures on to you know, we’ve got them working
on all sorts of things, so it’s how we manage that limited time they’ve got so that we
can get maximum benefit out of it really.”
“I was also surprised that we didn’t have a close relationship with secondary services
and also not a lot of good robust processes in place about how we talk to one
another on a regular basis”.
At a deeper level there was an awareness that mental health paradigms differed across the
boundary, leading to talking past each other and lack of understanding:
“we’re aware…there’s actually differences within our philosophical underpinnings
that we do in our delivery of care and not only is it us trying to understand from the
primary health’s point of view what that is, but also from the 4 or 5 kind of primary
health ways in which the local PHO may approach that too. We don’t want to
change them, nor do we really want one size fits all, we want to be able to ensure,
and that’s what I mean by not letting them down, you know, getting the relationship
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to work by recognising the difference and just working alongside it with that being as
a principle.”
“Probably the first one for me is access, access going from primary to primary and
secondary health services. At the moment it’s a bit of a mish mash how people
actually move between the 2 services. What we’re finding historically is that once
people enter the secondary mental health services, they don't leave it, they don't
leave. The GP doesn’t know where they are, or whether they've been discharged, or
whether, you know within the secondary mental health service, that sort of thing.
“That’s been, I think it’s an issue probably across the country. What we would like to
see in the future is that there’s a more seamless approach, a more seamless delivery
of service where the secondary mental health services are more accessible at a
primary level. And the intervention is defined, for secondary specialist services, is a
lot more defined and clear, where their role is, and when it starts and finishes. “
“So some of it’s identifying, you know when they finish with secondary mental health
services, which at the moment it’s very unclear. And we find that the community
mental health teams hold onto people for long periods. I mean they use the, I know
the people planning methodology to assess the majority of clients that are on their
caseloads, they have some people there who have been on their caseloads for
anything up to 6 to 10 years.”
There were also concerns that prevailing national policy and rules on funding would get in
the way of making practical progress towards a more integrated service.
“The Ministry [is] very clearly saying that we can’t spend blue print, which is funding
for mental health and addiction services on primary care, that’s a mistake 'cause
actually it’s one of our few funding streams to develop these programmes further,
the Ministry’s been very successful in keeping a national programme around the
primary mental health which is great, but it’s a small amount of money for the needs
within the population and they won’t be able to grow it, so I’m not sure how we push
back on some of that policy advice. They basically don’t want the programme that’s
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targeted at the 3% high needs to be spread to primary mental health but actually if
we were to get the best bang for our buck, it’s in these programmes and actually
that’s recognised by our clinical services so we put this high on our priority list so the
letter basically said, you can’t continue with this development.”
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2 PMH core mental
health services for
moderate to high end
moderate
3 Emotional ups &
down, relationship
issues
4 Not neatly defined
by diagnoses
5 Chronic pain
6 Mild psychosis,
personality problems
7 People who fall
between the cracks
8 People with very
external point of
view, no sense of
who they are; loss,
grief,
9 Brief centering
processes - bring
people back to who
they are and from
there they tend to
answer their own
questions
10 Large gap between
the assumptions made
by the PMH strategy
& the actual
presentation of the
population
12 Sadness, badness,
unfortunate events,
limited coping
strategies
14 Language can lead
you off the track
from a useful
dialogue19 Anxiety
manifesting as "I am
pissed off"
20 The mild, mod,
severe diagnostic
paradigm is not
useful to decribe
the population &
need
21 PMH set up for
the 18% who aren't
the 3%
22 Resiliency
building stuff
23 What these
services don't do is
reduce demand to SMH
25 The strategy is
based on a continuum
of need that is a
myth
26 Stressed children
and families
27 Some referral to
SMH for people with
chronic long term
conditions, needing
psychiatry,
medication or
support worker
28 We could benefit
from access to
psychiatric
assessment
31 Can't access the
service unless ill
enough to warrant
it, ie some risk
32 We can some times
get people in
through the 'CAT
door'
33 Once they get in
there do they liase
with me - no ... Do
they
34 Need more
enduring and wider
range of support
than we can provide
35 Made referrals &
get "on our wait
list please continue
to hold"
36 People with
severe needs arising
from a complex array
of life problems
40 We need a
narrative of what
the mild to moderate
look like
42 Only some with a
definable medical
diagnostic channel
that you could put
them in
43 People with
stress and
dysfunction
significantly
affecting their
lives , but not in a
disordered way
44 The quiet,
miserable,
vulnerable
49 Psycho/social
distress
50 Clear edge for
severe, boundary
with those with
pyschosis etc
55 How much ongoing
limited functioning
is enough to warrant
our attention?
59 Where we can
assist SMH by doing
a good primary
assessment first
60 If we take
pressure off anybody
its off GPs
Concepts from second cycle Primary MH discussion
Emerging, different, shape and focus to primary mental health
-Less suited to conventional diagnostic framing-More focussed on stress, complexity & dysfunction- Contains a spectrum of severity of
situations but ‘continuum’ concepts questioned-A less severe end very brief listening, problem solving resiliency development-But also handling quite high levels of
severity as a consequence of complexity -(situation that do not fit of reach specialist access thresholds)-Initial PMH service structures based on mild/mod ‘depression’ need rethinking
-Needs different connections to complex social and living support-Needs different access to specialist assessment and review advice to support primary based responses
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2 PMH core mental
health services for
moderate to high end
moderate
3 Emotional ups &
down, relationship
issues
4 Not neatly defined
by diagnoses
5 Chronic pain
6 Mild psychosis,
personality problems
7 People who fall
between the cracks
8 People with very
external point of
view, no sense of
who they are; loss,
grief,
9 Brief centering
processes - bring
people back to who
they are and from
there they tend to
answer their own
questions
10 Large gap between
the assumptions made
by the PMH strategy
& the actual
presentation of the
population
12 Sadness, badness,
unfortunate events,
limited coping
strategies
14 Language can lead
you off the track
from a useful
dialogue19 Anxiety
manifesting as "I am
pissed off"
20 The mild, mod,
severe diagnostic
paradigm is not
useful to decribe
the population &
need
21 PMH set up for
the 18% who aren't
the 3%
22 Resiliency
building stuff
23 What these
services don't do is
reduce demand to SMH
25 The strategy is
based on a continuum
of need that is a
myth
26 Stressed children
and families
27 Some referral to
SMH for people with
chronic long term
conditions, needing
psychiatry,
medication or
support worker
28 We could benefit
from access to
psychiatric
assessment
31 Can't access the
service unless ill
enough to warrant
it, ie some risk
32 We can some times
get people in
through the 'CAT
door'
33 Once they get in
there do they liase
with me - no ... Do
they
34 Need more
enduring and wider
range of support
than we can provide
35 Made referrals &
get "on our wait
list please continue
to hold"
36 People with
severe needs arising
from a complex array
of life problems
40 We need a
narrative of what
the mild to moderate
look like
42 Only some with a
definable medical
diagnostic channel
that you could put
them in
43 People with
stress and
dysfunction
significantly
affecting their
lives , but not in a
disordered way
44 The quiet,
miserable,
vulnerable
49 Psycho/social
distress
50 Clear edge for
severe, boundary
with those with
pyschosis etc
55 How much ongoing
limited functioning
is enough to warrant
our attention?
59 Where we can
assist SMH by doing
a good primary
assessment first
60 If we take
pressure off anybody
its off GPs
Concepts from second cycle Primary MH discussion
Better access and coordination with specialist services
- Access to assessment and advice in primary settings- Access to services (more enduring, wider range of supports) for people who can otherwise be well managed in primary settings- Complex comorbidities
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1 Variable usage ofSMH services by GPs
2 Dis illusionmentin Primary over SMH
support for PMH
3 DHB SMH havehistory of sayingthey will support
PMH & don't followthrough
4 Individual effortsto work alongside
GPs but notsustainable
5 Need to have clearthresholds for
different levels ofservice
6 SMH thresholds maynot be right
7 SMH not buildingcapability in PMH so
needing to refer?
8 Increase accessfor the 3%
'severe/acute'
9 Many SMH clientscould be better
managed in PMH
10 Provide morerigorous assessment
to focus service
11 Provide shortbrief interventions
for less acute needs
12 Both PHO & jointSpec Serv provided
13 Provide access &support for the 17%
14 How do you getthe PHOs in room toprovide leadership
for coordinatedresponse?
15 Work with thoseGPs have greatest
current reln
16 Many of Spec MHclients don't hace
access to CarePlus &can't get time
17 Who is going topay?
18 Work on jointindividualised plans
19 Better use oflimited SMH capacity
20 PHOs have verydifferent
populations &capacity
21 SMH don't havegood reln with
primary & PHOs22 Very limited GPworkforce capacity
25 Spec MH - oldattitude "once
clients ours theyare ours for life"
26 Need betteraccess to nurse,allied health social
work & ACC services
27 More intergratedcare, more appriate
setting
28 Include wellnessstrategies
29 Narrowspecialised focus in
MH services
30 Fear that therewill be a dump ofextra work on GP
31 SMH de-skilled indealing with
mild/mod32 SMH & PMH work
from differentparadigms
33 Reduce variationin access
34 Message from SMHthat primary doesn'tknow how to do MH35 Systematic
deskilling in PMHover many years
36 Developinterdiciplinaryskills & capacity
37 Outsource PMHinterventions, notrequire GP delivery
38 Use initiativefunding to provie
PMH options for GPs
39 Reduce inequityof funding acoss
PHOs
40 Develop fundingand service modelsto make best use of
the resourcesavailable
41 any developmentincl training
consumes time anddetracts from scarce
capacity
42 Support empower,utilise the capacityof people and their
families
43 More and morepeople having
difficulty copingwith life hit road
bump
44 GP does not havethe time in short
consult to do muchor know where to get
support
45 Adaptinterventions to
context & capacity... single standard
model
46 Must approach PMHwithin wider primary
strategy
Issue: Effective infrastructure, relationships
Effective infrastructure, relationships
-Relationships across PHOs, SMH, DHB-Integrated, coordinated response -Service models-Funding & access criteria-Capability development
Recognising-Different paradigms of PMH/SMH-Variation in PHO population/capacity-Integration with wider primary strategy
7/05/2009
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1 Variable usage ofSMH services by GPs
2 Dis illusionmentin Primary over SMH
support for PMH
3 DHB SMH havehistory of sayingthey will support
PMH & don't followthrough
4 Individual effortsto work alongside
GPs but notsustainable
5 Need to have clearthresholds for
different levels ofservice
6 SMH thresholds maynot be right
7 SMH not buildingcapability in PMH so
needing to refer?
8 Increase accessfor the 3%
'severe/acute'
9 Many SMH clientscould be better
managed in PMH
10 Provide morerigorous assessment
to focus service
11 Provide shortbrief interventions
for less acute needs
12 Both PHO & jointSpec Serv provided
13 Provide access &support for the 17%
14 How do you getthe PHOs in room toprovide leadership
for coordinatedresponse?
15 Work with thoseGPs have greatest
current reln
16 Many of Spec MHclients don't hace
access to CarePlus &can't get time
17 Who is going topay?
18 Work on jointindividualised plans
19 Better use oflimited SMH capacity
20 PHOs have verydifferent
populations &capacity
21 SMH don't havegood reln with
primary & PHOs22 Very limited GPworkforce capacity
25 Spec MH - oldattitude "once
clients ours theyare ours for life"
26 Need betteraccess to nurse,allied health social
work & ACC services
27 More intergratedcare, more appriate
setting
28 Include wellnessstrategies
29 Narrowspecialised focus in
MH services
30 Fear that therewill be a dump ofextra work on GP
31 SMH de-skilled indealing with
mild/mod32 SMH & PMH work
from differentparadigms
33 Reduce variationin access
34 Message from SMHthat primary doesn'tknow how to do MH35 Systematic
deskilling in PMHover many years
36 Developinterdiciplinaryskills & capacity
37 Outsource PMHinterventions, notrequire GP delivery
38 Use initiativefunding to provie
PMH options for GPs
39 Reduce inequityof funding acoss
PHOs
40 Develop fundingand service modelsto make best use of
the resourcesavailable
41 any developmentincl training
consumes time anddetracts from scarce
capacity
42 Support empower,utilise the capacityof people and their
families
43 More and morepeople having
difficulty copingwith life hit road
bump
44 GP does not havethe time in short
consult to do muchor know where to get
support
45 Adaptinterventions to
context & capacity... single standard
model
46 Must approach PMHwithin wider primary
strategy
Issue: Support for people, families, social context of mental wellbeing?
Support for people, families, social context of mental wellbeing
-Self care, family support-Integrated, coordinated response with social services -Interdisciplinary skills
-? Role of health promotion to support effective functioning/reduce stress - ‘person & context’?
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Research Partner 2 cognitive maps April-May 2009
1 Variable usage ofSMH services by GPs
2 Dis illusionmentin Primary over SMH
support for PMH
3 DHB SMH havehistory of sayingthey will support
PMH & don't followthrough
4 Individual effortsto work alongside
GPs but notsustainable
5 Need to have clearthresholds for
different levels ofservice
6 SMH thresholds maynot be right
7 SMH not buildingcapability in PMH so
needing to refer?
8 Increase accessfor the 3%
'severe/acute'
9 Many SMH clientscould be better
managed in PMH
10 Provide morerigorous assessment
to focus service
11 Provide shortbrief interventions
for less acute needs
12 Both PHO & jointSpec Serv provided
13 Provide access &support for the 17%
14 How do you getthe PHOs in room toprovide leadership
for coordinatedresponse?
15 Work with thoseGPs have greatest
current reln
16 Many of Spec MHclients don't hace
access to CarePlus &can't get time
17 Who is going topay?
18 Work on jointindividualised plans
19 Better use oflimited SMH capacity
20 PHOs have verydifferent
populations &capacity
21 SMH don't havegood reln with
primary & PHOs22 Very limited GPworkforce capacity
25 Spec MH - oldattitude "once
clients ours theyare ours for life"
26 Need betteraccess to nurse,allied health social
work & ACC services
27 More intergratedcare, more appriate
setting
28 Include wellnessstrategies
29 Narrowspecialised focus in
MH services
30 Fear that therewill be a dump ofextra work on GP
31 SMH de-skilled indealing with
mild/mod32 SMH & PMH work
from differentparadigms
33 Reduce variationin access
34 Message from SMHthat primary doesn'tknow how to do MH35 Systematic
deskilling in PMHover many years
36 Developinterdiciplinaryskills & capacity
37 Outsource PMHinterventions, notrequire GP delivery
38 Use initiativefunding to provie
PMH options for GPs
39 Reduce inequityof funding acoss
PHOs
40 Develop fundingand service modelsto make best use of
the resourcesavailable
41 any developmentincl training
consumes time anddetracts from scarce
capacity
42 Support empower,utilise the capacityof people and their
families
43 More and morepeople having
difficulty copingwith life hit road
bump
44 GP does not havethe time in short
consult to do muchor know where to get
support
45 Adaptinterventions to
context & capacity... single standard
model
46 Must approach PMHwithin wider primary
strategy
Concepts in first cycle DHB and Specialist MH discussion
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1 Variable usage ofSMH services by GPs
2 Dis illusionmentin Primary over SMH
support for PMH
3 DHB SMH havehistory of sayingthey will support
PMH & don't followthrough
4 Individual effortsto work alongside
GPs but notsustainable
5 Need to have clearthresholds for
different levels ofservice
6 SMH thresholds maynot be right
7 SMH not buildingcapability in PMH so
needing to refer?
8 Increase accessfor the 3%
'severe/acute'
9 Many SMH clientscould be better
managed in PMH
10 Provide morerigorous assessment
to focus service
11 Provide shortbrief interventions
for less acute needs
12 Both PHO & jointSpec Serv provided
13 Provide access &support for the 17%
14 How do you getthe PHOs in room toprovide leadership
for coordinatedresponse?
15 Work with thoseGPs have greatest
current reln
16 Many of Spec MHclients don't hace
access to CarePlus &can't get time
17 Who is going topay?
18 Work on jointindividualised plans
19 Better use oflimited SMH capacity
20 PHOs have verydifferent
populations &capacity
21 SMH don't havegood reln with
primary & PHOs22 Very limited GPworkforce capacity
25 Spec MH - oldattitude "once
clients ours theyare ours for life"
26 Need betteraccess to nurse,allied health social
work & ACC services
27 More intergratedcare, more appriate
setting
28 Include wellnessstrategies
29 Narrowspecialised focus in
MH services
30 Fear that therewill be a dump ofextra work on GP
31 SMH de-skilled indealing with
mild/mod32 SMH & PMH work
from differentparadigms
33 Reduce variationin access
34 Message from SMHthat primary doesn'tknow how to do MH35 Systematic
deskilling in PMHover many years
36 Developinterdiciplinaryskills & capacity
37 Outsource PMHinterventions, notrequire GP delivery
38 Use initiativefunding to provie
PMH options for GPs
39 Reduce inequityof funding acoss
PHOs
40 Develop fundingand service modelsto make best use of
the resourcesavailable
41 any developmentincl training
consumes time anddetracts from scarce
capacity
42 Support empower,utilise the capacityof people and their
families
43 More and morepeople having
difficulty copingwith life hit road
bump
44 GP does not havethe time in short
consult to do muchor know where to get
support
45 Adaptinterventions to
context & capacity... single standard
model
46 Must approach PMHwithin wider primary
strategy
Issue: An Integrated Mental Health System
‘An integrated mental health system’
-Optimise access for 3% (reduce burden in community)-Reduce variation in access-Optimise use of limited SMH resources
-Increase ‘step-down’ /graduate from SMH (not ‘ours
for life’)-Shared support plans-Build primary based support
-Optimise access/reduce variation of access
-More rigorous assessment-Reduce variation of GP usage-Build PMH capacity
BUT
-Poor relationship between SMH & GP/PHO-Limited GP capacity-Dumping suspicion-Funding constraints-Different paradigms in SMH & PMH
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1 Variable usage ofSMH services by GPs
2 Dis illusionmentin Primary over SMH
support for PMH
3 DHB SMH havehistory of sayingthey will support
PMH & don't followthrough
4 Individual effortsto work alongside
GPs but notsustainable
5 Need to have clearthresholds for
different levels ofservice
6 SMH thresholds maynot be right
7 SMH not buildingcapability in PMH so
needing to refer?
8 Increase accessfor the 3%
'severe/acute'
9 Many SMH clientscould be better
managed in PMH
10 Provide morerigorous assessment
to focus service
11 Provide shortbrief interventions
for less acute needs
12 Both PHO & jointSpec Serv provided
13 Provide access &support for the 17%
14 How do you getthe PHOs in room toprovide leadership
for coordinatedresponse?
15 Work with thoseGPs have greatest
current reln
16 Many of Spec MHclients don't hace
access to CarePlus &can't get time
17 Who is going topay?
18 Work on jointindividualised plans
19 Better use oflimited SMH capacity
20 PHOs have verydifferent
populations &capacity
21 SMH don't havegood reln with
primary & PHOs22 Very limited GPworkforce capacity
25 Spec MH - oldattitude "once
clients ours theyare ours for life"
26 Need betteraccess to nurse,allied health social
work & ACC services
27 More intergratedcare, more appriate
setting
28 Include wellnessstrategies
29 Narrowspecialised focus in
MH services
30 Fear that therewill be a dump ofextra work on GP
31 SMH de-skilled indealing with
mild/mod32 SMH & PMH work
from differentparadigms
33 Reduce variationin access
34 Message from SMHthat primary doesn'tknow how to do MH35 Systematic
deskilling in PMHover many years
36 Developinterdiciplinaryskills & capacity
37 Outsource PMHinterventions, notrequire GP delivery
38 Use initiativefunding to provie
PMH options for GPs
39 Reduce inequityof funding acoss
PHOs
40 Develop fundingand service modelsto make best use of
the resourcesavailable
41 any developmentincl training
consumes time anddetracts from scarce
capacity
42 Support empower,utilise the capacityof people and their
families
43 More and morepeople having
difficulty copingwith life hit road
bump
44 GP does not havethe time in short
consult to do muchor know where to get
support
45 Adaptinterventions to
context & capacity... single standard
model
46 Must approach PMHwithin wider primary
strategy
Issue: Effective, equitable PMH, efficiently operating within constraints
Effective equitable, efficient PMH
-Provide access & support to the 17%
- People in stress, ‘bumps in life’-Reduce variation in access-More integrated care/appropriate setting
-Increase options for GPs to meet needs
-Recognises their limited capacity-Build options wider primary based support
-Optimise access/reduce variation of access-Assessment, inclusion/exclusion
-Efficient models of care-Reduce inequities of funding
BUT-Severely limited GP capacity
-Variation in PHO population/capacity-Integration with wider primary strategy
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Development of the action research agenda
From the second cycle of refinement of the local issues two potential areas for action
research emerged which were tested with the local action research partners:
The first, driven from a primary health perspective was focused on the operational issues of
managing the limited funding provided by the PMHI in the face of large un-met demand.
Without a process for targeting and prioritising the flow of people with mental health issues
it was likely that available resources were not delivered in a coherent or consistent way.
Demand was likely to exceed supply putting pressure on the sustainability of the models of
care developed in the initiatives. It was feared that a waiting lists will develop for these
services.
Potential primary mental health action research agenda: Develop a framework that
provides layers of service with differing intensity and kinds of response, with a range of
resource requirements. Identify tools that facilitate selection of service kind and intensity to
match need with clear inclusion/exclusion guidelines, and criteria that take into account
need and resource or capacity driven constraints. Develop ideas or specifications for the
necessary infrastructure to implement and sustain this within the overall primary mental
health system.
From both a planning and specialist service perspective the issue was that the current
secondary mental health service model needed to change. Primary and secondary specialist
mental health services should ideally operate in a complementary fashion across the
continuum of mental health needs. However they had developed as silos in isolation with
very different prevailing professional paradigms and histories.
Primary mental health depends on secondary to provide additional levels of support for
those with severe/acute needs yet these services are stretched, overburdened and have
limited capacity to be responsive to a wider population of people with relatively severe
conditions who, by default, are handled in primary.
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Secondary services have tended to assume an ongoing responsibility for people who have
been users of their services since there is perceived to be inadequate capability/capacity to
handle care and risk in primary/community settings. This consumes scarce secondary
resource, further limiting support that secondary can provide to primary.
Integration is further constrained by funding silo’s and organisational boundaries that have
ring fenced resources and make it difficult to create a whole population response.
There is a wide range of perspectives on the role and purpose of both primary and
secondary serves at both DHB and PHO level. The current planning, funding and service
frameworks are not robust enough to support the development of a whole population
response to mental health needs that integrates the functions of primary, community and
specialist mental health responses. Because of the network of organisations involved and
the different professional paradigms efforts to create an integrated approach driven from
one perspective, (for example secondary specialist services) run the risk of suspicion and
misinterpretation.
Potential secondary mental health integrated action research agenda: Develop planning
tools and models that facilitate joint planning, service design and resourcing by DHB
Funders & Planners, PHOs, primary and secondary service clinicians and NGOs.
Action Learning Process
During the process of developing potential action research agenda’s it became clear that the
there was limited energy and capacity from primary health to engage directly with a broader
cross PHO initiative to develop primary mental health but there was continued energy and
commitment from secondary services to develop an effective shared care system with
primary care. It was recognised that this would require a programme of progressive
partnership development; relationships, communication, trust building and service
development.
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A project was formed with three provisional aims:
1. Improved access to primary health for physical health screening and treatment for
service users treated within the Mental Health Service.
2. Improved access for primary health to psychiatric clinical expertise located within
the Mental Health Service, inclusive of consultation, client assessment and
treatment, and education for clinicians.
3. Improved discharge to primary care (in the main, GP practice), shared-care
arrangements and mental health services re-entry trajectory as required.
The ideal was considered to be the development of standardised process/models applicable
across the sector to address the health needs of those with experiencing mental illness.
This was to be founded on a set of principles:
Focus on GP as central health provider in the clients care, not secondary mental
health
Evidenced Based Strategies – Use of highest hierarchy of evidence available
Plan, Do, Study, Act cycle
Enhancing client/family self-management support and access to community
services to promote holistic health outcomes
Fits within the regions long term care framework
Transparent communication
Ensure stakeholder consultation mental health clinicians / clients and primary care
providers
Ensure mental health services integration with this project (CATT, C/L, CREDS,
ICAFS, TWA, Adult MHS)
Mental health NGOs
One of the first challenges of the project team were to develop an effective engagement
with primary care to listen and explore the issues from their perspective and jointly develop
solutions to the combined need.
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Since this was seen as a first step towards a partnership it was decided to tackle the
relationship development at multiple levels:
Utilise the experience of previous successful joint programme development to guide
the process of engagement and issues exploration with each PHO
Develop direct clinician to clinician communication and relationships though a
programme of meetings between the secondary service clinical leader and GP
practices.
Promote better alignment and day to day communication between community-
based services and local practices.
In parallel with this process a series of workshops were held within the specialist service but
with invitations to primary care, NGOs and the consumer representatives. These explored
the issues, data and ideas about the changes necessary within secondary services that
would be required to make an integrated system work.
Research Partner 3
Overall the primary mental health services in this regions were seen as working well,
providing a level of care in primary health that had not existed three years previously. PHOs
in the region were at different stages of their implementation, (the final PHO started initial
implementation as the research process commenced), and with varying service approaches
according to their respective populations and service capacity. Despite this variation they
had a strong collaborative infrastructure for sharing ideas and developing shared capability,
skills and common processes.
The PMHI based services originally focussed on adults with mild/moderate
anxiety/depression but there was also focus on clients with specific cultural needs, complex
interactions of health, stress and living circumstances in one PHO.
Resources came from multiple funding silos; Primary mental health initiatives (PMHIs),
Service to increase access (SIA), DHB and PHO sources together with ACC and Ministry of
Social Development programmes. In total the funding was seen to be substantially less than
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demand. Service selection was through self referral, GP filtering (supported by common
assessment tools) and then eligibility criteria for more specialised services such as ACC.
Framework for engagement
The pathway to engagement was relatively straightforward with close collegial relationships
between the respective PHO service and clinical leads and the DHB Funding and Planning
portfolio manager who facilitated the engagement with the research team.
First cycle issues exploration
An initial issues exploration working session was held with a local working group to explore
the issues.
Based on session notes and transcripts an initial set of concept maps was prepared as
shown on the following pages:
Developing sustainable funding and resources
Issues of financial sustainability were topical in this research partner in the initial stages of
the action research inquiry. There were a number of drivers for this: The area had been
successful in augmenting health funding with social service and ACC funding sources to
provide greater depth of treatment for complex constellations impaired functioning; mental
health, social deprivation and unemployment. Some of these sources were at risk. Potential
policy shifts on ring fenced mental health funding in an area with chronic DHB deficits raised
questions over the sustainability of initiative funding. Combined with these issues was an
awareness of the magnitude of demand and its relative severity.
“If we had more flexibility and we didn’t have a mental health ring fence, then we
might make a strategic decision around investment in primary mental health. Since
we last met I've had the discussions with the Ministry about whether we can use our
mental health funding for primary mental health and they’ve explicitly said no. So
that’s not going to happen. …. So strategically perhaps the ring fence might be
removed. If it is, we need to look at total access to service, so acute services,
community-based services, GP services, you would look at all of the funding we’ve
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got and how that actually can work to best effect. The other thing the Ministry’s
been clear about is they’re happy to look at us working innovatively with primary
care. Their thoughts about innovative primary care working is, I think, quite
constrained, so they’re thinking about a community mental health nurse going out
and working in primary care. They’re not thinking about more flexible models or
different ways of doing things.”
“We don’t have enough [money for that]...but what we are doing, from the initiative
programme that we ran last year, we had some funds left over which the Ministry
allowed us to keep and so what we’ve done, we’re in the process of scoping a
programme for post-natal depression and we’re going to try and put some, either SIA
money towards it or service development money just to top it up just to run a pilot in
[four named areas], so we’re targeting two high needs areas and we’ll just be
working with two Plunket Nurses and taking referrals from them for this programme
and it’s through our group therapy so it’s a different tact altogether. And part of the
challenge for that will be referral pathways into other services, 'cause those services
actually don’t exist, so how do you manage that as part of implementing that
programme.”
Through discussion it was identified that a large part of the source of concern was the
relative weakness of the strategic context for PMHC. It was a new area that had developed
through PHO level initiatives rather than being part of a district wide strategy. The nature of
what mental health means in a primary health context was still emerging with agreement
that it was addressing a high level of demand but one that did not fit easily into the
conventional diagnostic view of mental health. This meant that the population, clinical and
business case was not well formed or socialised in the district, in terms of overall outcomes
and benefits, models of care or resources required. The connections with specialist services
were developing well in terms of personal relationships but not as an integrated service
strategy. Developing the strategic context for primary mental health means developing our
understanding of the what the purpose and function of all parts of our system for mental
health
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“[the terms] primary and secondary should be dropped, I think. We should talk about
community services, we should talk about residential services, we should talk about
hospital services. Once we start to do that, we start to break down some of the
barriers in our thinking which is very necessary. And I think one of the things which
clearly emerges from what you’ve described or read in the slide back is that unless we
join up with other service providers, other agencies, we are not going to address 90%
of need. “
What type of need, which populations are we targeting and how is this best managed?
While structured PMHC services were seen to be an effective response to presenting need
the research partners expressed deep concerns over equity. With such limited funding it
was easy for service capacity to be consumed by a limited range of people who present to
aware GPs with clear signs of stress or those who inquire and seek services. While happy
that the service was treating those with legitimate it was clear that large numbers of people
with relatively more complex and severe needs were not gaining access. Equally while the
services explicitly targeted Māori and high socio deprivation populations this was by no
means sufficient to address equity of access issues generated by the conjunction of mental
health, substance abuse, violence, social stress and unemployment. Likewise there were
conditions and populations with known high needs, such youth, drug and alcohol, post natal
depression that were not being reached.
“We are tinkering at the margins, at the best we will reach perhaps 0.5% of the
population, most of the people we are seeing have higher [k10] scores than we
expected, whatever we do will have a benefit, but not enough to have an impact at a
population level.”
This raised a number of subsidiary issues:
What is the impact we are after? What are the outcomes we need from PMHC?
How would we move from services targeting a limited range of diagnostic categories
to more systematically address the high levels of complex stress in out populations?
How would the prioritisation, targeting and access be managed at a practical level?
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How would we monitor the consequences of these prioritisation and exclusion
decisions?
Developing the most appropriate service models to meet diverse population needs
With limited resources and high levels of unmet need the research partners were concerned
about the effectiveness of the way their resources were used. Essentially this was seen to be
an issue of getting a better balance of breadth and depth. There were three areas for
development identified
Developing highly efficient models of care
Developing greater reach through mental promotion
Gaining greater impact where more intensive responses were needed, especially for
Māori and high socio deprivation populations with complex needs
Efficient service models were seen to be emerging through experience with effective
assessment and triage, use of brief interventions and use of structured care pathways.
To achieve greater breadth the partners were keen to achieve impact through earlier, more
preventative mental health promotion approaches.
“We’ve had lots of discussions around mental health promotion here; how we can
work more jointly between secondary services and public health and a range of other
agencies in the community. We’ve tried out different things and we’ve come full
circle, so we’re actually talking now about health promotion generally, not about
mental health promotion per se. We’re appointing a public health, population health
advisor position; they’ll know the expert advice on mental health promotion. But
actually they’re a generic health promoter and it’s about making sure you’re talking
about wellness and self care as part of that broader picture. It's not about saying
‘actually we’re doing mental health promotion’. So I just think the broader context
works better for us in that sequence.”
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The hardest issues were seen to lie in the development of effective models of care for the
complex issues seen in Māori and high needs populations and providing adequate,
accessible and culturally tuned approaches that match the need.
“I’m kind of noticing just what whaiora are bringing is probably more towards the
Kaupapa Māori end of that spectrum, simply because I think, of the historical stuff
that’s kind of been going on and that’s one of the impacts of colonisation and
therefore what they choose to disclose as well so a lot of people that kind of talk
about having difficulty communicating with their tupena or those who have passed
on, or you know, those that are kind of others who are in the room with us, you know
that sort of thing, there’s actually more and more of that that I’m kind of seeing,
whereas they would never disclose that to a Pakeha therapist, or discuss it with their
GP and things like rongoa, you know a lot of people are taking rongoa that they
might discuss with their GP, those sorts of things, so I think there’s a definite kind of
culture component there but how we kind of blend that, because we do still need to
have that balance of Pakeha as well to kind of uphold the integrity or what it is that
we’re doing.”
“Yeah, our diagnosis, I mean our GPs, I think most of them are kind of coming in
under depression, our whairoa don’t think we have, I’m saying we, they, have
depression at all, most of them say they have mamae o te wairua which literally
means my wairua has been broken, my spirit is lost, I’m disconnected. And so
therefore, that kind of lays a completely different korowai for their healing journey
because of the way they perceive it, rather than having a tauiwi label that they come
in [with], so they come in with a treatment plan and they’ve been, you know, as
opposed to a healing journey and a tino rangatiratanga plan of kind of moving
forward and empowering and reconnecting, whatever that might look like for that
particular person. But it actually kind of sets a really different scene that’s quite non-
clinical and in a different kind of kaupapa and in a different way. So as I say, we kind
of like it’s from bottom up rather than the top down approach.”
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Part of the concern is that the approach needed seems intrinsically more resource intensive
in order to provide access in the community and the time to both unravel the complexity
and build capability.
“We’ve got 6 kind of fixed venues in the community but you know, if somebody’s at
risk or can’t get to us or whatever, we’ll go to their place or meet them at nanny’s
place or in the car park at Pak ‘n Save if we have to, particularly is there’s risk
concerned to maintain their safety.”
“Well it’s very much a different kind of therapy, you know, I’m really very conscious
when I’m with non-Māori how my approach is really quite different, it’s very much a
cognitive approach so we kind of work top down, whereas with Māori , we work with
a wairua so we sit and we feel, and we work from the bottom up, so we don’t have to
sit and make sense of things like our non-Māori whaiora do. We can just kind of sit
and be…we can embrace our tupuna, we can kind of meet in this really spiritual place
but with non-Māori, it’s really different, it’s very much a cognitive process.”
However, the benefit in developing effective models of care that work in these
circumstances was seen to be the development of a different approach to mental health,
one that can address the interactions between social stress and mental health.
“I mean one of the things that I am thinking as I look at this programme and I’ve seen
it in other Māori programmes that I’ve seen is that when you get a programme that’s
starts of as bi-Māori for Māori, it eventually starts to become bi-Māori for everybody
and that there’s real value in that and that there’s a whole lot of things that are
added to the programme for mainstream because of coming from that other way.”
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Research Partner 3 cognitive maps from March 2009
1 What mix of modelsshould we be working
with, how muchvariety is necessary
2 Diverse &restrictive funding
sources rather thancoherent approach to
PMH
3 SIA funding eg
post natal & childattachment pilot
starting
4 MSD funding forback to workprogrammes 5 MoH has small and
limited $ for PMHinitiatives
6 ACC funding forabuse
7 Normal primarycare also supports
MH
8 MoH controlledinitiatives limitedDHB PHO PMH
engagement
9 PHOs evolvedmodels to suit
population
10 Not clear howdifferent approaches
fit or integratewith wider MH
services
11 Potential ofshift to PBF
funding, will $ besustainable?
12 Not clear whatoverall outcomes
seeking and whatresources would be
needed
13 Most modelsproducing good
results irrespectiveof type or level of
intervention
14 Wide variation innature & level of
intensity ofservice, use of
secondary packagesof care
15 We can providegood service to
those who manage toget access
16 How do weidentify, screen,
target within knownhigh risk popns?
17 Once identified
how do we assess?how much skill & $
put into assess?
18 Whatinclusion/exclusioncriteria should weuse & how apply?
19 What happens tothose we exclude?
Don't meet thresholdbut still have highneeds potentiual
benefit
20 What's the placeof Rx?
21 What is the fitof PMH within wider
primary healthstrategy
22 Are we movinginto concepts of
stress, complexityresilience, wellness
rather than justclinical labels?
23 Connection tosocial services &
support?
24 How do we managereferral pathways to
other services?
25 Can't utiliseblue print 3% $ fordeveloping PMH
capacity
26 PMH role in earlyintervention & flow
through to SMHconstrained
27 Demand muchgreater than funding
& capacity
28 People arehurting out there at
the moment, we haveraised community
expectations,engagement
floodgates are open
29 Right education &development for
service providers,right approach
30 Training GPs just
did not work
31 Primary does knowstuff, not
acknowledged
32 What is the rightmode of delivery &
how get protectedtime?
33 Need emerging forGPs how to use
tools, prioritisewith limited
resources, chooseright Tx
34 Can we apply
training tocommunity support so
people don't need
PMH
35 Retraintherapists who are
naturally fixated ontheir way of doing
things?
36 Huge differencesin resourceutilisation
37 How do wesystematically learn
& respond topatterns of
utilisation andresults?
38 Major issues withdrug & alcohol use
39 Increasing
awarenessunderstanding of
mainstream inapproach to Maori
40 Enable access andreduce DNA of Maori
to PMH
41 Provide
alernative, suitable& safe venues in
community for Maori
to access
42 Enable whanau tobe part of process
44 Find right blendwairoa, sprituality& belief & Pakeha
cognitive approachesto MH for Maori 45 Requires time &
dedicated team toprovide a wrap
around to deal with
complexity &entrenched issues
46 W&I access todisability supportfor crisis/severe
extended sessions
47 High levels of
complex stress inour populations
48 Work,relationship, social
49 'My wairoa isbroken, my spirit is
lost' creates adifferent
understanding ofresponse pathway
50 depression &anxiety
51 Current fundingwill reduce as
initiatives wind up
52 We are achieving
substantialreductions in
stress, symptoms &dysfunction
53 Need workforce
capacity developmentespecially Maori
54 Need educationalsupport for Maori &
cultural coursedevelopment
55 We don't know yethow to resource or
support whanauoutside of theprimary setting
56 Addressingspirituality, belief
& family supportalso works forPakeha too
57 Most people
assessed in PMH havehigher scores than
were expected to behandled >29
58 Idea that at lowlevels of need
community can takecare of itself
-
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What type of need, which populations are we targeting & how do we manage that?
1 What mix of modelsshould we be working
with, how muchvariety is necessary
2 Diverse &restrictive funding
sources rather thancoherent approach to
PMH
3 SIA funding egpost natal & childattachment pilot
starting
4 MSD funding forback to workprogrammes
6 ACC funding forabuse
10 Not clear howdifferent approaches
fit or integratewith wider MH
services
12 Not clear whatoverall outcomesseeking and what
resources would beneeded
15 We can providegood service to
those who manage to
get access
16 How do weidentify, screen,
target within knownhigh risk popns?
17 Once identifiedhow do we assess?how much skill & $
put into assess?18 What
inclusion/exclusioncriteria should weuse & how apply?
19 What happens tothose we exclude?
Don't meet thresholdbut still have high
needs potentiualbenefit
21 What is the fitof PMH within wider
primary healthstrategy
23 Connection tosocial services &
support?
24 How do we manage
referral pathways toother services?
26 PMH role in earlyintervention & flow
through to SMH
constrained 27 Demand muchgreater than funding
& capacity
28 People are
hurting out there atthe moment, we have
raised communityexpectations,engagement
floodgates are open
37 How do wesystematically learn
& respond topatterns of
utilisation andresults?
38 Major issues with
drug & alcohol use
47 High levels ofcomplex stress in
our populations
48 Work,relationship, social
49 'My wairoa isbroken, my spirit is
lost' creates adifferent
understanding ofresponse pathway
50 depression &anxiety
52 We are achievingsubstantial
reductions instress, symptoms &
dysfunction
57 Most people
assessed in PMH havehigher scores than
were expected to behandled >29
7 2 0 1 4 1 3
4 6 1 1 3 6 2 0 7 5
8 9
3 9
3 3
-
3 4 2 2
1 1
3 4
2 5
5 1
2 2
9
1 4
4 4
What outcomes do we need?
How would we focus and integrate our funding streams?- Balance administrative needs for focus &
accountability with breadth needed for flexibility and PMH system development
Shift from diagnostic categories to recognition of stress & complexity- Nature of need and demand is not just a less severe form of specialist MH
What is the system that manages targeting & inclusion while monitoring & responding to consequences of exclusion?
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Developing sustainable funding & resources
2 Diverse &restrictive funding
sources rather thancoherent approach to
PMH
3 SIA funding eg
post natal & childattachment pilot
starting
4 MSD funding for
back to workprogrammes
5 MoH has small and
limited $ for PMHinitiatives
6 ACC funding forabuse
7 Normal primary
care also supports
MH
10 Not clear howdifferent approaches
fit or integratewith wider MH
services
11 Potential of
shift to PBFfunding, will $ be
sustainable?
12 Not clear whatoverall outcomesseeking and what
resources would beneeded
14 Wide variation innature & level of
intensity of
service, use ofsecondary packages
of care
16 How do weidentify, screen,
target within knownhigh risk popns?
20 What's the place
of Rx?
21 What is the fitof PMH within wider
primary healthstrategy
25 Can't utiliseblue print 3% $ for
developing PMHcapacity
27 Demand muchgreater than funding
& capacity
36 Huge differencesin resourceutilisation
46 W&I access todisability support
for crisis/severeextended sessions
51 Current funding
will reduce asinitiatives wind up
9 8
1
2 6 8 9
1
3 7 1
4 5 9
1 7
3 9
1
2 6
3 7 2 3
4 7 2 8
Strategic Context- Being clear about what we are seeking to achieve in primary mental health- How this is integrated with wider mental
health services in the district- Fit of primary mental health within the
wider issues and outcomes of primary health including LTC
Efficiency of use- How efficiently our models of care use the funding available
Efficiency of allocation- How the resource we have is targeted
Level and structure of funding mechanisms- Level and sustainability of resource- How structured- Leveraging non health resources
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Service Models
1 What mix of modelsshould we be working
with, how muchvariety is necessary
7 Normal primarycare also supports
MH
9 PHOs evolvedmodels to suit
population
10 Not clear howdifferent approaches
fit or integratewith wider MH
services
13 Most modelsproducing good
results irrespective
of type or level ofintervention
14 Wide variation innature & level of
intensity ofservice, use of
secondary packagesof care
15 We can providegood service to
those who manage toget access
16 How do weidentify, screen,
target within knownhigh risk popns?
17 Once identified
how do we assess?how much skill & $
put into assess?
20 What's the placeof Rx?
22 Are we movinginto concepts of
stress, complexityresilience, wellness
rather than justclinical labels?
24 How do we managereferral pathways to
other services?
26 PMH role in earlyintervention & flow
through to SMHconstrained
36 Huge differencesin resourceutilisation
39 Increasingawareness
understanding ofmainstream in
approach to Maori
40 Enable access andreduce DNA of Maori
to PMH
41 Providealernative, suitable
& safe venues incommunity for Maori
to access
42 Enable whanau tobe part of process
44 Find right blendwairoa, sprituality& belief & Pakeha
cognitive approachesto MH for Maori
45 Requires time &dedicated team to
provide a wraparound to deal with
complexity &entrenched issues
55 We don't know yethow to resource or
support whanauoutside of theprimary setting
56 Addressing
spirituality, belief& family support
also works forPakeha too
1 2
2
2 8
5
1 2
8
3 5
3 7
5 2
2 7 2
1 8
2
1 9
2 8
3 8
5 7 2 5
2
2 9
5 8
5 2
5 3
5 3
5 8
Function and fit of diverse PHO models with DHB MH services
Developing highly efficient models of care that still retain flexibility and responsiveness to need- How much variety is necessary?
- How can we justify large differences in resource utilisation?
Developing sustainable approaches to primary mental health services for Maori- Balance of Maori & Pakeha approaches
- Complementary Maori specific and mainstream
Integrating self, whanau & community support with PMH
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Development of the action research agenda
From the initial exploration of the issues with the research partner the proposal from the
academic team was to develop a research agenda focused on the depth/breadth issue.
The issue of depth is that primary mental health is addressing severe needs in terms of
complexity, requiring both time to address and connections to whānau and community for
support. The nature of this complexity is not well understood in conventional diagnostic
terms or well represented by standard assessment tools. Yet complexity is seen to be a
major driver of service demand and variability in resource usage, particularly for high needs
populations. The nature of an appropriate service response for complex circumstances
needs clarification, what mix of health, community, social services, education, justice, child
and youth services should we be using and how do we mobilise this?
The argument for breadth comes from inequity and unmet need. Results from the PMHI
evaluation suggest that effective symptom reduction is not necessarily dependent on
intervention type or number of sessions, although in most initiatives there were people for
whom either the tailoring of intervention or treatment intensity was important. This makes
the distinction between the more straight forward anxiety/depression and the more
complex situations an important issue for clinical practice, service design and resource
requirements. Could better matching of need and intensity of response enable more people
to be seen?
Increasing the range of populations served, e.g. post natal, child and youth asks questions
about the rationale for service investments, what data, evidence and values inform those
decisions? Is there a more thoughtful way of making allocation and development decisions?
Would taking a more whānau /family oriented approach be another way of addressing some
of these needs?
Possible ways of putting into action this research agenda were proposed:
1. Facilitation of a clinical conversation across the PHOs. What do we mean by the
complex circumstances, can we better understand the practical judgement
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dimensions that are being used to discriminate complexity and use that to guide
better treatment or service responses?
2. Collaboratively explore the service model options that could provide a better
response to the issues of inequity/volume and complex circumstances, including
implications for work force and resources.
3. Work with the process of developing services for post-natal depression and
child/youth to develop a planning framework that would assist in investment
targeting decisions across primary mental health.
4. To articulate the lessons from this partner described positive experience in forming
trusted collaborative network relationships and infrastructure in primary mental
health, to enhance existing and future service delivery.
Action Learning Process
Unlike the previous two examples there was no formally structured action learning process
in this partner region, rather the action research partners committed to meeting for two
subsequent sessions to support the process of reflective learning within the informal PHO
primary mental health leaders group.
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Research Partner 4
This partner is unique within our research partners in having a formal strategic plan for
primary mental health, developed just prior to the action research process by the two
district PHOs, framed as part of a district wide, whole of system integrated mental health
strategic plan.
The plan sought to provide a more strategic context for the services supported through the
primary mental health initiative although at the time of commencement of our research
process most of the action items within the plan were yet to be initiated.
The PMHI service model in this region used an extended GP consult for people with mild to
moderate mental health, (with the PHQ9 used to support clinical judgement on
severity/need). This provided access through a funded referral, to a wide network of
providers who supplied packages of care of up to 6 sessions of talking therapy.
Framework for engagement
As the lead in developing the districts primary mental health plan the areas main PHO
provided the engagement point for the action research process. Practically this was
provided by the small two person PHO primary mental health team together with the DHB
Funding and Planning mental health portfolio manager.
First cycle issues exploration
An initial issues exploration working session was held with a local working group to explore
the issues. Based on session notes and transcripts an initial set of concept maps was
prepared as shown on the following pages:
An immediate issue of financial sustainability
The first cycle of issues exploration became focused on an immediate issue of financial
sustainability. Demand was higher than had been expected and, at the time of the action
research process, providers were using more sessions per patient than planned.
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The combination of these two factors was using resources at a faster rate than planned with
the real prospect of blowing the PHOs contracted budget.
“We can provide 52 packages of care a month and that is being topped up by our
funds so we’re about to shift about $40,000 worth of funds from our service
management fund simply because the programme is just over stretching at the
moment. Historically we’ve done that well, we had some funding left over from our
setup funding so we transferred that into professional services and then we’ve also
had another wee dip into the management funds as well.”
“The other challenge for us is we are only small and so we don’t have the extra SIA or
budget within our management to top this up like we would like to, it’s just not there,
with such complex needs, we’ve put most of the other SIA funding into chronic illness
'cause that’s our biggest one and a lot of the stuff goes hand in hand, chronic illness
and mental health, they’re not separate field, they’re seen as separate fields but
they’re not, it’s continual. So yeah, we will keep our programme but I just don’t know
how in what way we would have to limit that, because I just don’t see that we can.”
With this greater than expected drain on limited resources an urgent presenting issue in the
area was how to make hard choices in terms of limiting cost per treatment (reducing
number of sessions from 6 to 4) and rationing access by providing limits on the number of
packages of care available to each GP.
“Initially probably in the first 12 months we had about 50 GP’s referring through the
programme and we’re now up to about 110, which of course has it’s own issues… all
our packages of care are allocated out on a percentage basis to what the GP’s
managing with our population, because we always have some GPs that weren’t
referring and so we always had those packages of care that we could sort of shift to
the higher needs area, [but] because now that we’ve got such great participation in
the programme, we don’t have that residual of packages of care which is posing a bit
of a problem.”
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“Its probably time to sort of analyse a little bit more of what we’ve done and learn
from what’s happening…[for example] on the end care reports, [there have been]
requests for second packages of care, last month we got 17 which is, well we already
got 52 a month so historically we’ve been able to take from the residual, we don’t
have that residual anymore, and there’s no point saying no to those subsequent
packages of care because otherwise you’ve lost what you’ve provided so I mean, it’s
just a moral thing that you just can’t say no. But then would it make a difference,
you know how many second packages of care are being requested from a clinical
psychologist as against psychotherapists, you know whether we could have that, look
at that sort of data and whether that would make a difference.”
“We went to Clinical Governance and said, we’re blowing the budget guys what do
we do? And they said well cut it back, cut it right back. Then there’s international
evidence that says, no you need at least this number of sessions to make it a viable
service. So we’re trying to sit here and often in our little own world trying to
implement this programme to the best of our knowledge.”
Options and choices of service model
In response to tight funding the PHO and DHB had agreed to utilise a modest resource from
Services to Improve Access funding (SIA) to support the service and address the perceived
shortfall relative to need, particularly in geographical areas of high need and limited service
availability. This raised issues with regards to what model of care to use which would make
best use of this resource and the capacity available.
There was a reluctance to simply increase the level of funding of existing services when
there was this inequity of provision. The funding was seen as an opportunity to explore
different models:
“…We listened to…[others] that said that there will be a hump, and you will get a
huge influx of people and it will tailor off, it never tailored off, it continues to climb
so we’re stuck now with a necessity to rationalise the money we have… And that is
providing us with a dilemma, how do we do that? The best model would have been
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to throw all the money into one initiative…but we have now got a situation where
that’s a stand alone model [the extended consult and refer] and here is another
model [Brief Intervention Coordinator] that’s used in other parts of New Zealand how
do we integrate them?”
In essence the area would have three models of care emerging:
The extended GP consultation plus external referral to psychological service
providers for packages of care.
A Māori provider care model which used a hybrid approach of either an extended
GP consultation and referral to a Māori service provider or an integrated approach
within a wider whānau ora based service delivery model.
A proposal for the PHO to employ practitioners in particular areas to deliver an
integrated practice based ‘brief intervention coordinator’ model.
This raised questions about how choice of model of care could and should be made. This
was not simply a clinical issue of alternative means to the same end. The brief intervention
coordinator model was seen to be an opportunity that both addressed the service shortfall
in a high needs location and to develop a lower cost service model that could increase the
reach of the service as a whole. However, if extended outside of the initial geographically
bound area this would effectively set the PHO up in competition with existing providers. It
would also require a workforce development strategy and potentially create a different set
of relationships between the PHO and its member practices. There was seen to limited
accessible or appropriate guidance that the area could draw on to address these questions.
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Research Partner 4 cognitive maps from March 2009
Potential issues and opportunities for primary mental health development
1 Need to reflectand learn from ourexperience to date
2 We picked oneparticular model
extended consult +referred packages ofcare + case & flow
coordination
3 Invested incinical project
management & networksupport
4 Expected a hump ofdemand but still
continuing to grow
5 Must rationalisethe money we have,
delimna about how todo that
6 SIA funding 2 FTEclinical roles to
augment programme,what best use?
7 PMH Initiativesprovide a range of
options & models ofservice
9 Depressionguidelines BPACdecision support
PHQ9 tools
10 Pressure to cutback # sessions/costof packages of care
11 Intl evidence ofminimum # sessions
to gain benefit
12 What is the rightserv ice model weshould be using in
the furture?
13 Packages of care6 sessions
reasonably costly$500
14 Demand exceedingfunding available ,
unsustainable
17 Target mild mod,no age, identified
by GP
18 Demand arisingfrom known issues
with existingpatients
19 Demand arisingfrom newly
identified MH issues
20 Patient selfgenerated request
for extended consult
21 Tighten criteriafor inclusion &exclusions &
referral to SMH
22 Are GPs gamingscores to use PoC asalternative to SMH
waiting list?
23 How engage GPs inupskilling &
capacitydevelopment?
24 What is a goodplanning and fundinginvestment model?
26 Retaining moneyis critical to
sustain service andinfrastructure
27 Need alignmentbetween PMH and Long
Term Conditionsapproaches
28 We are cuttingdown attention to
LTC to focus on thecritical government
prioities
29 PMH leading theway for us in
engaging peopleoutside of practices
- role model forother areas
30 Packages providedby a total of 65
providers beyondpractices31 Still working out
how ourrelationships work
for us all
33 Once peopleidentified as having
a mental healthissues tend to
become ring fencedand isolated from
wider support needed
34 Use of SIA fundedFTE could fill gap
in Motueka
35 Use of SIA FTEcould support
assessment,short TXor referral
36 Need to becareful not tocompete with
existing providers
37 Our use of fullpackages of care ishigher than otherinitiatives (Timaru)
38 Initiativeevaluation showsbenefits almost
irrespective of typeor length of Tx
39 Variability inlevel of referral byGPs, some heavy
referrers
40 Counselorstending to keep
people on41 Maori health
providers can alsoaccess POC not very
tight criteria
43 Gaps in some areasuch as Motueka
44 Our mission isnot to provide
services that areotherwise provided
in community
45 Opportunity toprov ide a different
type or layer ofserv ice that is less
intensive
46 Trial in GoldenBay to triage whatpeople need, nurseassess & direction
47 Nelson made up oflarge numbers of
small practices
48 Don't have enoughfinancial resources
under currentservice structure toprovide cover forour population
-
-
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2 We picked one
particular model
extended consult +
referred packages of
care + case & flow
coordination
4 Expected a hump of
demand but still
continuing to grow
5 Must rationalise
the money we have,
delimna about how to
do that
7 PMH Initiatives
provide a range of
options & models of
service
9 Depression
guidelines BPAC
decision support
PHQ9 tools13 Packages of care
6 sessions
reasonably costly
$500
14 Demand exceedingfunding available ,
unsustainable
17 Target mild mod,
no age, identified
by GP
18 Demand arising
from known issues
with existing
patients
19 Demand arising
from newly
identified MH issues
20 Patient self
generated request
for extended consult
30 Packages provided
by a total of 65
providers beyond
practices
37 Our use of full
packages of care is
higher than other
initiatives (Timaru)
39 Variability in
level of referral by
GPs, some heavy
referrers
40 Counselors
tending to keep
people on
41 Maori health
providers can also
access POC not very
tight criteria
43 Gaps in some area
such as Motueka
44 Our mission is
not to provide
services that are
otherwise provided
in community
47 Nelson made up of
large numbers of
small practices
Core sustainability issue
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2 We picked one
particular modelextended consult +referred packages of
care + case & flowcoordination
5 Must rationalise
the money we have,delimna about how to
do that
6 SIA funding 2 FTEclinical roles to
augment programme,what best use?
10 Pressure to cutback # sessions/costof packages of care
11 Intl evidence of
minimum # sessionsto gain benefit
12 What is the rightservice model weshould be using in
the furture?
14 Demand exceedingfunding available ,
unsustainable
21 Tighten criteriafor inclusion &exclusions &
referral to SMH
22 Are GPs gaming
scores to use PoC asalternative to SMH
waiting list?
34 Use of SIA fundedFTE could fill gap
in Motueka
35 Use of SIA FTEcould support
assessment,short TXor referral
36 Need to be
careful not tocompete with
existing providers
38 Initiative
evaluation showsbenefits almost
irrespective of type
or length of Tx
43 Gaps in some areasuch as Motueka
44 Our mission isnot to provide
services that areotherwise provided
in community
45 Opportunity toprovide a different
type or layer ofservice that is less
intensive
-
Options in choice of service model
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Action Learning Process
Given the urgency of the need to rationalise funding a fast cycle action research
process took place during the exploration stage. This involved the academic research
team sharing the emerging evidence and understanding on the options, benefits,
risks and trade-offs of very short interventions versus norms that had been
established through therapeutic traditions such as CBT.
In the short term the action research supported the local team to develop their case
to the PHO Clinical Governance Group for reducing the funded sessions from six to
four and to engage with providers who maintained that shortening session
allowances would jeopardise care outcomes.
In addition an action research agenda was framed up based on a collaborative
approach to modelling the two potentially competing service models described
earlier. This recognised that the two service models had developed in an emergent
process and operated under quite different assumptions, intervention models,
resource requirements and organisational management structures.
The goal or the action research project was to develop a clear articulation of the two
service models, PMHI and BIC; rationale, evidence base, key differences in terms of
clinical and service model, population served, how they would operate under
different inclusion/exclusion criteria and the consequent impact on resource
requirements.
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Toolkit summary
The Toolkit accompanies this Research Report. It contains five components which are
the Navigation Guide, Knowledge Bank, Guides to tackling issues with illustrative
vignettes, workshop plans and population based system modelling.
Navigation Guide
The Navigation Guide:
Outlines some principles that will help users get maximum benefit from the
Toolkit;
Lists the Toolkit components – the Toolkit includes a range of components
that you can use in any way you wish.
Includes a suggested process outline for using the Toolkit components to
develop solutions for users planning or service issues. After the
introductory phase of the first workshop, we suggest referring to the
Navigation Guide to ‘ground’ workshop discussions on the basic principles
which users have prioritised for this particular decision-making/planning
process.
Can be used to choose an entry point to the Toolkit if users want to bypass
a workshop process for problem identification and prioritising. For example,
if a user is a service manager and they know they must find a way to
provide Primary Mental Health Care (PMHC) for children and young people.
Includes an appendix with some single page ‘jump start’ sheets to help
users focus on key process issues in planning. Some of these reiterate
material in the Navigation Guide but are easy to pull out or copy to have
them on hand.
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Knowledge Bank
The Knowledge Bank contains four perspective papers. These are drawn from the
research process, our knowledge of the literature and experience in the sector.
The topics are:
Where next for Primary Mental Health Care? - current issues and
opportunities
Diagnosis and management in Primary Mental Health Care: a paradox and a
dilemma
Quality in Primary Mental Health Care
Towards the future Primary Mental Health Care: Optimal Model II
It also contains copies of the following guidelines:
Identification of Common Mental Disorders and Management of
Depression in Primary Care (2008)
And other useful links:
www.primarymentalhealth.org.nz (Ministry of Health’s primary mental health and addiction website)
www.nzgg.org.nz (see Guidelines for Identification of Common Mental Disorders and Management of Depression in Primary Care)
www.hiirc.org.nz (Health Improvement & Innovation Resource Centre)
www.tepou.co.nz (New Zealand’s National Centre of Mental Health Research, Information and Workforce Development)
http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_
improvement_tools/creativity_tools_-_bullet_proofing.html (NHS Quality and Service Improvement Tools)
http://www.thelowdown.co.nz/ (The Lowdown - Youth depression website)
http://www.depression.org.nz/ (National Depression Initiative, featuring John
Kirwan and the Journal)
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Guides to tackling issues, with illustrative vignettes
This section contains guides to tackling specific issues in PMHC. Each of these is
linked to a corresponding vignette which provides a fictional (but drawn from
research partner experience) example of the problem to be worked through. The
guides and vignettes are grouped together as: ways of working together; using your
resources; making the system work; population groups.
The guides are:
Ways of working together
Teamwork
Leadership for Primary Mental Health Systems
Relationships and communication
Using your resources
Prioritisation and establishing the boundaries of Primary Mental Health
Care
Time and time management
Financial sustainability of Primary Mental Health Care services
IT and systems
Eligibility to receive Primary Mental Health Care
Connecting with the consumer
Making the system work
Coordination of care
Mental Health and chronic conditions
Integration across the continuum of primary, community and specialist
settings
Models of care
Mental health promotion
Future proofing Primary Mental Health Care
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Population groups
Specific issues for child and youth Primary Mental Health Care
Issues in alcohol and substance use
Primary Mental Health in the elderly
Primary Mental Health Care for Māori
Primary Mental Health Care for Pacific Peoples
Workshop plans
The workshop plans provide two options for supporting user’s use of the primary
mental health Toolkit. Other parts of the toolkit provide examples of the way that
primary mental health care is being developed and offer questions and suggestions
about the decisions we think users should be considering for their own organisation.
You can use these as material for your workshops. By the end of the users
workshop(s) they should have a clear set of plans for their own development work
over one to two years and hopefully a strategic direction beyond that. This section
also includes some suggestions for ‘jump-starting’ a stalled process.
Population based system modelling
The Systems Planning Guide (Part 5a) and Dynamic Systems Model (Part 5b) are
designed to help facilitate planning conversations about PMHC in the users region,
so that they can design solutions that best fit their particular circumstances. To
facilitate the conversations we have designed a system model of the key elements
within PMHC and how those elements link together. The model focuses on common
knowledge derived from our extensive conversations with planners and providers
within the partner DHBs, and our combined knowledge of the literature, health
system design and planning, and clinical practice.
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Section 6: Discussion
Overview
In this concluding section we reflect on the translational research process and
describe the specific challenges associated with this project.
The project had three funded outputs;
The Toolkit, which is presented in a separate document and will also be
available on CD following final review and approval. This is the main output;
The participatory action research/consultancy process that we undertook
with the research partners was the second key output;
This report, which is a summary of the project as a whole.
Translational research process
We approached this project from a translational research perspective because one
of the aspirations of the Steering Group who designed the Request for Proposals
(RFP) was to ensure knowledge transfer during the research process. This was also
behind the desire for a Participatory Action Research (PAR) approach as expressed in
the RFP. Among the research team’s early tasks was the need to develop an
understanding of ‘translational research’ in the context of a project such as this.
Translational research is usually considered as an approach to getting knowledge
from ‘bench to bedside’. This means the application of fundamental biomedical
knowledge to clinical problems as they present to clinicians. One of the drivers for
this is that the great expense of improving our fundamental knowledge of the
biological basis of human health, disease and illness has not contributed sufficiently
to advancing the health outcomes arising from ordinary clinical practice. One of the
benefits of the move to a translational research ethos is that there is an emerging
improvement in direct engagement between basic scientists and clinicians (although
not service users, yet). While this communication and the resulting collaborations
are promising, we think this approach to translational research is too limited in
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scope, especially in areas such as mental health, where there is still limited
confidence in the clinical application of our biological understanding.
We argue that the social sciences have potential to contribute to the further
development of the translational research effort. The application of our advancing
scientific knowledge is ultimately dependent on the knowledge, skills and behaviour
of clinicians, as that is where the translation occurs. This is why we explored the
literature on diffusion of health innovation.
There are three important areas to consider here. Firstly, clinicians need to know
about the technology, its purposes and limits, and the technology has to be able to
achieve outcomes consistent with clinicians’ goals. To achieve this, these goals must
be known and understood. Some of them will be linked to clinical outcomes but as
was revealed in this study, some are not. In systems reliant on high throughput
where practitioners are having to constantly juggle competing demands, some of the
goals will be such things as “leave work at six o’clock one night this week”, as we
discovered. Such goals may be covert but still exert powerful influences on the
willingness of clinicians to try new approaches.
Secondly, the technology has to be available at the right time and place and
presented in a way that is fit for purpose in the eyes of the user, both clinician and
service user. In the case of PMHC we can consider screening instruments, clinical
assessment skills, and consultation and therapeutic skills as our technologies,
alongside more ‘mainstream’ technologies such as pharmaceuticals. Do we have
enough knowledge of how primary care clinicians use these technologies? Are they
presented in the best way to maximise appropriate use? How will ‘new’ technologies
in PMHC, such as clinician assisted self-help, become incorporated into routine
practice? What do clinicians need to learn to do differently in order to do this? What
are the key design features of such technologies that make them more attractive to
users? Sometimes the unexpected happens: the primary mental health initiative
evaluation showed that while clinicians were initially sceptical about the use of
measurement tools such as the K10 partly because they assumed it would interfere
in the clinical process, most service users liked it.
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Thirdly, clinicians have to be able to create relationships with service users that
invite participation in and joint ownership of the clinical process. This will become
more critical as we move towards more supported self-care as is being strongly
signalled in government health policy.
The nature of these issues and how they can be influenced can best be revealed
using social science methods. The most useful material supporting our
understanding in these areas was literature on diffusion of innovation in healthcare
and developmental evaluation, both of which are, in essence, applied social sciences.
Linking aspects of this material to the current project, we have arrived at several
ideas that contribute to an improved understanding of the social aspects of
translational research. These are:
Effective translational research is ultimately underpinned by social processes,
the understanding of which must be acknowledged and invested in. The
social processes with the research partners were critical to the success of this
study, yet they are an ‘invisible’ component of the project. There was also a
social process to be negotiated in the formation of a research team across
two organisations with distinct aims, cultural practices and styles of working ;
We can expect emergent research methods which combine features of
several approaches. In the case of this project we combined aspects of case
study research with PAR, in a developmental evaluation frame;
The clinical partners must be in a position to fully engage in the research,
which requires a commitment from provider organisations that may not
consider (or be funded for) research and innovation as an important part of
their work. Research and innovation should become part of business as usual
for major clinical providers. This is not the case in PMHC in New Zealand at
present. This is an aspiration in a system where funding is tied to very specific
activities and was beyond the reach of Optimal Model II. However, it is a
logical extension of quality improvement activity, which is an important
aspect of the model;
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An in depth understanding of the clinical process is required. This is likely to
be specific to different clinical problems, for example, the clinical process
around dealing with mental health problems in primary care may be different
to that for, say, diabetes although there may be more similarities than we
expect. At present this is a relative unknown, and this may remain as a barrier
to better integration across primary care programmes ;
Research programmes in the social aspects of translational research must be
flexible enough to allow deviation from the initial plan in light of emerging
findings, which may require a commitment to advance funding of a planned,
linked series of small projects.
Challenges
We benefitted from a number of challenges in conducting this project.
The extent to which people working in the field in healthcare are already
overcommitted, and have to deal with the unexpected cannot be overstated.
We are extremely grateful to our research partners for maintaining their
commitment to the project over a turbulent 18-month period in New Zealand
primary care. While this meant that progress was at times slower than we
had hoped, there were many learning opportunities in it, and the shape and
content of the Toolkit has been greatly influenced by our vicarious
experience of the time-poor nature of people’s work contexts.
In PAR-informed research it is common to exit the research programme when
the research partners signal that it is acceptable to do so. In a project of this
kind, this is not possible. This meant we have had to devise a simple and
explicit exit strategy in order to ‘keep faith’ with the process and increase the
chances of the Toolkit being taken up. For us, this represents unfunded
future non-intensive work with the partners, but it also means we will
continue to get feedback about the Toolkit so there is the possibility of slight
refinement.
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We had to adjust our expectations of the partners, three of whom were less
active overall than we had planned for. This meant we had to allow our
method to be responsive to what was offered. This is unusual in research as
commonly practiced, but it also meant we were taken beyond our familiar
areas. As a result the Toolkit has been significantly informed by material from
areas new to us. In retrospect we can see that an emergent method was
inevitable and necessary, and if doing a similar project again we would build
this in as part of the process.
The management of this contract was much ‘tighter’ than the usual HRC
process, and the reporting requirements significantly more burdensome. In
the case of this project, we think in retrospect that requiring a major report
aimed at a very diverse audience as well as the Toolkit was not necessary.
There would have been more benefit from requiring evidence of submissions
to peer reviewed journals. The key advantage of this would have been that
the important aspects of the project, such as method, could be fully
described in a technical sense, and subject to peer review. This would have
made the Toolkit more ‘credible’ in an academic sense. The test of its
credibility in the field will be in its uptake and use, so that is a separate issue.