toolkit for primary mental health care development ... › wellington › otago023688.pdf ·...

___________________________________________________________

__________________________________________________________________

Toolkit for Primary Mental Health Care Development: Research report Authors: Collings S, Mckenzie S, Dowell AC, Currey N, Gandar P, Rees D

___________________________________________________________

_____________________________________________________________________ © 2010

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.

__________________________________________________________i

____________________________________________________________________ © 2010

Toolkit for Primary Mental Health Care Development: Report

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

__________________________________________________________ii

____________________________________________________________________ © 2010


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).

_________________________________________________________

____________________________________________________________________ © 2010


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

_________________________________________________________

____________________________________________________________________ © 2010


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

________________________________________________________ iii

____________________________________________________________________ © 2010


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.

________________________________________________________ iv

____________________________________________________________________ © 2010


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.

________________________________________________________ v

____________________________________________________________________ © 2010


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

________________________________________________________ vi

____________________________________________________________________ © 2010


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).

________________________________________________________ 1

____________________________________________________________________ © 2010


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,

________________________________________________________ 2

____________________________________________________________________ © 2010


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.

________________________________________________________ 3

____________________________________________________________________ © 2010


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.

________________________________________________________ 4

____________________________________________________________________ © 2010


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.

________________________________________________________ 5

____________________________________________________________________ © 2010


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

________________________________________________________ 6

____________________________________________________________________ © 2010


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

________________________________________________________ 7

____________________________________________________________________ © 2010


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

________________________________________________________ 8

____________________________________________________________________ © 2010


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

________________________________________________________ 9

____________________________________________________________________ © 2010


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.

________________________________________________________ 10

____________________________________________________________________ © 2010


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,

________________________________________________________ 11

____________________________________________________________________ © 2010


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

________________________________________________________ 12

____________________________________________________________________ © 2010


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

________________________________________________________ 13

____________________________________________________________________ © 2010


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.

________________________________________________________ 14

____________________________________________________________________ © 2010


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

________________________________________________________ 15

____________________________________________________________________ © 2010


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).

________________________________________________________ 16

____________________________________________________________________ © 2010


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

________________________________________________________ 17

____________________________________________________________________ © 2010


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

________________________________________________________ 18

____________________________________________________________________ © 2010


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

________________________________________________________ 19

____________________________________________________________________ © 2010


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

________________________________________________________ 20

____________________________________________________________________ © 2010


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

________________________________________________________ 21

____________________________________________________________________ © 2010


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.

________________________________________________________ 22

____________________________________________________________________ © 2010


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.

________________________________________________________ 23

____________________________________________________________________ © 2010


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.”

________________________________________________________ 24

____________________________________________________________________ © 2010


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

________________________________________________________ 25

____________________________________________________________________ © 2010


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).

________________________________________________________ 26

____________________________________________________________________ © 2010


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

________________________________________________________ 27

____________________________________________________________________ © 2010


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

________________________________________________________ 28

____________________________________________________________________ © 2010


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

________________________________________________________ 29

____________________________________________________________________ © 2010


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.

________________________________________________________ 30

____________________________________________________________________ © 2010


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.

________________________________________________________ 31

____________________________________________________________________ © 2010


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

________________________________________________________ 32

____________________________________________________________________ © 2010


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 –

________________________________________________________ 33

____________________________________________________________________ © 2010


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.

________________________________________________________ 34

____________________________________________________________________ © 2010


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

________________________________________________________ 35

____________________________________________________________________ © 2010


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

________________________________________________________ 36

____________________________________________________________________ © 2010


• 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.

________________________________________________________ 37

____________________________________________________________________ © 2010


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,

________________________________________________________ 38

____________________________________________________________________ © 2010


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).

________________________________________________________ 39

____________________________________________________________________ © 2010


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.

________________________________________________________ 40

____________________________________________________________________ © 2010


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.

________________________________________________________ 41

____________________________________________________________________ © 2010


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.

________________________________________________________ 42

____________________________________________________________________ © 2010


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).

________________________________________________________ 43

____________________________________________________________________ © 2010


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

________________________________________________________ 44

____________________________________________________________________ © 2010


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

________________________________________________________ 45

____________________________________________________________________ © 2010


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,

________________________________________________________ 46

____________________________________________________________________ © 2010


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

________________________________________________________ 47

____________________________________________________________________ © 2010


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

________________________________________________________ 48

____________________________________________________________________ © 2010


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

________________________________________________________ 49

____________________________________________________________________ © 2010


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.

________________________________________________________ 50

____________________________________________________________________ © 2010


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

________________________________________________________ 51

____________________________________________________________________ © 2010


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.

________________________________________________________ 52

____________________________________________________________________ © 2010


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

________________________________________________________ 53

____________________________________________________________________ © 2010


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

________________________________________________________ 54

____________________________________________________________________ © 2010


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,

________________________________________________________ 55

____________________________________________________________________ © 2010


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

________________________________________________________ 56

____________________________________________________________________ © 2010


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.

________________________________________________________ 57

____________________________________________________________________ © 2010


References

Agnew F, Pulotu-Endemann F.K, Robinson G, Suaali’i-Sauni S, Warren H, Wheeler A, Erick M, Hingano T, Schmidt-Sopoaga H. 2004. Pacific Models of Mental Health Service Delivery in New Zealand “PMMHSD” Project. Auckland: Health Research Council of New Zealand.

Allen J & Laycock J. 1997. Major mental illness in the Pacific: a review. Pacific Health Dialog 4(2): 105−18.

Anae M. 1998. Fofoaivaoese: Identity journeys of NZ-born Samoans. Unpublished doctoral dissertation, University of Auckland, New Zealand.

Andrews G & Henderson S. 2000. Unmet need in psychiatry. Cambridge University Press. Cambridge, England.

Asiaisiga L, Falanitule L, Tu’itahi S & Guttenbeil Y. (n.d.). From Abuse to Strength Project. Family violence: A Pacific perspective. (pp. 69 – 87). Wellington: New Zealand.

Baker P. T, Hanna J. M. & Baker & Thelma S. 1986. The Changing Samoans: behaviour and health in transition. New York, USA: Oxford University Press.

Bashir K, Blizard B, Bosanquet A, Bosanquet N, Mann A & Jenkins R. 2000. The evaluation of a mental health facilitator in general practice: effects on recognition, management, and outcome of mental illness. British Journal of General Practice 50: 626-629.

Bateman A & Tyrer P. 2004. Services for personality disorder: organisation for inclusion. Advances in Psychiatric Treatment 10: 425-433.

Bathgate M, & Pulotu-Endemann F.K. 1997. Pacific People in New Zealand. In Pete M. Ellis & Sunny C.D. Collings (Eds.), Mental Health from a public health perspective. Wellington: Ministry of Health.

Baxter J, Kingi T. K, Tapsell R & Durie M. 2006. Māori . In Oakley Browne M.A, Wells J.E. & Scott K.M. (Eds). Te Rau Hinengaro: The New Zealand Mental Health Survey. Wellington: Ministry of Health.

Bedford R & Didham R. 2001. Who are the “Pacific peoples”? Ethnic identification and the New Zealand census. In C. Macpherson, P. Spoonley & M. Anae (Eds.), Tangata O Te Moana Nui: The evolving identities of Pacific peoples in Aotearoa/New Zealand. Palmerston North, New Zealand: Dunmore Press.

Berry J. 1997. Immigration, acculturation, and adaptation. Applied Psychology: An International Review, 46(1) 5-68.

________________________________________________________ 58

____________________________________________________________________ © 2010


Bower P, Gask L. 2002. The changing nature of consultation-liaison in primary care: bridging the gap between research and practice. General Hospital Psychiatry 24:63-70.

Bushnell J, Collings S, Sutton F, Howden-Chapman P, Carter H, Macmillan M, Salmond G & Cumming J. 1994. Barriers to mental health care in the community: towards an economic model. Mental Health Research Consortium, Health Services Research Centre, Victoria University. Wellington, New Zealand.

Cheung P. 1993 Somatisation as a presentation in depression and post-traumatic stress disorder among Cambodian refugees. Australian and New Zealand Journal of Psychiatry, 27, 422-428.

Cheung P. 1994 Post-traumatic stress disorder among Cambodians in New Zealand. International Journal of Social Psychiatry, 40, 17-26.

Cheung P & Spears G. 1995a. Illness aetiology construct, health status and use of health services among Cambodians in New Zealand. Australian and New Zealand Journal of Psychiatry, 29(2), 257-265.

Cheung P & Spears G. 1995b. Psychiatric morbidity among New Zealand Cambodians: the role of psychosocial factors. Social Psychiatry and Psychiatric Epidemiology, 30, 92-97.

Collins C, Hewson D, Munger R & Wade T. 2010. Evolving models of behavioural health integration in primary care. New York, Millbank Memorial Fund.

Collings S & the MaGPIe Research Group. 2005. Disability and the detection of mental disorder in primary care. Social Psychiatry and Psychiatric Epidemiology 40: 994-1002.

Cook L, Didham R & Khawaja M. 1999. On the demography of Pacific people in New Zealand. Wellington: Statistics New Zealand.

Cribb J & Barnett R. 1999. Being bashed: Western Samoan women’s responses to domestic violence in Western Samoa and New Zealand. Gender, Place and Culture 6(1), 49-65.

Davey J. 1993. From Birth to Death III. Wellington: Institute of Policy Studies, Victoria University of Wellington.

Davidson L, M. O'Connell et al. 2006. "The Top Ten Concerns About Recovery Encountered in Mental Health System Transformation." Psychiatric Services 57(5): 640-645.

________________________________________________________ 59

____________________________________________________________________ © 2010


Department of Health. 2010. Realising the benefits: IAPT at full roll out. IAPT programme, National Mental Health Development Unit, Department of Health. London, UK. www.dh.gov.uk/publications

Dew K, Dowell A, McLeod D, Collings S, Bushnell J. 2005. ‘This glorious twilight zone of uncertainty’: mental health consultations in general practice in New Zealand. Social Science & Medicine 61(6):1189-1200.

Dowell A, Garrett S, Collings S, McKinley E, McBain L, Stanley J. 2009. Evaluation of the Primary Mental Health Initiatives: Summary Report. Wellington: University of Otago & Ministry of Health.

Drummond C, Oyefeso A, Phillips T et al. 2004. Alcohol needs assessment research project. England: Department of Health.

Durie, M. 1997. Māori Cultural Identity and its Implications for Mental Health Services. International Journal of Mental Health 6 (3), p 23-35.

Durie M. 1998. Whairoa: Māori Health Development. Auckland: Oxford University Press.

Durie M. 1999. Mental health and Māori development. Australian and New Zealand Journal of Psychiatry 33(1), 5-12.

Durie M. 2001. Mauriora: The dynamics of Māori Health. Auckland: Oxford University Press.

Durie M, Cooper R, Grennell D, Snively S, & Tuaine N. 2010. Whānau Ora: Report of the Taskforce on Whānau -Centred Initiatives. Wellington, New Zealand.

Dyall L. 1997. Māori . In Ellis P & Collings S. (Eds). Mental Health from a public health perspective. Wellington: Ministry of Health.

England E & Lester H. 2005. Integrated mental health services in England: a policy paradox? International Journal of Integrated Care 5(3): 1-8.

Fleming M & Manuel L. 1999. Brief intervention in primary care settings: a primary treatment method for at-risk, problem and dependent drinkers. Alcohol Research and Health.

Foliaki S, Kokaua J, Schaaf D & Tukuitonga C. 2006. Pacific People. In Oakley-Browne, M.A., Wells, J.E. & K.E. Scott (Eds.), Te Rau Hinengaro: The New Zealand Mental Health Survey (pp. 178-208). Wellington: Ministry of Health.

Funk M & Ivbijaro G, eds. 2008 Integrating mental health into primary care: a global perspective. Geneva, Switzerland: World Health Organisation and London, UK: World Organisation of Family Doctors. Available at:

http://www.dh.gov.uk/publications

________________________________________________________ 60

____________________________________________________________________ © 2010


http://www.who.int/mental_health/policy/Integratingmhintoprimarycare2008_lastversion.pdf

Gilbody S, Bower P, Fletcher J, Richards D & Sutton A. 2006. Collaborative care for depression: A cumulative meta-analysis and review of longer-term outcomes. Archives of Internal Medicine 166: 2314-2321.

Goldberg D & Huxley P. 1980. Mental illness in the community – the pathway to psychiatric care. Tavistock, London.

Graves T, Graves N. 1985. Stress and health among Polynesian migrants to New Zealand. Journal of Behavioural Medicine 8(1): 1−19.

Hafferty F & Light D. 1995. Professional dynamics and the changing nature of medical work. Journal of Health and Social Behaviour 35: 132-153.

Handiside, A. 2004. Our Physical Health... Who Cares? Wellington: Mental Health Commission.

Harris R, Tobias M, Jeffreys M, et al. 2006. Racism and health: The relationship between experience of racial discrimination and health in New Zealand. Social Science & Medicine 63:1428–41.

Health Research Council of New Zealand. 2005. The Health Research Council of New Zealand Guidelines on Pacific Health Research. Wellington, New Zealand: Health Research Council of New Zealand.

Hiplsey-Cox J, Fielding K, et al. 1998. Depression as a risk factor for ischaemic disease in men: population based case control study. British Medical Journal 316:1714-911.

Ho E, Au S, Bedford C & Cooper J 2003. Mental health issues for Asians in New Zealand: a literature review. Wellington: Mental Health Commission.

Ho E, Cheung E, Bedford C & Leung P. 2000. Settlement Assistance Needs of Recent Migrants. A Report Commissioned by the New Zealand Immigration Service. Wellington: New Zealand Immigration Service.

Hsu L & Folstein M. 1993. Somatoform disorders in Caucasian and Chinese Americans. Journal of Nervous and Mental Disease, 185(6), 382-387.

Jenkins R. 1992. Developments in the primary care of mental illness- a forward look. International Review of Psychiatry 4:237-242.

Jonas B, Mussolino M. 2000. Symptoms of depression as a prospective risk factor for stroke. Psychosomatic Medicine 62:(4)463-472.



________________________________________________________ 61

____________________________________________________________________ © 2010


Katon W, Von Korff M, Lin E, Simon G. 2001. Rethinking practitioner roles in chronic illness: the specialist primary care physician and the practice nurse. General Hospital Psychiatry 23:138-144.

Killaspy H. 2006. Psychiatric out-patient services: origins and future. Advances in Psychiatric Treatment 12: 309–319.

Kim-Cohen J, Caspi A, Moffitt T, et al. 2003. Prior juvenile diagnoses in adults with mental disorder developmental: Follow-back of a prospective-longitudinal cohort. Archives of General Psychiatry 60:709-717.

Koloto A. H & Sharma S. 2005. The needs of Pacific women when they are victims of family violence. Social Policy Journal of New Zealand 26, 84 – 96.

MaGPIe Research Group. 2003. The nature and prevalence of psychological problems in New Zealand primary health care: a report on Mental Health and General Practice Investigation. NZMJ 116, 1171, 1-15.

MaGPIe Research Group. 2004. General practitioner recognition of mental illness in the absence of a "gold standard". Australian & New Zealand Journal of Psychiatry 38: 789-794.

MaGPIe Research Group. 2005. General practitioners' perceptions of barriers to their provision of mental healthcare: a report on Mental Health and General Practice Investigation. New Zealand Medical Journal 188(1222):1-8.

MaGPIe Research Group. 2005a. The effectiveness of case-finding for mental health problems in primary care. British Journal of General Practice 55: 665-669.

MaGPIe Research Group. 2006. The treatment of common mental health problems in general practice. Family Practice 23: 53-59.

Malo V. 2000. Pacific People in New Zealand Talk about Their Experiences with Mental Illness. Recovery Series, 3. Wellington: Mental Health Commission.

McGrath, F. 2002. A review of primary health care in New Zealand. Report for the Western Pacific Region of the WHO. Wellington, New Zealand.

Meleisea M & Schoeffel P. 1998. Samoan families in New Zealand: The cultural context of change. In V. Adair & R. Dixon (Eds.). The family in Aotearoa New Zealand (pp. 158-178). Auckland, New Zealand: Longman.

Mental Health Commission. 1998. Blueprint for mental health services in New Zealand: How things need to be. Wellington, Mental Health Commission.

________________________________________________________ 62

____________________________________________________________________ © 2010


Mental Health Commission. 2000. Pupu Whakaaro: The development of mental health services for Pacific people in New Zealand. Wellington: Mental Health Commission.

Mental Health Commission. 2001. Recovery competencies for New Zealand mental health workers. Wellington, Mental Health Commission.

Mental Health Commission. 2001. Pacific Mental Health Services and Workforce: Moving on the Blueprint. Wellington: Mental Health Commission.

Mental Health Commission. 2001. Pacific People Talk about their Experiences with Mental Illness. Wellington: Mental Health Commission.

Mental Health Commission (2007). Te Haererenga mo te Whakaoranga 1996-2006: The journey of recovery for the New Zealand mental health sector. Wellington, Mental Health Commission.

Ministry of Health. 1995. Strategic Directions for the Mental Health Services for Pacific Islands People. Wellington: Ministry of Health.

Mila-Schaaf K & Hudson M. 2009. Negotiating space for indigenous theorising in Pacific mental health and addictions. Auckland: Le Va, Pasifika within Te Pou.

Ministry of Health. 1997. Making a Pacific Difference: Strategic initiatives for the health of Pacific peoples in New Zealand. Wellington: Ministry of Health.

Ministry of Health. 1999. Taking the pulse: the 1996-97 New Zealand Health Survey. Wellington, New Zealand.

Ministry of Health. 2001. The Primary Health Care Strategy. Ministry of Health. Wellington, New Zealand.

Ministry of Health. 2002. He Korowai Oranga: Māori Health Strategy. Ministry of Health. Wellington, New Zealand.

Ministry of Health. 2003. Māori public health action plan 2003 – 2004. Ministry of Health. Wellington, New Zealand.

Ministry of Health. 2004. Primary Health Organisations: Service development toolkit for mental health services in primary health care. Wellington: Ministry of Health.

Ministry of Health. 2005. Te Tahuhu: Improving mental health 2005-2015: The second New Zealand mental health and addiction plan. Wellington, Ministry of Health.

Ministry of Health. 2005b. Te Orau Ora: Pacific Mental Health Profile. Wellington: Ministry of Health.

________________________________________________________ 63

____________________________________________________________________ © 2010


Ministry of Health. 2006. Te Kokiri: The mental health and addiction action plan 2006-2015. Wellington, Ministry of Health.

Ministry of Health. 2006b. Asian health chart book Wellington: Ministry of Health. URL: http://www.moh.govt.nz/moh.nsf/indexmh/asian-health-chart-book-2006. Accessed 10/7/2010.

Ministry of Health. 2006c. Suicide Facts: 2003 all-ages provisional statistics. Wellington: Ministry of Health.

Ministry of Health. 2008. Pacific Peoples and Mental Health: A paper for the Pacific Health and Disability Action Plan review. Wellington: Ministry of Health.

Ministry of Health. 2010. Trends in service design and new models of care: a review. Wellington: Ministry of Health.

Mental Health Commission. 2007. Te Haererenga mo te Whakaoranga 1996-2006: The journey of recovery for the New Zealand mental health sector. Wellington, Mental Health Commission.

Miller B, Paschall C & Svendsen D. 2006. Mortality and medical comorbidity among patients with serious mental illness. Psychiatric Services 57(10) 1482-7.

Ministry of Health. 2008. Pacific Peoples and Mental Health: A paper for the Pacific Health and Disability Action Plan review. Wellington: Ministry of Health.

Ministry of Health. 2008. A Portrait of Health: Key results of the 2006/07 New Zealand Health Survey. Wellington, New Zealand.

Ministry of Health. 2009. Towards optimal primary mental health care in the new primary care environment: a draft guidance paper. Wellington, New Zealand.

Moriarty H, Stubbe M, Bradford S. 2009. Opportunities for alcohol and other drug advice in the GP consultation. Wellington: University of Otago.

Mulligan K. 2003. "Recovery Movement Gains Influence in Mental Health Programs." Psychiatric News 38(1): 10.

Ngai M, Latimer S & Cheung V. 2001. Healthcare Needs of Asian People: Survey of Asian People and Health Professionals in the North and West Auckland. Auckland: Asian Health Support Service, Waitemata District Health Board.

Neuwelt P, Matheson D, Arroll B, Dowell A, Winnard D, Crampton P, Sheridan N & Cumming J. 2009. Putting population health into practice through primary health care. New Zealand Medical Journal 122 (1290): 98-104.

http://www.moh.govt.nz/moh.nsf/indexmh/asian-health-chart-book-2006.%20Accessed%2010/7/2010

http://www.moh.govt.nz/moh.nsf/indexmh/asian-health-chart-book-2006.%20Accessed%2010/7/2010

________________________________________________________ 64

____________________________________________________________________ © 2010


Niroshan Siriwardena, A. 2009. Engaging clinicians in quality improvement initiatives: art or science? Quality in Primary Care 17:303–305

Oakley Browne M, Joyce P, Wells J, et al. 1989. Christchurch Psychiatric Epidemiology Study Part II: six month and twelve month and other period prevalence’s of specific psychiatric disorders. Australian and New Zealand Journal of Psychiatry 23: 327–40.

Oakley Browne M, Wells J, Scott K (eds). 2006. Te Rau Hinengaro: The New Zealand Mental Health Survey. Wellington: Ministry of Health.

Pere R. 1994. The health of the family. New Zealand Health Review 4 (17).

Peterson D, Barnes A et al. 2008. Fighting Shadows: Self-stigma and mental illness: Whawhai atu te whakama hihira. Auckland, Mental Health Foundation.

Peterson D & Gordon S. Eds. 2010. Stepping Out of the Shadows: Insights into self-stigma and madness. Wellington, Case Consulting.

Pulotu-Endemann. 2004. In Primary Health Organisations: Service development toolkit for mental health services in primary health care. Wellington: Ministry of Health.

Pulotu-Endemann F.K, Annandale M, & Instone A. 2004. A Pacific Perspective on the NZ Mental Health Classification and Outcomes Study (CAOS). Wellington: Mental Health Commission.

Ramon S, Shera W et al. 2009. "The Rediscovered Concept of Recovery in Mental Illness." International Journal of Mental Health 38(2): 106-126.

Rasanathan K, Ameratunga S & Tse S. 2006. Asian health in New Zealand – progress and challenges. NZMJ 119:1224.

Rasanathan K, Ameratunga S, Chen J, et al. A health profile of young Asian New Zealanders who attend secondary school: findings from Youth2000. Auckland: University of Auckland; 2006. URL: http://www.youth2000.ac.nz/pdf/hp-young-asian-nz.pdf

Reid P & Robson B. 2007. Understanding health inequities. In Robson B, Harris R. (Eds). Hauora: Māori Standards of Health IV. A study of the years 2000-2005. Wellington: Te Rōpū Rangahau Hauora a Eru Pōmare.

Resnick S, Rosenheck R et al. 2004. "An Exploratory Analysis of Correlates of Recovery." Psychiatric Services 55(5): 540-547.

Salmond C, Crampton P & Kirkpatrick R. 2004. Degrees of deprivation in New Zealand: an atlas of socioeconomic difference. 2nd ed. Auckland: David Bateman Ltd.

http://www.youth2000.ac.nz/pdf/hp-young-asian-nz.pdf

http://www.youth2000.ac.nz/pdf/hp-young-asian-nz.pdf

________________________________________________________ 65

____________________________________________________________________ © 2010


Sartorius N. 2009. Mental health and primary healthcare: an international policy perspective. In: Primary Care Mental Health. Eds: Gask L, Lester H, Kendrik T & Peveler R. London: Royal College of Psychiatrists.

Scragg R, Maitra A. Asian health in Aotearoa: an analysis of the 2002–2003 New Zealand Health Survey. Auckland: The Asian Network Inc.; 2005. URL: http://www.asianhealth.govt.nz/Publications/AsianHealthAotearoa0508.pdf

Seligman M & Csikszentmihaly M. 2000. Positive psychology: an introduction. American Psychologist, 55(1) 5-14.

Shepherd M, Cooper B, Brown A & Kalton G. 1966. Psychiatric illness in general practice. London: Oxford University Press.

Slade M. 2009. Personal recovery and mental illness: A guide for mental health professionals. New York, Cambridge University Press.

Starfield B. 1998. Primary care: Balancing health needs, services and technology. New York: Oxford University Press.

Statistics New Zealand. 2002. Pacific progress: A report on the economic status of Pacific peoples. Wellington, New Zealand: Statistics New Zealand.

Statistics New Zealand. 2007. Quick stats about Māori. Wellington, New Zealand: Statistics New Zealand.

Statistics New Zealand. 2006. Quick stats about Pacific peoples. Wellington, New Zealand: Statistics New Zealand.

Statistics New Zealand. 2006. National Ethnic Population Projections: 2006 (base) – 2026. Wellington, New Zealand: Statistics New Zealand. http://www.stats.govt.nz/browse_for_stats/population/estimates_and_projections/NationalEthnicPopulationProjections_HOTP06-26/Commentary.aspx Accessed 3/7/2010

Strathdee G & Williams. 1984. A survey of psychiatrists in primary care: the silent growth of a new service. Journal of the Royal College of General Practitioners 34: 615–618.

Strosahl K. 1998. Integrating behavioural health and primary care services: the primary mental health care model. In: Integrated Primary Care: the future of medical and mental health collaboration. Ed: Blount, A. New York, WW Norton.

Suaalii-Sauni T, Wheeler A, Etuate S, Robinson G, Agnew F, Warren H, Erick M & Hingano T. 2009. Exploration of Pacific perspectives of Pacific models of mental health service delivery in New Zealand. Pacific Health Dialogue 15 (1): 18 - 27.

http://www.asianhealth.govt.nz/Publications/AsianHealthAotearoa0508.pdf

http://www.stats.govt.nz/browse_for_stats/population/estimates_and_projections/NationalEthnicPopulationProjections_HOTP06-26/Commentary.aspx

http://www.stats.govt.nz/browse_for_stats/population/estimates_and_projections/NationalEthnicPopulationProjections_HOTP06-26/Commentary.aspx

________________________________________________________ 66

____________________________________________________________________ © 2010


Tomes N. 2006. "The patient as a policy factor: A historical case study of the consumer/survivor movement in mental health." Health Affairs 25(3): 720-729.

Te Puni Kōkiri. 2010. Whānau ora factsheet. Wellington, New Zealand: Te Puni Kōkiri.

U.S. Department of Health and Human Services. 1999. Mental Health: A report of the Surgeon-General. Rockville MD, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Centre for Mental Health Services, National Institutes of Health, National Institute of Mental Health.

Vaithianathan R and Pram K. 2010. Cost benefit analysis of the New Zealand national mental health destigmatisation programme ("Like Minds programme"). Auckland, Uniservices.

Weich S & Lewis G. 1998. Poverty, unemployment and common mental disorders: population based cohort study. BMJ 317:115.

Wells E, Baxter J, Schaaf D (eds). 2006. Substance use disorders – Te Rau Hinengaro: the New Zealand Mental Health Survey. Wellington: Ministry of Health.

Wilson M, Gahlout P, Liu L & Mouly S. 2005. A rose by any other name: the effect of ethnicity and name on access to employment. University of Auckland Business Review 7:65–72.

World Health Organisation. 1978. The WHO Primary Heath Care Statement. Conference at Alma-Ata.

World Health Organisation. 1973. Primary Care of Mental Illness. Geneva, World Health Organisation.

World Health Organisation. 2008. Policies and practices for mental health in Europe: Meeting the challenge. Geneva, World Health Organisation. http://www.euro.who.int/__data/assets/pdf_file/0006/96450/E91732.pdf

Wyllie A, Cameron A et al. 2008. Impacts of national media campaign to counter stigma and discrimination associated with mental illness: Survey 9 results for campaign 4: Research report for Ministry of Health. Auckland, Phoenix Research.

http://www.euro.who.int/__data/assets/pdf_file/0006/96450/E91732.pdf

________________________________________________________ 67

____________________________________________________________________ © 2010


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

________________________________________________________ 68

____________________________________________________________________ © 2010


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.

________________________________________________________ 69

____________________________________________________________________ © 2010


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).

________________________________________________________ 70

____________________________________________________________________ © 2010


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

________________________________________________________ 71

____________________________________________________________________ © 2010


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”.

________________________________________________________ 72

____________________________________________________________________ © 2010


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.

________________________________________________________ 73

____________________________________________________________________ © 2010


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

________________________________________________________ 74

____________________________________________________________________ © 2010


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

________________________________________________________ 75

____________________________________________________________________ © 2010


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.

________________________________________________________ 76

____________________________________________________________________ © 2010


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).

________________________________________________________ 77

____________________________________________________________________ © 2010


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

________________________________________________________ 78

____________________________________________________________________ © 2010


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).

________________________________________________________ 79

____________________________________________________________________ © 2010


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.

________________________________________________________ 80

____________________________________________________________________ © 2010


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

________________________________________________________ 81

____________________________________________________________________ © 2010


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).

________________________________________________________ 82

____________________________________________________________________ © 2010


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).

________________________________________________________ 83

____________________________________________________________________ © 2010


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.

________________________________________________________ 84

____________________________________________________________________ © 2010


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

________________________________________________________ 85

____________________________________________________________________ © 2010


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

________________________________________________________ 86

____________________________________________________________________ © 2010


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.

________________________________________________________ 87

____________________________________________________________________ © 2010


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.

________________________________________________________ 88

____________________________________________________________________ © 2010


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

________________________________________________________ 89

____________________________________________________________________ © 2010


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

________________________________________________________ 90

____________________________________________________________________ © 2010


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

________________________________________________________ 91

____________________________________________________________________ © 2010


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.

________________________________________________________ 92

____________________________________________________________________ © 2010


References

Baum F, MacDougall C, Smith D. 2006. Participatory action research. Journal of Epidemiology and Community Health 62:854-857.

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.

________________________________________________________ 93

____________________________________________________________________ © 2010


Homer J & Hirsch G. 2006. System Dynamics Modeling for Public Health: Background and Opportunities. American Journal of Public Health 96(3):452-458.

Howell J & Higgins C. 1990. Champions of Technological Innovations. Administrative Science Quarterly 35(2): 317-341.

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

Moseley SF. 2004. Everett Rogers' Diffusion of Innovations Theory: Its Utility and Value in Public Health. Journal of Health Communication 9: 149-151.

National Government, Better, Sooner, More Convenient: Health discussion paper by Hon Tony Ryall MP. 2009.

Omachonu V.K. 2010. Innovation in Healthcare Delivery Systems: A Conceptual Framework. The Innovation Journal 15(1).

Patton M.Q. 1994. Developmental Evaluation. American Journal of Evaluation 15(3):

Patton M.Q. 2008. Evaluation Focus Options: Developmental Evaluation and Other Alternatives, in Utilization-Focused Evaluation, Sage. p. 271-306.

Petticrew M et al. 2009 Better evidence about wicked issues in tackling health inequities. Journal Public Health 31(3):453-456.

Pidd M. 1996. Tools for Thinking: Modelling in Management Science. Chichester, John Wiley and Sons.

Rees D & Orr-Walker B. 2006 System Dynamics Modelling as a Tool in Healthcare Planning, International Systems Dynamics Conference. Nijmegen.

________________________________________________________ 94

____________________________________________________________________ © 2010


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).

Rogers, E.M., Diffusion of Innovations. 4th ed. 1995, New Tork: The Free Press.

Sterman J D. 2000. Business Dynamics: Systems Thinking and Modelling for a Complex World. Boston, The McGraw Hill Companies

Simons H. 2009. Case study research in practice. London: Sage.

Stringer E. 1996. Action research: a handbook for practitioners. California, Sage.

Wallerstein N & Duran B. 2003. The Conceptual, Historical, and Practice Roots of Community Based Participatory Research and Related Participatory Traditions. In M. Minkler and N. Wallerstein (eds). Community Based Participatory Research for Health. San Francisco, Jossey-Bass, 27-45.

Waterman H. 2007. Action Research and Health. Researching health: Qualitative, quantative and mixed methods. M. Saks and J. Allsop. Los Angeles, Sage.

West M. A. & Farr J. L. 1990. Innovation at work. In M.A. West & J. L. Farr (Eds.), Innovation and Creativity at Work: 3-13. Chichester, UK: John Wiley & Sons.

Yin R.K. 1994. Case study research: design and methods. Thousand Oaks, California: Sage.

________________________________________________________ 95

____________________________________________________________________ © 2010


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).

________________________________________________________ 96

____________________________________________________________________ © 2010


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

________________________________________________________ 97

____________________________________________________________________ © 2010


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

________________________________________________________ 98

____________________________________________________________________ © 2010


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

________________________________________________________ 99

____________________________________________________________________ © 2010


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

________________________________________________________ 100

____________________________________________________________________ © 2010


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.

________________________________________________________ 101

____________________________________________________________________ © 2010


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

________________________________________________________ 102

____________________________________________________________________ © 2010


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”.

________________________________________________________ 103

____________________________________________________________________ © 2010


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

________________________________________________________ 104

____________________________________________________________________ © 2010


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.

________________________________________________________ 105

____________________________________________________________________ © 2010


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:

________________________________________________________ 106

____________________________________________________________________ © 2010


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..

________________________________________________________ 107

____________________________________________________________________ © 2010


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

________________________________________________________ 108

____________________________________________________________________ © 2010


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

________________________________________________________ 109

____________________________________________________________________ © 2010


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.

________________________________________________________ 110

____________________________________________________________________ © 2010


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

________________________________________________________ 111

____________________________________________________________________ © 2010


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

________________________________________________________ 112

____________________________________________________________________ © 2010


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.

________________________________________________________ 113

____________________________________________________________________ © 2010


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.

________________________________________________________ 114

____________________________________________________________________ © 2010


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.

________________________________________________________ 115

____________________________________________________________________ © 2010


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

________________________________________________________ 116

____________________________________________________________________ © 2010


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

________________________________________________________ 117

____________________________________________________________________ © 2010


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.

________________________________________________________ 118

____________________________________________________________________ © 2010


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

________________________________________________________ 119

____________________________________________________________________ © 2010


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

________________________________________________________ 120

____________________________________________________________________ © 2010


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

________________________________________________________ 121

____________________________________________________________________ © 2010


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.”

________________________________________________________ 122

____________________________________________________________________ © 2010


“…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.

________________________________________________________ 123

____________________________________________________________________ © 2010


“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.”

________________________________________________________ 124

____________________________________________________________________ © 2010


“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

________________________________________________________ 125

____________________________________________________________________ © 2010


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.”

________________________________________________________ 126

____________________________________________________________________ © 2010


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

________________________________________________________ 127

____________________________________________________________________ © 2010


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.

________________________________________________________ 128

____________________________________________________________________ © 2010


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.

________________________________________________________ 129

____________________________________________________________________ © 2010


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.

________________________________________________________ 130

____________________________________________________________________ © 2010


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


Hutt Valley Counties Manakau

JANUARY

Counties

FEBRUARY

Counties

MARCH

Counties

APRIL

Full meeting


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

________________________________________________________ 131

____________________________________________________________________ © 2010


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

________________________________________________________ 132

____________________________________________________________________ © 2010


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?

________________________________________________________ 133

____________________________________________________________________ © 2010


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.

________________________________________________________ 134

____________________________________________________________________ © 2010


“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

________________________________________________________ 135

____________________________________________________________________ © 2010


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?

________________________________________________________ 136

____________________________________________________________________ © 2010


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:

________________________________________________________ 137

____________________________________________________________________ © 2010


“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

________________________________________________________ 138

____________________________________________________________________ © 2010


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

________________________________________________________ 139

____________________________________________________________________ © 2010


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?

________________________________________________________ 140

____________________________________________________________________ © 2010


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

________________________________________________________ 141

____________________________________________________________________ © 2010


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

________________________________________________________ 142

____________________________________________________________________ © 2010


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

________________________________________________________ 143

____________________________________________________________________ © 2010


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

________________________________________________________ 144

____________________________________________________________________ © 2010


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.

________________________________________________________ 145

____________________________________________________________________ © 2010


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

________________________________________________________ 146

____________________________________________________________________ © 2010


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,

________________________________________________________ 147

____________________________________________________________________ © 2010


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.


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.

________________________________________________________ 148

____________________________________________________________________ © 2010



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

________________________________________________________ 149

____________________________________________________________________ © 2010


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.

________________________________________________________ 150

____________________________________________________________________ © 2010


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

________________________________________________________ 151

____________________________________________________________________ © 2010


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.

________________________________________________________ 152

____________________________________________________________________ © 2010


“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

________________________________________________________ 153

____________________________________________________________________ © 2010


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

________________________________________________________ 154

____________________________________________________________________ © 2010


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.”

________________________________________________________ 155

____________________________________________________________________ © 2010


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

________________________________________________________ 156

____________________________________________________________________ © 2010


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

________________________________________________________ 157

____________________________________________________________________ © 2010


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

________________________________________________________ 158

____________________________________________________________________ © 2010




support for PMH









needing to refer?


'severe/acute'


managed in PMH


to focus service








current reln













work & ACC services


setting



MH services











PMH options for GPs


PHOs





capacity


families



bump



support



model


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’?

________________________________________________________ 159

____________________________________________________________________ © 2010


Research Partner 2 cognitive maps April-May 2009



support for PMH









needing to refer?


'severe/acute'


managed in PMH


to focus service








current reln













work & ACC services


setting



MH services











PMH options for GPs


PHOs





capacity


families



bump



support



model


strategy

Concepts in first cycle DHB and Specialist MH discussion

________________________________________________________ 160

____________________________________________________________________ © 2010




support for PMH









needing to refer?


'severe/acute'


managed in PMH


to focus service








current reln













work & ACC services


setting



MH services











PMH options for GPs


PHOs





capacity


families



bump



support



model


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

________________________________________________________ 161

____________________________________________________________________ © 2010




support for PMH









needing to refer?


'severe/acute'


managed in PMH


to focus service








current reln













work & ACC services


setting



MH services











PMH options for GPs


PHOs





capacity


families



bump



support



model


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

________________________________________________________ 162

____________________________________________________________________ © 2010



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.

________________________________________________________ 163

____________________________________________________________________ © 2010


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.


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.

________________________________________________________ 164

____________________________________________________________________ © 2010


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.

________________________________________________________ 165

____________________________________________________________________ © 2010


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

________________________________________________________ 166

____________________________________________________________________ © 2010


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.


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.



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

________________________________________________________ 167

____________________________________________________________________ © 2010


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

________________________________________________________ 168

____________________________________________________________________ © 2010


“[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?

________________________________________________________ 169

____________________________________________________________________ © 2010


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.”

________________________________________________________ 170

____________________________________________________________________ © 2010


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.”

________________________________________________________ 171

____________________________________________________________________ © 2010


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.”

________________________________________________________ 172

____________________________________________________________________ © 2010


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

-

________________________________________________________ 173

____________________________________________________________________ © 2010


What type of need, which populations are we targeting & how do we manage that?





PMH

3 SIA funding egpost natal & childattachment pilot

starting

4 MSD funding forback to workprogrammes




services

12 Not clear whatoverall outcomesseeking and what

resources would beneeded


those who manage to

get access



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



23 Connection tosocial services &

support?

24 How do we manage

referral pathways toother services?


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?

________________________________________________________ 174

____________________________________________________________________ © 2010


Developing sustainable funding & resources



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


7 Normal primary

care also supports

MH



services

11 Potential of

shift to PBFfunding, will $ be

sustainable?

12 Not clear whatoverall outcomesseeking and what

resources would beneeded


intensity of

service, use ofsecondary packages

of care



20 What's the place

of Rx?



25 Can't utiliseblue print 3% $ for

developing PMHcapacity

27 Demand muchgreater than funding

& capacity


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

________________________________________________________ 175

____________________________________________________________________ © 2010


Service Models



7 Normal primarycare also supports

MH

9 PHOs evolvedmodels to suit

population



services

13 Most modelsproducing good

results irrespective

of type or level ofintervention


intensity ofservice, use of

secondary packagesof care


those who manage toget access



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?


through to SMHconstrained


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

________________________________________________________ 176

____________________________________________________________________ © 2010



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

________________________________________________________ 177

____________________________________________________________________ © 2010


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.


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.

________________________________________________________ 178

____________________________________________________________________ © 2010


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.


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.



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.

________________________________________________________ 179

____________________________________________________________________ © 2010


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.”

________________________________________________________ 180

____________________________________________________________________ © 2010


“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

________________________________________________________ 181

____________________________________________________________________ © 2010


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.

________________________________________________________ 182

____________________________________________________________________ © 2010


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

-

-

________________________________________________________ 183

____________________________________________________________________ © 2010


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


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

________________________________________________________ 184

____________________________________________________________________ © 2010


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?


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

________________________________________________________ 185

____________________________________________________________________ © 2010



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.

________________________________________________________ 186

____________________________________________________________________ © 2010


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.

________________________________________________________ 187

____________________________________________________________________ © 2010


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)

http://www.primarymentalhealth.org.nz/

http://www.nzgg.org.nz/

http://www.hiirc.org.nz/

http://www.tepou.co.nz/

http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/creativity_tools_-_bullet_proofing.html

http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/creativity_tools_-_bullet_proofing.html

http://www.thelowdown.co.nz/

http://www.depression.org.nz/

________________________________________________________ 188

____________________________________________________________________ © 2010


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

________________________________________________________ 189

____________________________________________________________________ © 2010


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.

________________________________________________________ 190

____________________________________________________________________ © 2010


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

________________________________________________________ 191

____________________________________________________________________ © 2010


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.

________________________________________________________ 192

____________________________________________________________________ © 2010


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;

________________________________________________________ 193

____________________________________________________________________ © 2010


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.

________________________________________________________ 194

____________________________________________________________________ © 2010


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.

toolkit for primary mental health care development ... › wellington › otago023688.pdf ·...

Documents