Primary Mental Health - A review of the opportunities

Primary Mental Health
A review of the opportunities

Date of publication: May 2002

The Mental Health Directorate of the Ministry of Health has commissioned this report. Its aim is to identify and summarise key issues in relation to primary mental health care that will need to be considered in planning for the implementation of the National Primary Health Care Strategy and for the ongoing implementation of the National Mental Health Strategy.

Estimates of the prevalence of mental health problems amongst adult New Zealanders suggest that:

about 3 percent of the population have severe mental health problems or disorders

another 5 percent of adult New Zealanders have moderate/severe mental health problems or disorders

another 12 percent of adult New Zealanders have mild/moderate mental health problems or disorders.

The focus of the National Mental Health Strategy is the 3 percent of the population with the most severe mental health problems; specialist services are targeted at this group. Of particular relevance to primary health care services are the 17 percent of the population with mild to moderately severe mental health problems. It is well recognised internationally that the mental health needs of most people in this group must be met in a primary care setting.

Good national and international evidence shows a high prevalence of mental health problems amongst people presenting to primary health care services. A World Health Organization study identified that 24 percent of people presenting to primary care services have a major psychiatric disorder, while a further 9 percent have a subthreshold disorder. Furthermore, preliminary data from a local study suggest that as many as 35 percent of people presenting to general practitioner (GP) practices in New Zealand meet the criteria for mental disorder. However, mental health problems are frequently missed in primary care consultations; up to 50 percent are not detected explicitly.

Although many people with mental disorders present to primary care services, service provision in response to their needs depends on the interest and expertise of individual practitioners. Therefore models and standards of service delivery are haphazard and inconsistent. In the current primary health care system, barriers to the provision of effective primary mental health services include:

cost to the GP

cost to the service user

GP confidence and competence.

In particular, the current fee-for-service funding system and service user part-charges create financial incentives for both the GP and service user to meet the user’s needs through specialist mental health care.

The provision of primary mental health services in New Zealand is predominantly GP-based. Internationally, in contrast, other professional groups such as nurses, social workers, counsellors and psychologists have an increasing role in such provision. Despite very little formal evaluation of the effectiveness of these roles, recent work suggests interventions that consistently improved outcomes for people presenting to primary health care services with depression incorporated some form of case management approach. Typically the case management role is taken on by staff other than GPs at relatively low cost.

The literature shows clear support for primary health care practitioners taking the lead role in the provision of mental health services for people with mild to moderate mental health problems. With respect to mental health services for the 3 percent of the population with severe mental health problems, however, the role of primary health care practitioners is less well defined.

In New Zealand there is a somewhat ad hoc approach to the provision of primary health care services for this group. In recent years a few ‘pilot initiatives’ have aimed at transferring the lead role in clinical service provision for people with severe mental health problems from specialist mental health services to GPs. Because these initiatives are generally locally initiated, the way in which they are funded and delivered varies considerably.

A key issue in relation to the provision of primary health care services for people with severe mental health problems is the interface between primary and specialist services. Various models to improve this interface have been suggested, although the literature offers little evidence-based material on their effectiveness. Most models focus on various mechanisms for attaching mental health clinicians to primary health care services; their roles and responsibilities differ from model to model.

New Zealand has no national guidelines regarding the interface between specialist mental health and primary care services. Most often they operate as two ‘hard-pressed’ services that relate poorly to each other. A growing trend has been to improve this interface with the development of primary care liaison services. These services aim to encourage appropriate referrals to specialist services and enhance the skills of the GP so that they can deliver services to those people with mild to moderate mental health problems. Currently this type of initiative is locally driven and dependent on the interests and skills of individual providers.

In relation to improving the interface between specialist mental health and primary mental health services, the key issues may be summarised as follows.

Improving this interface should not mean diverting scarce, highly trained specialist resources from services to those with the greatest need.

Mental health workers who work at the interface should divide their time among face-to-face work with those most in need, shared care and consultation activities and providing support and education to the primary health care team.

The interface works more efficiently and effectively with good communication between the services, agreed criteria for referral and discharge, agreed guidelines and mutual support.

Summary of recommendations

Plans for the implementation of the Primary Health Care Strategy should state explicitly that primary health care providers will be expected to incorporate a substantial mental health component into their work in a systematic way. This could be initiated by the development of a detailed service specification for mental health to be included in the initial set of Establishment Service Specifications.

Over the medium term, primary health care providers should take the lead role in delivering mental health services to people with mild to moderate mental health problems. Effective primary care interventions for this group will include a combination of:

pharmacology
therapeutic interventions of known efficacy
provision of information to support self-help
a case management approach.

Once a service specification is developed, the capitated funding formula for primary health care will need to be adjusted to include primary mental health services. The costs to both GP and service user should be considered in this regard. Furthermore, if the capitated funding model includes additional targeted payments for specific service areas mental health should be considered as one such service, given that:

mental health is a national health gain priority
the prevalence of mental health problems in primary care is high
the costs associated with time-consuming assessment, interventions and case management are higher than average treatment costs.

Effective primary mental health care services require the development of mechanisms for multidisciplinary input into their delivery. It is important that the expansion of the primary mental health workforce includes appropriate guidelines and mechanisms to ensure that service delivery is based on best practice and interventions of known efficacy.

The government’s Primary Health Care Strategy provides challenges and opportunities for nurses to develop more integrated and collaborative models of service delivery in community and primary health care settings. Mental health nurses working in community and primary health care settings will need to be involved in the development of new ways of working as Primary Health Organisations (PHO) are progressively implemented. It seems appropriate to consider developing the primary health care nursing role as the top priority in establishing a multidisciplinary approach to mental health service delivery. Part of actioning this priority would be to develop mechanisms that ensure:

registered nurses working in primary health care settings demonstrate core mental health competencies, to effectively screen and assess clients with mental health problems

mental health primary health care providers work with PHOs to develop innovative nursing initiatives based on evidence and best practice to provide assessment, brief interventions of known efficacy and case management services for people with mild to moderate mental health problems in the community.

In addressing primary health care workforce development needs, credentialing and quality improvement issues, an essential expectation is that primary health care providers are competent in managing mild to moderate mental disorders. Although the move to capitation may remove the financial disincentives against GP participation in specialist mental health training, a remaining need, once the work to develop service components is completed, is the need to identify and organise suitable training for GPs and primary health care nurses. Implementing this recommendation should include establishing mechanisms for ensuring that primary health care practitioners receive ongoing support and training in primary mental health care.

Ongoing planning should be cognisant of new, innovative models of service delivery that are both cost effective and beneficial to service users. Implementing this recommendation would include considering further the use of cognitive behavioural therapy programmes that are CD-ROM–based.

To inform future policy development, there should be a stocktake of local initiatives that aim to transfer clinical service provision for people with severe mental health problems from specialist mental health services to primary health care services. This stocktake should include a review of:

current and planned initiatives
funding and pricing models used in these initiatives
mechanisms for monitoring and evaluating initiatives
results of any evaluations.

Further work on the national service framework for specialist mental health services should identify as a priority the improvement of the interface between specialist mental health services and primary health care services. The possibility of developing a more integrated model of service provision should be considered.

Provision of mental health services to people with multi-agency high support needs (severe disability) should remain the role of specialist mental health services. However, the role of primary health care providers is likely to develop considerably over the next few years, with moves to a broader base of multidisciplinary service provision and the ongoing workforce constraints in the specialist mental health sector. Given this probable trend, there is a need for further clarity and consistency with respect to the role of primary health care providers in delivering mental health services to the remaining people with severe mental health problems. Information from the stocktake and review, as recommended above, should be used in decision-making regarding this issue.

Document availability

This publication is not available in hard copy. It is only available on this website in PDF format below.

(PDF, 194 kB)

This document has been converted to Adobe's Portable Document Format (PDF). Here is a link to information on downloading and viewing PDFs.

Related information

Mental Health Publications

Primary Health Organisations and mental health

Media releases

Like Minds website: www.likeminds.govt.nz

Mental Health Directorate page