Exploring the 'fit' between people and providers: refugee health needs and health care services in Mt Roskill, Auckland, New Zealand

The needs of refugees and the struggles on the part of service providers to address this diverse population have received limited attention within the academic literature. This paper profiles Hauora o Puketapapa/Roskill Union and Community Health Centre (HoP), which is a non-profit, community owned and operated health clinic designed to deliver accessible, affordable and appropriate primary health care services to low-income groups in the Mt Roskill area of Auckland, New Zealand. The clinic's locality has undergone considerable demographic change over recent years with the arrival of refugees from diverse backgrounds. This situation has resulted in new sets of health needs and expectations which need to be addressed. The study took place in 2002-2003 and employed qualitative methods. In-depth interviews with community representatives, clinic users and health service staff members revealed that refugees face considerable barriers in accessing and utilising health services. Similarly, we found that health practitioners face the daunting task of endeavouring to meet these needs in an effective and culturally appropriate manner within a limited funding environment. We conclude that, despite these challenges, HoP has successfully established itself as a well-regarded place of primary health care. In so doing, it has strengthened the capacity of the local community to respond to the changing policy environment. However, long-term sustainability issues remain unless resourcing issues are adequately addressed.     

Service management: a New Zealand model for shifting the balance from hospital to community care

New Zealand's health system has undergone a radical reform in recent years. A central feature of this reform is the area health board, a partly elected and partly appointed body responsible for all health services for its defined population. Within the area health board, the organizational structure which is based upon general management is moving away from institutional towards service or programme management. This is involving clinicians in the management process as service managers, within an accountability structure which cuts across the traditional hospital/community service boundaries. This is a major paradigm shift in health services management which could have major implications for a shift from hospital to community-based care and from secondary to primary health care.     

Community participation in a rural community health trust: the case of Lawrence,New Zealand

Since the mid-1980s, the New Zealand health sector has been in a state of continual change. The most radical changes were in the early-1990s, with the creation of an internal market system for public health care delivery. Rural health services, seen to be unviable, were given the option of establishing themselves as 'community trusts', owning and running their own services. Community trusts have since become a feature of rural health care in New Zealand. An expectation was that community trusts would facilitate community participation. This article reports on a study of participation in a rural community health trust. The 'pentagram model' of Rifkin and coworkers, with its five dimensions of participation-needs assessment, leadership, resource mobilization, management and organization-was applied. High levels of participation were found across each of these dimensions. The research revealed additional dimensions that could be added to the framework, including 'sustainability of participation', 'equity in participation' and 'the dynamic socio-political context'. In this regard, it supports recent theoretical work by Laverack (2001) and Laverack and Wallerstein (2001). Finally, the article comments on the future of rural health trusts in the current round of health sector restructuring.     

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.     

Developing community mental health services: an evaluation of Glasgow's mental health resource centres

Greater Glasgow Health Board's strategy for the development of community mental health services includes the establishment, over a 7-year period, of multi-disciplinary community mental health resource centres throughout Glasgow. An evaluation of the first phase of the development was carried out in three resource centres. This focused on three key themes: the establishment of multi-disciplinary teams, targeting of those with the most severe illnesses and the participation of users in the care process. The evaluation exercise comprised five substantive elements: analysis of the clinical database; interviews with staff within each of those centres, interviews with representatives of key external agencies associated with each centre; a survey of general practitioners; and a survey of the views of clients, their carers, their key workers, and their general practitioners (GPs). Clients were generally very satisfied with the services and felt that the resource centres met all their mental health needs. Although the majority of current centre cases had severe mental illnesses and those with the more severe conditions had the highest contact rates there was evidence that in the absence of a clear framework for referral the centres were also providing services for those with less severe illnesses. Despite a wish by centre staff to move towards modes of working less dominated by health professionals and more inclusive of other resources and especially of clients themselves, these goals remained to be achieved: there was a lack of clarity in the definition of the appropriate target groups for the centres; access to crisis support was regarded as problematic; the concept of multi-disciplinary team working had yet to be fully realized with evidence suggesting that some psychiatrists working in the resource centres had not embraced many aspects of the new approach to service delivery including a focus on the severely ill; and progress towards the ideal of active client involvement had been slow.     

Occupational therapy in mental health: challenges and opportunities

The National Mental Health Policy and National Mental Health Plan published in 1992 provided directions for the reform of mental health services in Australia. They stated that mental health services should be part of the mainstream health system and that integrated mental health programmes should be developed to cover the full range of specialist mental health services, focusing on improved quality of service, the consumers, equity of access, continuity of care and redistribution of resources. The Queensland Mental Health Plan published in 1994 set out specific objectives and strategies for implementing mental health service reform in Queensland. In Queensland there has been a concentration on developing core mental health services involving the reorientation of service delivery from institutions to the community, based on the principles of integration, mainstreaming and regional self-sufficiency. Major restructuring of mental health services is taking place, which has meant changes in service development, organizational structures and work practices. There has been a significant impact on the roles and skills required by the mental health workforce in the context of today's mental health services climate. There is a focus on staff providing individualized assessment and continuing treatment using a case management approach, within a continuum of care. Implications for occupational therapists include developing a generic skill base in preparation for broad-spectrum mental health professional roles while maintaining their professional identity. It is recommended that research be conducted to examine the capacity of occupational therapists to adapt to the changing mental health environment. Copyright © 1999 Whurr Publishers Ltd.     

Working atmosphere,job satisfaction and individual characteristics of community mental health professionals in integrated care

Working requirements of community mental healthcare professionals in integrated care are complex. There is a lack of research concerning the relation of job satisfaction, working atmosphere and individual characteristics. For the current study, a survey evaluating job satisfaction and working atmosphere of mental healthcare professionals in integrated care was performed. About 321 community mental healthcare professionals were included in the survey; the response rate was 59.5%. The professional background of community mental healthcare professionals included nursing, social work and psychology. Community mental healthcare professionals reported the highest satisfaction with colleagues and the lowest satisfaction with income. Moreover, it could be shown that more responsibility, more recognition and more variety in job tasks lead to an increase of overall job satisfaction. Healthcare for mentally ill patients in the community setting is complex and requires well‐structured care with appropriate responsibilities within the team. A co‐operative relationship among colleagues as well as clearly defined responsibilities seem to be the key for the job satisfaction of community mental healthcare professionals in integrated care.     

Supporting positive dimensions of health,challenges in mental health care

This paper will explore two contrasting paradigms in mental health care and their relationship to evidence-based practice. The biomedical perspective of pathogenesis and the health perspective of salotogenesis are two major diverse views in mental health care. Positive dimensions of health are traditionally viewed as software not suitable for statistical analysis, while absence of symptoms of disease are regarded as measurable and suitable for statistical analysis and appropriate as a foundation of evidence-based practice. If the main goal of mental health care is to enhance subjectively experienced health among patients, it will not be sufficient to evaluate absence of symptoms of disease as a measure of quality of care. The discussion focuses on the paradox of evidence-based absence of illness and disease versus subjectively experienced health and well-being as criterions of quality of care in mental health care.     

Joint working in community mental health: prospects and challenges

This paper reviews the opportunities for, and the challenges facing, joint working in the provision of community mental health care. At a strategic level the organization of contemporary mental health services is marked by fragmentation, competing priorities, arbitrary divisions of responsibility, inconsistent policy, unpooled resources and unshared boundaries. At the level of localities and teams, these barriers to effective and efficient joint working reverberate within multi-disciplinary and multi-agency community mental health teams (CMHTs). To meet this challenge, CMHT operational policies need to include multiagency agreement on: professional roles and responsibilities; target client groups; eligibility criteria for access to services; client pathways to and from care; unified systems of case management; documentation and use of information technology; and management and accountability arrangements. At the level of practitioners, community mental health care is provided by professional groups who may have limited mutual understanding of differing values, education, roles and responsibilities. The prospect of overcoming these barriers in multidisciplinary CMHTs is afforded by increased opportunities for interprofessional 'seepage' and a sharing of complementary perspectives, and for joint education and training. This review suggests that policy-driven solutions to the challenges facing integrated community mental health care may be needed and concludes with an overview of the prospects for change contained in the previous UK government's Green Paper, 'Developing Partnerships in Mental Health'.     

Contracting opportunities: interpreting post-asylum geographies of mental health care in Auckland, New Zealand

In New Zealand, the process of deinstitutionalization is continuing to unfold as a specific manifestation of welfare state restructuring rather than as a discrete process within the health care sector. In this paper we consider the geography of mental health care in Auckland, New Zealand's only metropolitan city. Here, a highly fluid and competitive housing market has profoundly (re)shaped the opportunities for community care. We report on findings from a survey of representatives of the key agencies providing mental health care in central Auckland. We argue that the re-placing of mental health care into the community has often involved the separation of residential and treatment issues, to the detriment of the communities, institutions and (especially) individuals involved. We trace this fragmentation back to the primacy of the ideology of restructuring over the philosophy of deinstitutionalization. We build our argument around a discussion of the Mental Health (Compulsory Assessment and Treatment) Act 1992 and the apparent subordination of the Act to the emerging of a 'contract state' and broader legislation, such as the Resource Management Act 1991, the Privacy Act 1992 and the Commerce Act 1986, which underpins the re-regulation of New Zealand society.     

The first sunrise: an experience of cultural immersion and community health needs assessment by undergraduate medical students in New Zealand

CONTEXT: Cultural factors in health and illness, and an awareness of community health needs analysis, are important issues for medical education. Both have received relatively little recognition in the medical education literature. This paper describes the development of an educational attachment to remote predominantly Maori rural communities in New Zealand. The twin purposes of the programme were to encourage students to adopt broad public health approaches in assessing the health needs of defined communities, and to increase their awareness of the importance of cultural issues. METHODS: During a one week attachment, 51 students from the Wellington School of Medicine were hosted in six small communities in the East Cape region of New Zealand. Students gained an insight into the health needs of the communities and were encouraged to challenge their own attitudes, assumptions and thinking regarding the determinants of health and the importance of cultural factors in health and illness. The programme included both health needs assessment and cultural immersion. Students made visits with primary health care professionals and were also introduced to Maori history and cultural protocol, and participated in diverse activities ranging from the preparation of traditional medicines to performing their own songs in concert. CONCLUSIONS: The students evaluated the course extremely highly. Attachments of this sort provide an opportunity for students to appreciate how cultural values have an impact on health care, and how they also make the teaching and learning of topics such as community health needs analysis an enjoyable and dynamic experience.     

Physical health,mental health,and behaviour problems among early adolescents in foster care

Background Adolescents with chronic illness in the general population are at increased risk of mental health and behaviour problems. Depression is also associated with delinquency. Adolescents in foster care are more at risk for chronic illness and mental health issues. We investigated whether adolescents in long‐term foster care with chronic illness have associated higher rates of internalizing and externalizing problems and delinquency. We also investigated if depression mediates the relationship between physical health and externalizing behaviours. Methods Data are from the National Survey of Child and Adolescent Well‐Being; adolescents age 11 and older residing in long‐term foster care (n= 188). Children whose caregivers reported on the occurrence of a chronic illness were compared using anova on internalizing and externalizing subscale scores and total scores of the Youth Self Report (YSR) and Child Behavior Checklist (CBCL), and modified Self‐Report of Delinquency (MSRD) scores of delinquency and total number of delinquent acts. Bootstrapping analyses were used to test our hypothesis that depressive symptoms (Children's Depression Inventory) function as a mediator. Results Adolescents with a chronic illness reported greater internalizing (YSR: F= 7.069, P= 0.009; CBCL: F= 4.660, P= 0.032) and externalizing (YSR: F= 5.878, P= 0.016; CBCL: F= 3.546, P= 0.061) problems, a greater number of delinquent acts (6.66, F= 5.049, P= 0.026) and heightened overall delinquency (F= 5.049, P= 0.026). Depression significantly mediated the effects of overall health on delinquency (95% CI, 0.03–1.76). Conclusions It is important to consider the complex interrelationships between physical health, mental health, and behaviour for adolescents in foster care. These findings support the need for comprehensive services for these youths, including specialized assessments and collaboration between protective services and healthcare systems.     

Rethinking professional prerogative: managed mental health care providers

Managed care represents a response to the wider institutional demand for technical rationality and efficiency. In the US, managed care exemplifies the commodification of health and is governed by a technocratic-rationality that often conflicts with the professionally governed value rationality of providers. Providers must negotiate between contradictory institutional demands for cost containment and quality care in their everyday work practices, and consequently experience a series of ethical dilemmas. This paper examines the effect the commodification of health care has had upon the work of mental health care providers, their loss of professional prerogative, their concrete experience of the ethical dilemmas which result from the commodification of care, and evidence of countervailing power.     

Joint working in community mental health teams: implementation of an integrated care pathway

Abstract Integration of community mental health services is a key policy objective that aims to increase quality and efficiency of care. Integrated care pathways (ICPs) are a mechanism designed to formalise multi-agency working at an operational level and are currently being applied to mental health services. Evidence regarding the impact of this tool to support joint working is mixed, and there is limited evidence regarding the suitability of ICPs for complex, community-based services. The present study was set in one primary care trust (PCT) in Scotland that is currently implementing an ICP for community mental health teams (CMHTs) across the region. The aim of the study was to investigate professionals' experiences and views on the implementation of an ICP within adult CMHTs in order to generate learning points for other organisations which are considering developing and implementing such systems. The study used qualitative methods which comprised of individual interviews with three CMHT leaders and two service development managers, as well as group interviews with members of four adult CMHTs. Data was analysed using the constant comparison method. Participants reported positive views regarding joint working and the role of an ICP in theory. However, in practice, teams were not implementing the ICP. Lack of integration at higher organisational levels was found to create conflicts within the teams which became explicit in response to the ICP. Implementation was also hindered by lack of resources for ongoing support, team development and change management. In conclusion, the study suggests that operational systems such as ICPs do not address and cannot overcome wider organisational barriers to integration of mental health services. Integrated care pathways need to be developed with strategic input as well as practitioner involvement and ownership. Team development, education about integration and change management are essential if ICPs are to foster and support joint working in integrated teams.     

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.     

Specialty health care,treatment patterns,and quality: the impact of a mental health carve-out on care for depression

OBJECTIVES: To assess the effect of a mental health carve-out on treatment patterns and quality of care for outpatient treatment of depression. DATA SOURCES: Outpatient and pharmaceutical claims from September 1993 through March 1997 for one large managed care organization in the Midwest that carved-out mental health and substance abuse benefits in September 1995. RESEARCH DESIGN: Using the treatment episode as the unit of analysis (n = 1,747), changes in treatment patterns associated with the change to a carve-out were evaluated. Logistic regression was used to assess whether in the postperiod a treatment episode was more likely to be treated with (1) an antidepressant and (2) a type and intensity of treatment with proven efficacy. To strengthen confidence in a causal relationship, I search for structural breaks in treatment patterns across a wide range of dates, assuming no a priori knowledge of the timing of the impact of the carve-out. RESULTS: I find the carve-out to be associated with an increase in the use of drug treatments. Although I find a decrease in the use of guideline-level treatment over the entire study period, there is an increase in the number of episodes treated with guideline-level treatment over what would be the case in the absence of the carve-out. CONCLUSIONS: The increase in the use of drug treatments suggests previous research that excluded these costs may have overestimated the savings attributable to carve-outs. Guideline-level care appeared to increase as a result of carve-out implementation suggesting the use of management and specialization to reduce costs is not antithetical to quality improvement.     

The development of a community child and family mental health service

The Community Child and Family Service is a primary care and community-based child mental health service working in a socio-economically disadvantaged area of inner London. This paper outlines the strategic framework and value base from which the service has developed. The clinical projects set up by the service in general practice, community and education settings are described, as are the training and supervision programmes that have been undertaken. The framework for evaluating the clinical and economic outcomes of the projects is outlined. There has been a positive response from purchasers, providers and clients to the introduction of this Service. The relationship between community- and hospital-based child mental health services is discussed, as is the future direction of the Service.