A discourse analysis on how service providers in non-medical primary health and social care services understand their roles in mental health care

Enhancing collaboration between specialist mental health services, primary health care and social care services has been a key priority in mental health policy reform in many countries for about 20 years and remains so. Yet progress in terms of widespread implementation of demonstrably effective models of collaborative care has been slow. The views that different providers hold regarding the parameters of their roles, and the values that guide their approach to service delivery, are likely to exert profound effects on engagement with collaborative initiatives. Little research has explored these issues.     

Evaluation of community mental health services: comparison of a primary care mental health team and an extended day hospital service

Alongside mental health policies emphasising the need to focus on people experiencing serious, long-term problems, recent general healthcare policy is leading to the development in the UK of a primary care-led National Health Service. While most primary care-led mental health initiatives have focused on supporting general practitioners (GPs) in managing milder depression and anxiety, this article describes an evaluation comparing primary care-based and secondary care-based services for people with serious long-term problems. A survey of service users was carried out at three points in time using three measures: the Camberwell Assessment of Need, the Verona Satisfaction with Services Scales and the Lancashire Quality of Life Profile. Staff views were sought at two time intervals and carers' views were obtained towards the end of the 2-year study period. The results indicate that both services reduced overall needs and the users' need for information. The primary care service also reduced the need for help with psychotic symptoms whereas the secondary care service reduced users' need for help with benefits and occupation. There were no major differences in terms of satisfaction or quality of life. Primary care-based services therefore appear to have the potential to be as effective as more traditional secondary care services. However, a more comprehensive range of services is required to address the whole spectrum of needs, a conclusion supported by the views of staff and carers.     

Professional and service-user perceptions of self-help in primary care mental health services

Self-help is becoming an increasingly accessible option for addressing mental health problems. Despite this, self-help is subject to a variety of interpretations, little is known about how professionals and service-users conceptualise self-help, or how service-users engage in self-help activities. This study aimed to explore the views of self-help by service-users and health professionals in one area of Scotland, including the perceptions of what constitutes self-help and how it might be used to address mental health problems in primary care. The research involved semistructured interviews with 31 primary care mental health professionals, and in-depth interviews with 34 service-users. We found that professionals and service-users describe self-help in different ways, which has great implications for referral to and implementation of self-help in primary care settings. It also emerged that self-help was not necessarily perceived to be able to address the causes of mental distress, which could leave some professionals defaulting to offering no interventions despite the fairly positive attitude service-users show to self-help strategies. Finally, professionals need to be convinced that interventions are useful, effective and accessible as there are significant barriers in professionals using self-help; if they are not convinced, such approaches will support their therapeutic approach. The research supports the need to develop methods of delivery that offer self-help as part of a broad package of care that also considers social causes of distress.     

Factors shaping intersectoral action in primary health care services

Objective: To examine case studies of good practice in intersectoral action for health as one part of evaluating comprehensive primary health care in six sites in South Australia and the Northern Territory. Methods: Interviews with primary health care workers, collaborating agency staff and service users (Total N=33); augmented by relevant documents from the services and collaborating partners. Results: The value of intersectoral action for health and the importance of partner relationships to primary health care services were both strongly endorsed. Factors facilitating intersectoral action included sufficient human and financial resources, diverse backgrounds and skills and the personal rewards that sustain commitment. Key constraining factors were financial and time limitations, and a political and policy context which has become less supportive of intersectoral action; including changes to primary health care. Conclusions: While intersectoral action is an effective way for primary health care services to address social determinants of health, commitment to social justice and to adopting a social view of health are constrained by a broader health service now largely reinforcing a biomedical model. Implications: Effective organisational practices and policies are needed to address social determinants of health in primary health care and to provide a supportive context for workers engaging in intersectoral action.     

Self-reported patient psychosocial needs in integrated primary health care: A role for social work in interdisciplinary teams

Despite being identified as significant determinants of health, depression and anxiety continue to be underdiagnosed and undertreated in primary care settings. This study examined the psychosocial health needs of patients at four urban interdisciplinary primary health teams. Quantitative analysis revealed that nearly 80% of patients reported anxiety and/or depression. Self-reported anxiety and depression was correlated with poor social relationships, compromised health status and underdeveloped problem-solving skills. These findings suggest that social workers have a vital role to play within interdisciplinary primary health teams in the amelioration of factors associated with anxiety and depression.     

The process of social participation in primary health care: the case of Palencia,Guatemala

Background In 2008, the World Health Organization issued a callback to the principles of primary health care, which renewed interests in social participation in health. In Guatemala, social participation has been the main policy for the decentralization process since the late 1990s and the social development council scheme has been the main means for participation for the country’s population since 2002. Aim The aim of this study was to explore the process of social participation at a municipal‐level health commission in the municipality of Palencia, Guatemala. Methods Analysis of legal and policy documents and in‐depth interviews with institutional and community‐level stakeholders of the commission. Results The lack of clear guidelines and regulations means that the stakeholders own motivations, agendas and power resources play an important part in defining the roles of the participants. Institutional stakeholders have the human and financial power to make policies. The community‐level stakeholders are token participants with little power resources. Their main role is to identify the needs of their communities and seek help from the authorities. Satisfaction and the perceived benefits that the stakeholders obtain from the process play an important part in maintaining the commission’s dynamic, which is unlikely to change unless the stakeholders perceive that the benefit they obtain does not outweigh the effort their role entails. Conclusion Without more uniformed mechanisms and incentives for municipalities to work towards the national goal of equitable involvement in the development process, the achievements will be fragmented and will depend on the individual stakeholder’s good will.     

Changes in primary health care policy: the implications for joint commissioning with social services

Both the primary health care team (PHCT) and social services departments in the UK have undergone substantial changes to their organization and function since 1990. This paper looks at developments in primary health care policy that have affected the relationships between them regarding the commissioning of health and social care services. It focuses on evidence from seven initiatives designed to involve members of the PHCT in commissioning social care services. It examines some of the benefits and challenges of working together to commission services for health authority managers, GPs, district nurses, care managers and social work team managers in the light of impending changes to the PHCT, particularly the abolition of fundholding and the introduction of Primary Care Groups.     

The continuing care guidelines and primary and community health services

The confirmation of NHS responsibilities for continuing health care has important implications for primary and community health services. In early 1996, during the period of consultation on draft local policies and eligibility criteria, exploratory interviews were carried out with general practitioners (GPs), community nursing managers, primary care development officers and social services purchasers in three health authority areas. The interviews indicated that few GPs had responded to local consultation and were only slowly becoming aware of the implications for the provision and purchasing of primary and community health services. Moreover, local continuing care policies had apparently not addressed two issues which GPs and community nursing staff indicated were currently highly problematic: their responsibilities in relation to independent sector residential and nursing home patients; and the consequences for primary health and community nursing services of hospital discharge decisions. The need for purchasers and commissioners of health services, whether health authorities or GPs, to begin collecting information on patients' potential needs for continuing care services was widely recognised as an urgent priority.     

Enhancing social networks: a qualitative study of health and social care practice in UK mental health services

People with severe mental health problems such as psychosis have access to less social capital, defined as resources within social networks, than members of the general population. However, a lack of theoretically and empirically informed models hampers the development of social interventions which seek to enhance an individual's social networks. This paper reports the findings of a qualitative study, which used ethnographic field methods in six sites in England to investigate how workers helped people recovering from psychosis to enhance their social networks. This study drew upon practice wisdom and lived experience to provide data for intervention modelling. Data were collected from 73 practitioners and 51 people who used their services in two phases. Data were selected and coded using a grounded theory approach to depict the key themes that appeared to underpin the generation of social capital within networks. Findings are presented in four over‐arching themes – worker skills, attitudes and roles; connecting people processes; role of the agency; and barriers to network development. The sub‐themes which were identified included worker attitudes; person‐centred approach; equality of worker–individual relationship; goal setting; creating new networks and relationships; engagement through activities; practical support; existing relationships; the individual taking responsibility; identifying and overcoming barriers; and moving on. Themes were consistent with recovery models used within mental health services and will provide the basis for the development of an intervention model to enhance individuals’ access to social capital within networks.     

The evaluation of a model of primary mental health care in rural Tasmania

OBJECTIVE: The aim of this study was to evaluate the effectiveness of a primary care mental health service. DESIGN: The study used a naturalistic longitudinal design to follow groups of participants who received intervention from a rural mental health worker, or 'usual' mental health service, or no treatment, over a period of 12 months. SETTING: The service was evaluated in a rural primary care setting. PARTICIPANTS: One hundred and forty-five primary care patients. OUTCOME MEASURES: Changes in symptomatology were assessed using the SCL-90R summary scales, and changes in quality of life were assessed using the EuroQOL. RESULTS: Those participants treated by the primary mental health worker showed significant improvements in symptoms and quality of life compared to both the usual and no-treatment groups. CONCLUSION: There are few studies evaluating mental health services in rural settings. This study demonstrated that a particular model of primary mental health care was more effective than usual mental health care and no treatment at resolving symptoms and improving quality of life.     

小学生心理健康与社会支持调查

目的了解小学生心理健康与社会支持情况,为有效提高小学生心理健康水平提供参考。方法采用分层整群随机抽样方法,对调查对象进行问卷调查。结果 31.10%的调查对象自我意识水平在正常范围,49.70%自我意识水平过高,19.20%自我意识水平过低。自我意识量表总分均值和全国常模差异没有统计学意义。农村调查样本的客观支持及社会支持总分显著低于城市;在小学生社会支持系统中,父母影响占31.62%,老师影响占15.31%,家人影响合计占54.26%。结论小学生自我评价过高即自负,这种心理对孩子的成长极为不利,应予重视;小学生社会支持系统中,父母影响最大。     

Challenges faced by general practitioners and allied mental health services in providing mental health services in rural Queensland

OBJECTIVE: To examine the views of rural practitioners concerning issues and challenges in mental health service delivery and possible solutions. DESIGN: A qualitative study using individual semi-structured interviews. SETTING: Eight general practices from eight rural Queensland towns, three rural mental health services and two non-government organisations, with interviews being conducted before recent changes in government-subsidised access to allied health practitioners. PARTICIPANTS: A sample of 37 GPs, 19 Queensland Health mental health staff and 18 participants from community organisations. MAIN OUTCOME MEASURES: Analysis of qualitative themes from questions about the key mental health issues facing the town, how they might be addressed and what challenges would be faced in addressing them. RESULTS: There was substantial consensus that there are significant problems with inter-service communication and liaison, and that improved collaboration and shared care will form a critical part of any effective solution. Differences between groups reflected differing organisational contexts and priorities, and limitations to the understanding each had of the challenges that other groups were facing. CONCLUSIONS: Improvements to mental health staffing and to access to allied health might increase the ability of GPs to meet the needs of less complex patients, but specific strategies to promote better integrated services are required to address the needs of rural and regional patients with complex mental health problems. The current study provides a baseline against which effects of recent initiatives to improve mental health care can be assessed.     

GP Clinic: promoting access to primary health care for mental health service clients

Objective: To evaluate an innovative rural service offering comprehensive primary health care for mental health service clients. Design: A formative evaluation using mixed methods. Setting: A rural NSW community. Participants: Fifteen health care providers and 120 adult clients. Intervention: A monthly clinic held in a general practice to provide primary health care for clients of the community mental health team. Main outcome measures: Client utilisation and clinic activity data. Provider views of service effectiveness, possible improvements and sustainability. Results: The GP Clinic has operated successfully for 2.5 years without access block. Some 52% of clients had no physical illness and 82% were referred to other health and community services. In total, 40% continued to attend the clinic while 32% went on to consult a GP independently. Client access to care improved as did collaboration between the community mental health team and primary care providers. Conclusion: The GP Clinic is a straightforward and flexible service model that could be used more widely.     

Determinants of health status and the influence of primary health care services in Latin America, 1990-98

Primary health care (PHC) services have been advocated as a means by which less developed countries may improve the health of their populations even in the face of poverty, low levels of literacy, poor nutrition and other factors that negatively influence health status. Using aggregated data from the World Bank and UNICEF this study examined which factors, both within the health care system and outside of it, are associated with under-5 mortality rates in 22 countries of Latin America and the Caribbean during the 1990s. In a multivariate analysis using generalized estimating equations for repeated measures, five factors were found to be independent predictors of lower under-5 mortality rates (U5MRs). These were vaccination levels, female literacy, the use of oral rehydration therapy, access to safe water and GNP per capita. When the magnitude of these associations were assessed, higher levels of GNP per capita was found to be very weakly associated with lower U5MRs, compared with female literacy and vaccination rates. These findings suggest that government policies which focus only on promoting economic growth, while not making important investments in PHC services, female education and access to safe water are unlikely to see large improvements in health status.     

Sustainable primary health care services in rural and remote areas: innovation and evidence

Objective: To highlight how evidence from studies of innovative rural and remote models of service provision can inform global health system reform in order to develop appropriate, accessible and sustainable primary health care (PHC) services to ‘difficult‐to‐service’ communities. Methods: The paper synthesises evidence from remote and rural PHC health service innovations in Australia. Results: There is a strong history of PHC innovation in Australia. Successful health service models are ‘contextualised’ to address diverse conditions. They also require systemic solutions, which address a range of interlinked factors such as governance, leadership and management, adequate funding, infrastructure, service linkages and workforce. An effective systemic approach relies on alignment of changes at the health service level with those in the external policy environment. Ideally, every level of government or health authority needs to agree on policy and funding arrangements for optimal service development. A systematic approach in addressing these health system requirements is also important. Service providers, funders and consumers need to know what type and level of services they can reasonably expect in different community contexts, but there are gaps in agreed indicators and benchmarks for PHC services. In order to be able to comprehensively monitor and evaluate services, as well as benchmarks, we need adequate national information systems. Conclusions: Despite the gaps in our knowledge, we do have a significant amount of information about what works, where and why. At a time of global PHC reform, applying this knowledge will contribute significantly to the development of appropriate, sustainable PHC services and improving access.