Toolkit for Primary Mental Health Care Development: Research Report

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Toolkit for Primary Mental Health Care Development: Research report

Authors: Collings S, Mckenzie S, Dowell AC, Currey N, Gandar P, Rees D

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Citation: Collings S, Mckenzie S, Dowell AC, Currey N, Gandar P, Rees D. 2010. Toolkit for Primary Mental Health Care Development: Report. Wellington: University of Otago and Synergia Ltd.

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Acknowledgements

The research team would gratefully like to acknowledge and thank our four research partners: Counties Manukau District Health Board, Hawke’s Bay District Health Board, Hutt Valley District Health Board and Nelson-Marlborough District Health Board for their support and commitment to the project. We would especially like to acknowledge the individuals and agencies ranging from DHB personnel to clinicians in both primary and secondary mental health care within each research locality that worked directly with us, gave up their valuable time to meet, and discussed ideas, problems and solutions.

Core Research team

The core research team comprises the following members:

Associate Professor Sunny Collings, Principal Investigator, University of Otago Mr Philip Gandar, Synergia Professor Tony Dowell, University of Otago Mr David Rees, Synergia Ms Sarah Mckenzie, University of Otago Ms Nandika Currey, University of Otago

Contributors

Dr Debbie Peterson, University of Otago Ms Helen Montgomery, University of Otago Ms Joni Wang, University of Otago

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).

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

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

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.

 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.

Figure 1 Optimal II for Primary Mental Health Care

Elements within PHO/PHO network District Health Board Philosophy of PMHC service Services for any person with mild-moderate mental health needs Prioritise primary mental health care Funding: following removal of ring fence of Explicit service provision for Child & Youth; over 65s Clear inclusion/exclusion criteria based on explicit values ‘Mason’ protected mental health funding, prioritise primary mental health programmes supports Infrastructure Evidence-led constraint Infrastructure: prioritise linkages Clinical champion Culturally to programme variety Patient management system Whānau ora appropriate Adaptation to local need Information technology based services within clearly articulated  platform approaches as available constraints led by policy Links with community appropriate and guidance where possible PMHC is congruent with DHB programmes Local PHO or PHO grouping primary links mental health Continuous Workforce Prioritise policy and practice linkages to: Links with other Secondary mental health clinical champion, Quality primary care Sufficient staff with appropriate knowledge Health promotion working within Improve- programmes and skills i.e. new roles of specialists in PMHC Primary prevention & supported by ment including Career path Other secondary care programmes distributed alcohol & drug Protected time for funded professional leadership development, supervision

Workforce development Formalised links with Mandatory initial training funded by external body Government agencies e.g. WINZ, Education Uniform training across nation NGOs e.g. Salvation Army, Foodbanks, self-help groups, Rolled out in a timely way using existing courses Other services provided by a range of social entrepreneurs Interdisciplinary Contracting to be managed to ensure it is not burdensome To be delivered by educators in current clinical and research practice in primary care and services are experienced as seamless’ by service users ‘ 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

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Figure 2 Service user pathways Service user identified (through General Practice or other route- e.g. Māori health provider) (within the context of figure 1). Initial assessment including clinical indicators and appropriate assessment tool(s) e.g. K10

Inclusion criteria No met?

Yes

Select from usual range of GP interventions e.g. pharmacological Clinical/social intervention intervention; lifestyle advice General Practitioner/ Clinical coordinator and Practice Nurse: assessment or extended consultation

Treatment interventions Secondary Examples: talking therapy, pharmacological prescription referral (from GP), lifestyle interventions, self-management

Provide treatment within practice as much as possible Referral to other Monitoring and follow-up (over extended period) organisations including appropriate assessment tool e.g. NGOs GP/PN/Coordinator: phone, text, email, face-to-face

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,

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______2 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.

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.

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.

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

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______6 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 ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______7 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 ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______8 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 C

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)

rd Do not pass 3 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.

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.

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,

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______11 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

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______12 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

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______13 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.

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

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).

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

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

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______18 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

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

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______20 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).

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.

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.

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.” ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______24

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

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).

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).

Mana

Kotahitanga

Rangatiratanga

Whānau ngatanga Manaakitanga Whakamana

Kaupapa Māori Wairuatanga

Tangata Whenua Taurahere

Position on the wharenui:

Ātea Whānau /hapū Family, extended family unit

Amo Tangata whenua Local people, tribal members Those who whakapapa to Taurahere other areas Maihi Manaakitanga Value, respect, accept, support, guide, motivate, deliver and host Whakamana Enable, empower, build confidence and understanding Rangatiratanga Lead with confidence and integrity Whānau ngatanga Partnering, networking, information sharing, service co-ordination and shared kaupapa Pouporuru Kaupapa Māori Tikanga, Māori values, Māori for Māori Wairuatanga 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

Factors critical to Māori mental health Kotahitanga 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 Lack of understanding by communities and illness and support families

Being treated with dignity and respect Discrimination

Involvement of Māori clients and families in Lack of knowledge within whānau of mental design and delivery of interventions health

Faith and spirituality Cultural stigma of having mental illness

Personal strength to overcome adversity of Lack of self-help information, especially in mental health experience early stages of illness

Effective strategies for overcoming language Cultural inequality and misunderstanding and cultural barriers

Community-oriented services Ineffective and uninspiring services

Supportive staff who are invested in their Lack of care and support from staff clients’ recovery

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 Exclusion by whānau and community a consumer advisor etc without discrimination

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.

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.

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

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______32 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 –

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.

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 Lack of strong leadership or recognition of being recognised authority Parenting – two parents and extended family Parenting – solo and/or no extended family life support Parenting supportive and confident of Parenting is not supportive or confident transition to or balance of Western and about negotiating Western and traditional traditional perspectives perspectives and expectations Safe and secure environment Insecure – violence in the home (physical, verbal) Successful adaptation and co-existence Confusion about acceptable and appropriate between Western and traditional culture, cultural mores and behaviours. Discomfort mores and behaviours 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 Inadequate income to support family and meet church and social obligations 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

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 ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______36

• 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.

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, ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______38 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).

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. ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______40

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.

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.

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).

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

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______44 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

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______45 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,

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______46 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 ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______47 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 ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______48 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

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 2 participation, and the same goals for recovery. 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. ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______50

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 ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______51 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.

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

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______53 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

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______54 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,

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______55 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

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______56 compared to those using secondary services. We need new research to uncover what these are and find out any implications for PMHC.

Finally, there are implications for how best to represent the viewpoints of those seeking help from primary mental health services, and how to encourage the participation of these users in their own care. These are important for people using secondary services, and are issues that the consumer movement has traditionally focused on from the perspectives of secondary service users. Because of the differences between the users of primary and secondary services it is likely that one group cannot adequately represent the other. There has been little consultation to date with users of primary mental health services to determine whether this is, in fact, the case, let alone whether these issues are as important to primary mental health users as they are to those using secondary services. Future service and policy development should include consideration of such consultation.

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Section 3: Framing the research

Introduction

This project was informed by two methods and three theories or frameworks. In this section we discuss the key methods and theories that we used. Firstly, we give a brief overview of the Evaluation of the Primary Mental Health Initiatives which were used to explore the research queries and assumptions during early engagement with the research partners. Next we discuss the main methodological approaches that informed the emergent method used in this project, which include case study and participatory action research (PAR). Finally, we discuss the different lenses used to frame this work, which have informed the entire research process. These include Diffusion of Innovation theory, Developmental Evaluation and Systems theory.

The Primary Mental Health Initiatives

The development of the primary mental health initiatives (PMHI)

In April 2004 the Ministry of Health sent out requests to Primary health Organisations (PHOs) for proposals for primary mental health care. By November 2004 the proposals had been assessed and funding was provided for initiatives proposed by 42 PHOs and distributed to 256 different groupings. The PMHI programme in PHOs was seen as being part of a package of initiatives being undertaken to develop PHOs and support the implementation of the Primary Health Care Strategy. The principal target population for these initiatives was those with mild to moderate mental health.

Other than the provision of ‘usual’ GP-delivered primary mental health care, the majority of the PHOS involved in the initiatives did not have any formalised primary mental health programmes prior to the implementation of this new funding stream. Until the introduction of the PMHIs there had been no central funding to specifically support primary mental health care, with this kind of activity limited to a small number of PHOs or DHB projects. As a result, the Ministry of Health recognised that

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.

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).

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 ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______71 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”. ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______72

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.

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 ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______74 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

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______75 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.

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).

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

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______78 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).

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.

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

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).

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).

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.

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- Develop new measures and monitoring mechanism as determined goals goals emerge and evolve Design the evaluation based on linear Based on complex systems thinking, nonlinear, cause-and-effect modelling emergent dynamics, and interdependent interconnections Render definitive judgements of Provide rapid feedback, generate learnings, support success or failure direction, or affirm changes in direction Position the evaluator outside to Position the evaluator as a design team members

assure independence and objectivity integrated into developmental decision making Aim to provide generalisable findings Aim to produce context-specific understandings that so that effective practices can be inform ongoing innovation; innovate principles are applied elsewhere generalisable Accountability focuses on and directed Accountability centred on the innovators deep sense to external authorities and funders of fundamental values and commitment Accountability aimed at control and Learning to respond to lack of control and staying in locating source of failures touch with what’s unfolding and thereby responding strategically Evaluation is often a compliance Evaluation is a leadership function : reality testing, function delighted down within the results focused and learning –oriented leadership organisations Evaluator determines the design based Evaluator collaborate with those engage in the on the evaluators perspective about change effort to design an evaluation process that what is important. The evaluator matched the innovation philosophically and organisationally controls the evaluation Evaluation results in opinion of success Evaluation supports ongoing learning or failure

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.

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.

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

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

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______90 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 ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______91 together to discuss important issues they come with their own language. The language of accountants, of planners, of doctors, of nurses, and of managers is spoken in different dialects and misunderstanding is common. SD provides a neutral mapping language which can be used to ensure all relevant interests are mapped and understood. Mapping, using the language of SD delivers a rich view of the system that is relevant and understandable.

The visual nature of SD modelling also makes it a powerful communication tool, enabling people to inform and educate others’ about the system, showing where they fit in and how their actions influence the whole.

Toolkit Models

The most explicit use of the systems approach in the toolkit is the Planning Guide and the simulation model, designed to help translate national data into data useful at a regional and local level. Both use the SD approach described above. The Planning Guide limits it’s modelling to a qualitative approach, describing key elements within PMHC and how they are linked together. The simulation model takes the national data from Te Rau Hinengaro: The New Zealand Mental Health Survey and uses SD software to provide a model that provides some insight into the implication of the National survey for local populations.

Throughout the toolkit however we have tried to take a systems perspective and provide material that points to the importance of local context and understanding the relationships that are at play within any system of PMHC.

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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.

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

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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).

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

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______97 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

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______98 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

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

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______100 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.

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

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______102 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”.

somehow we need a debate about how and where we spend our MH money 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 $

age and stage; predictable stress points - transitions into we being too gaps & area's of adulthood, relationship focused and anal in poor focus, such as separation, loosing our targeting child & youth job, retirement

focused on depression but in age and stage, terms of loss of further move to function a number of youth the closer to other high value health promotion areas

a youth focus

our programme will not be a

very structured, too disease/condition

complicated, need focus

simpler approaches an 80/20 rule

An example of the issues and connections made during cognitive mapping.

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.

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:

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..

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

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______108 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

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______109 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

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

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 No met?

Yes

Select from usual range of GP interventions e.g. Clinical/social intervention pharmacological intervention; General Practitioner/ Clinical coordinator and lifestyle advice Practice Nurse: assessment or extended consultation

Treatment interventions Secondary Examples: talking therapy, pharmacological prescription referral (from GP), lifestyle interventions, self-management

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. ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______111

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

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.

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.

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.

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

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______116 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

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______117 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.

Figure 1: Fourteen key themes from group discussions

Holistic Participation, partnership and Family and protection Whānau focused

Includes the broader Accessible determinants of health

Consumer Provides ongoing focused care

What is primary mental health care?

For all ages Uncommon

Integrated and co-ordinated care Community focused

Alternative approach to Involves primary Issues raised by all 4 groups health care Focuses on well being Issues raised by 3 groups ______Issues raised by 2 groups © 2010 Toolkit for Primary Mental Health Care Development: Report Issues raised by 1 group ______119

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

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 ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______121 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.”

“…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. ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______123

“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.”

“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

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.”

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

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.

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.

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. ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______130

Pattern of partner face-to-face and formal meetings March 2009 to June 2010

MARCH MAY JUNE JULY AUGUST OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE (All)

Full meetings Hutt Valley Full meeting or Hutt Valley Hutt Valley Hutt Valley Counties Full with each Counties teleconference Nelson Nelson meeting Counties Counties Counties Full Counties research with each Ropata Hutt Valley with each meeting partner research PHO research with each partner partner research partner Sector PHO meetings engagement NGO meeting Hutt Valley workshop Service users Counties Child & meeting Manakau Youth

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

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 ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______132

 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? ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______133

 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.

“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 ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______135 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?

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:

“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

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 ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______139

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?

Research Partner 1 cognitive maps from May 2009 Programme Sustainability / CCM Linkages Integrating PMH & wider LTC approaches

71 use project to 5 how do we move on form core of a 43 impact of MH on from initiation to 22 there is likely stream of activity 59 move towards a LTC is absolutely maintenance & to be no more PMH $ around CCM 41 can we create spectrum approach of key to making sustainability, what depression, shift links and synergies MH & LTC? progress 3 how would we grow do we change the PMH workforce towards outcomes with what is already 4 what is the return with some priority happening (LTC on investment of so we have the initiatives) 58 would it help 35 developing steps PMH, what difference 7 how do we know if leverage and refocus capacity needed we have made a in intensiveness, will it make to 33 some how we need CCM, eg address MH difference? 6 what systems & using the all the growth in acute a debate about how structures to we issues directly 34 metered resources in the medicine? and where we spend have to demonstrate investment across system our MH money whether we make a 52 the MH the contiuum of difference need, how to portray consequences and opportunities of LTC the pattern of our 8 what changes will 45 service 67 level of need 15 choice of response intensiveness, 4 or make a difference? I efficiency benefits based responses 11 where would we 6 makes a huge of links put additional difference to resource? 57 good evidence for numbers treated & the links between capacity required 44 MH as impediment LTC & MH 26 focussing and 29 CCM a lot of eggs on self care 17 focused on 36 Patients in one basket & a 54 CCM parts don't accessing SMH not shifting difficult interact well with depression but in to do at all levels lot of other issues terms of loss of that different from in PMH that we are each other of practice and 14 services have function a number of those we see in our not addressing practices organisation grown organically other high value areas

60 what should be 86 90% of investment labelled a MH 2 comparing CCM in CCM deppression, 19 benefits of problem? 13 choice of versus some other is this right? functionality treatment and way how do we widespread but not intensiveness not 16 relatively broaden it to other well understood clear cut haphazard targeting things and inclusion 56 advantages and 28 CCM are we being diadvantages of too focused and anal in our targeting silos in ownership, 24 depression accountability, 12 potent treatment easiest first target 53 CCM too 21 change in effect but a black funding streams, complicated, need employment status, 20 health service box as to what engagement 42 overlap between simpler approaches unhealthy days utilisation cuases it an 80/20 rule 55 comprehensive needs of those primary care or Focusing on outcomes, complex end in CCM & Refocusing CCM selective programes sustainability & value for those accessing the Depression for specific issues separate CCM ______money in PMH Depression © 2010 Toolkit for Primary Mental Health Care Development: Report ______141

Wider focus on complexity, Shift of focus – age/stage & mental distress? & age/stage issues?

61 PMH for compexity/stress 90 what we need is 33 some how we need access to SRI, electic CBT and a 31 in the midst of a debate about how and where we spend social worker making cuts in 89 age and stage; programmes, concern our MH money predictable stress 85 lebelling and about equity, points - including age equity marketing of CCM transitions, into inappropriate adulthood, reln 88 if we could make message for all PMH separation, loosing 32 mismatch between stress & its impacts job, retirement where MH problems explicit could be a start and where we different window 66 a youth focus 38 age and stage, into responding spend our $ 60 what should be will not be a further move to 17 focused on labelled a MH youth the closer to depression but in disease/condition problem? health promotion terms of loss of focus 91 how can we avoid function a number of diagnostic drag - other high value the label drags areas services and resources 39 more move towards child & youth the less clear the 65 supports an 28 CCM are we being 23 gaps & area's of 63 strongly heald evidence base industry too focused and anal poor focus, such as beleif structures in in our targeting youth MOH and NGO

84 the recovery 64 early model thinking as preventative action 83 philosphical driver of long term 53 CCM too theories 'dependancy' complicated, need 62 but no evidence issue about simpler approaches for progressiveness chronicity an 80/20 rule to severe MH longrevity vs short sharp help Developing a better understanding about what outcomes we want in Avoiding the pitfalls of entrenched primary mental health mental models of what mental health ______support services require © 2010 Toolkit for Primary Mental Health Care Development: Report ______142

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

 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

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.

 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

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,

you know. So I mean you’ve got a workforce that’s going to change over the coming years.”

Research Partner 2

The 2007 Primary Mental Health Initiatives programme provided the starting point for structured PMHC with this partner. These were developed by each of the five PHOs in the district with varying approaches, from an integrated practice based service at one smaller PHO to a large primary mental health team operating as a referral based primary health service supporting a number of practices at a large PHO. The services had largely developed in isolation from each other and from secondary care. Integration at a district planning level was seen as desirable and part of the reason for participating in the action research process.

Framework for engagement

The energy for engagement in the action research process in this partner came from secondary services who had undertaken a “Knowing the People Planning” process with their secondary service consumers that highlighted a need for better functioning across the primary /secondary boundary.

The action research project was seen to be aligned with planned work of secondary services to improve the interface and work more effectively with primary mental health services in this research partner locality. It was seen as an opportunity to improve networks with colleagues in the primary health sector and explore how available specialist resources could be better employed to meet the clinical needs of those with mental illness in the regions.

Through the support of DHB Funding and Planning a series of exploratory workshops with primary, secondary, NGO and consumer representatives provided the framework for engagement although the primary source of energy and resource for the project remained with a secondary based clinical leader, service manager and project manager.

First cycle issues exploration

Five separate issues exploration sessions were held in the area: two with primary care, together with NGO, consumer and specialist services.

Primary care: Core focus – people with mild to moderate stress

There was a strong representation from both primary health teams that there was a large gap between the assumptions of the primary health strategy; a continuum of mild, moderate to severe with primary health expected to address the mild to moderate end of the spectrum, and the need that presented in primary care. In their view primary health is providing effective response for a mild to moderate level of need largely arising from a complex array of life problems only some of which is represented by mental health disorders. The core business of primary mental health is to address presenting need created by complex combinations of the effect of stress, complexity, lack of resiliency and loss of capacity to function. In their view, there is a clear boundary between severity in these terms and smaller proportion of those with severe psychosis needing specialist treatment and ongoing social support.

The primary health teams were proud of the results achieved by the PMHI to date but also acutely aware that their level of resource was limited. This raised a number of issues:

Questions of threshold and intensity for mild to moderate stress. The PMHI model of brief problem solving interventions is seen as being appropriate but with constrained funding. The cost of care is heavily influenced by the number of session contracted per episode. This varies considerably across PHOs. If the funding is to be effectively utilised there needs to be some rationale and consistency. Options with a lower level of services intensity were seen as potentially needed to meet the level of demand that has been exposed by the introduction of the service. Development of the most effective model of care for those significant stress and dysfunction but who can most effectively be treated in primary and community settings

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.

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

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.

“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

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

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.”

32 We can some times 31 Can't access the 35 Made referrals & Concepts from second cycle Primary MH discussion get people in service unless ill get "on our wait list please continue through the 'CAT enough to warrant to hold" door' it, ie some risk 9 Brief centering 22 Resiliency processes - bring building stuff 27 Some referral to people back to who 2 PMH core mental 34 Need more 33 Once they get in 55 How much ongoing 28 We could benefit SMH for people with they are and from health services for enduring and wider there do they liase limited functioning Emerging,from access todifferent,chronic shape long term and focus to there they tend to moderate to high end range of support with me - no ... Do is enough to warrant primarypsychiatric mental healthconditions, needing answer their own moderate than we can provide they our attention? questions assessment psychiatry, -Less suited to conventionalmedication diagnostic or 59 Where we can framing support worker assist SMH by doing 49 Psycho/social 42-More Only some focussed with a on stress, complexitya good& primary distress 43 People with 36 People with dysfunctiondefinable medical assessment first stress and - Contains a spectrum of severity of 44 The quiet, dysfunction severe needs arising diagnostic channel situations but ‘continuum’ concepts miserable, significantly from a complex array that you could put vulnerable affecting their of life problems questionedthem in lives , but not in a -A less severe end very brief listening, 26 Stressed children disordered way problem 50solving Clear edge resiliency for development23 What these and families -But alsosevere, handling boundary quite high serviceslevels don't of do is 20 The mild, mod, with those with 12 Sadness, badness, 5 Chronic pain severity as a consequence ofreduce complexity demand to SMH - severe diagnostic (situation pyschosisthat do etc not fit of reach specialist unfortunate events, paradigm is not 40 We need a access thresholds) limited coping narrative of what useful to decribe -Initial PMH service structures based on strategies 4 Not neatly defined the mild to moderate the population & by diagnoses look like need mild/mod ‘depression’ need rethinking 8 People with very -Needs different60 If we take connections to complex external point of social andpressure living off anybody support view, no sense of -Needs differentits off GPs access to specialist who they are; loss, 14 Language can lead 10 Large gap between grief, you off the track the assumptions madeassessment and review advice to support from a useful primary based responses 19 Anxiety by the PMH strategy 7 People who fall dialogue 25 The strategy is 3 Emotional ups & & the actual between the cracks manifesting as "I am based on a continuum down, relationship presentation of the pissed off" of need that is a issues population 21 PMH set up for myth 6 Mild psychosis, the 18% who aren't ______personality problems the 3% © 2010 Toolkit for Primary Mental Health Care Development: Report ______156

Concepts from second cycle Primary MH discussion 32 We can some times 31 Can't access the 35 Made referrals & get people in service unless ill get "on our wait list please continue through the 'CAT enough to warrant to hold" door' it, ie some risk 9 Brief centering 22 Resiliency processes - bring building stuff 27 Some referral to people back to who 2 PMH core mental 34 Need more 33 Once they get in 55 How much ongoing 28 We could benefit SMH for people with they are and from health services for enduring and wider there do they liase limited functioning from access to chronic long term there they tend to moderate to high end range of support with me - no ... Do is enough to warrant psychiatric conditions, needing answer their own moderate than we can provide they our attention? questions assessment psychiatry, medication or support worker 59 Where we can assist SMH by doing 49 Psycho/social 42 Only some with a a good primary distress 43 People with stress and 36 People with definable medical assessment first 44 The quiet, dysfunction severe needs arising diagnostic channel miserable, significantly from a complex array that you could put vulnerable affecting their of life problems them in lives , but not in a 26 Stressed children Better access and coordinationdisordered way with specialist 50 Clear edge for 23 What these and families services severe, boundary services don't do is 20 The mild, mod, with those with 12 Sadness, badness, 5 Chronic pain reduce demand to SMH severe diagnostic pyschosis etc unfortunate events, - Access to assessment40 We need and a advice inparadigm primary is not limited coping narrative of what useful to decribe strategies settings - Access4 Not neatly definedto servicesthe mild (more to moderate enduring,the wider population & by diagnoses look like need 8 People with very range of supports) for people who can 60 If we take external point of otherwise be well managed in primary settings pressure off anybody view, no sense of its off GPs who they are; loss, - Complex comorbidities14 Language can lead 10 Large gap between grief, you off the track the assumptions made from a useful 19 Anxiety by the PMH strategy 7 People who fall dialogue 25 The strategy is 3 Emotional ups & & the actual between the cracks manifesting as "I am based on a continuum down, relationship presentation of the pissed off" of need that is a issues population ______21 PMH set up for myth 6 Mild psychosis, the 18% who aren't personality problems © 2010 the 3% Toolkit for Primary Mental Health Care Development: Report ______157

7/05/2009

Issue: Effective infrastructure, relationships

46 Must approach PMH 42 Support empower, utilise the capacity 13 Provide access & within wider primary 27 More intergrated 33 Reduce variation 8 Increase access of people and their support for the 17% strategy care, more appriate in access for the 3% families setting 'severe/acute' 26 Need better access to nurse, allied health social Effective infrastructure, relationships 28 Include wellness work & ACC services 11 Provide short strategies brief interventions 10 Provide more rigorous assessment for less acute needs 18 Work on joint 19 Better use of to focus service -Relationships across PHOs,individualised SMH, plans DHB limited SMH capacity 36 Develop -Integrated, coordinated response interdiciplinary 45 Adapt interventions to skills & capacity 12 Both PHO & joint -Service models context & capacity 5 Need to have clear 37 Outsource PMH Spec Serv provided ... single standard -Funding & access criteriathresholds for interventions, not model 15 Work with those different levels of require GP delivery -Capability development 14 How do you get GPs have greatest service current reln 6 SMH thresholds may the PHOs in room to not be right provide leadership for coordinated 20 PHOs have very Recognising 30 Fear that there 9 Many SMH clients response? different 1 Variable usage of will be a dump of could be better populations & SMH services by GPs -Different paradigmsextra of work PMH/SMH on GP managed in PMH capacity -Variation in PHO population/capacity 39 Reduce inequity of funding acoss 7 SMH not building-Integration17 Who is going with to wider primary strategy 2 Dis illusionment PHOs capability in PMH so pay? 25 Spec MH - old in Primary over SMH 44 GP does not have needing to refer? 16 Many of Spec MH attitude "once support for PMH the time in short clients don't hace clients ours they consult to do much access to CarePlus & are ours for life" or know where to get can't get time support 21 SMH don't have good reln with 31 SMH de-skilled in primary & PHOs 38 Use initiative dealing with 32 SMH & PMH work 22 Very limited GP funding to provie mild/mod 29 Narrow from different workforce capacity PMH options for GPs specialised focus in paradigms 3 DHB SMH have MH services history of saying 4 Individual efforts they will support to work alongside PMH & don't follow GPs but not 41 any development sustainable through 43 More and more incl training 40 Develop funding 34 Message from SMH people having consumes time and and service models that primary doesn't difficulty coping detracts from scarce 35 Systematic to make best use of know how to do MH with life hit road capacity deskilling in PMH the resources ______bump over many years available © 2010

Toolkit for Primary Mental Health Care Development: Report ______158

Issue: Support for people, families, social context of mental wellbeing?

46 Must approach PMH 42 Support empower, utilise the capacity 13 Provide access & within wider primary 27 More intergrated 33 Reduce variation 8 Increase access of people and their support for the 17% strategy care, more appriate in access for the 3% families setting 'severe/acute' 26 Need better access to nurse, allied health social 28 Include wellness work & ACC services 11 Provide short strategies brief interventions 10 Provide more rigorous assessment for less acute needs 18 Work on joint 19 Better use of to focus service individualised plans limited SMH capacity 36 Develop interdiciplinary 45 Adapt interventions to skills & capacity 12 Both PHO & joint context & capacity 5 Need to have clear 37 Outsource PMH Spec Serv provided ... single standard thresholds for interventions, not model 15 Work with those different levels of require GP delivery 14 How do you get SupportGPs forhave greatest people, families,service social context current reln 6 SMH thresholds may the PHOs in room to of mental wellbeing not be right provide leadership for coordinated 20 PHOs have very 30 Fear that there 9 Many SMH clients response? different 1 Variable usage of will be a dump of could be better populations & SMH services by GPs -Self care, family supportextra work on GP managed in PMH capacity -Integrated, coordinated response with social 39 Reduce inequity of funding acoss 7 SMHservices not building 17 Who is going to 2 Dis illusionment PHOs capability in PMH so pay? 25 Spec MH - old in Primary over SMH 44 GP does not have needing-Interdisciplinary to refer? skills 16 Many of Spec MH attitude "once support for PMH the time in short clients don't hace clients ours they consult to do much access to CarePlus & are ours for life" or know where to get -? Role of health promotion can'tto getsupport time effective support 21 SMH don't have functioning/reduce stress - ‘person & context’? good reln with 31 SMH de-skilled in primary & PHOs 38 Use initiative dealing with 32 SMH & PMH work 22 Very limited GP funding to provie mild/mod 29 Narrow from different workforce capacity PMH options for GPs specialised focus in paradigms 3 DHB SMH have MH services history of saying 4 Individual efforts they will support to work alongside PMH & don't follow GPs but not 41 any development sustainable through 43 More and more incl training 40 Develop funding 34 Message from SMH people having consumes time and and service models that primary doesn't difficulty coping detracts from scarce 35 Systematic to make best use of know how to do MH with life hit road capacity deskilling in PMH the resources bump over many years available ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______159

Research Partner 2 cognitive maps April-May 2009

Concepts in first cycle DHB and Specialist MH discussion

39 Reduce inequity of funding acoss 7 SMH not building 17 Who is going to 2 Dis illusionment PHOs capability in PMH so pay? 25 Spec MH - old in Primary over SMH 44 GP does not have needing to refer? 16 Many of Spec MH attitude "once support for PMH the time in short clients don't hace clients ours they consult to do much access to CarePlus & are ours for life" or know where to get can't get time support 21 SMH don't have good reln with 31 SMH de-skilled in primary & PHOs 38 Use initiative dealing with 32 SMH & PMH work 22 Very limited GP funding to provie mild/mod 29 Narrow from different workforce capacity PMH options for GPs specialised focus in paradigms 3 DHB SMH have MH services history of saying 4 Individual efforts they will support to work alongside ______PMH & don't follow GPs but not 41 any development sustainable through 43 More and more incl training 40 Develop funding 34 Message from SMH © 2010 people having consumes time and and service models that primary doesn't difficulty coping detracts from scarce 35 Systematic Toolkit for Primary Mental Health Careto make Development: best use of Report know how to do MH with life hit road capacity deskilling in PMH the resources bump over many years available ______160

Issue: An Integrated Mental Health System

46 Must approach PMH 42 Support empower, utilise the capacity 13 Provide access & within wider primary 27 More intergrated 33 Reduce variation 8 Increase access of people and their support for the 17% strategy care, more appriate in access for the 3% families setting 'severe/acute' ‘An integrated mental health26 Need better system’ access to nurse, allied health social 28 Include wellness work & ACC services 11 Provide short -Optimisestrategies access for 3% (reduce burden in community)brief interventions 10 Provide more rigorous assessment -Reduce variation in access for less acute needs 18 Work on joint 19 Better use of to focus service -Optimise use of limited SMH resources individualised plans limited SMH capacity 36 Develop interdiciplinary 45 Adapt interventions to -Increaseskills ‘step & capacity-down’ /graduate from SMH (not ‘ours12 Both PHO & joint context & capacity 5 Need to have clear 37 Outsource PMH Spec Serv provided for life’) ... single standard thresholds for interventions, not model 15 Work with those different levels of -Shared support plans require GP delivery 14 How do you get GPs have greatest service -Build primary based support current reln 6 SMH thresholds may the PHOs in room to not be right provide leadership for coordinated 20 PHOs have very 30 Fear that there 9 Many SMH clients response?-Optimise access/reducedifferent variation of access 1 Variable usage of will be a dump of could be better populations & SMH services by GPs extra work on GP managed in PMH -More rigorouscapacity assessment -Reduce variation of GP usage -Build PMH capacity39 Reduce inequity of funding acoss 7 SMH not building 17 Who is going to 2 Dis illusionment PHOs capability in PMH so pay? 25 Spec MH - old in Primary over SMH 44 GP does not have needing to refer? 16 Many of Spec MH attitude "once supportBUT for PMH the time in short clients don't hace clients ours they -Poor relationship between SMH & GP/PHOconsult to do much access to CarePlus & are ours for life" or know where to get can't get time -Limited GP capacity support -Dumping suspicion21 SMH don't have good reln with 31 SMH de-skilled in -Funding constraintsprimary & PHOs 38 Use initiative dealing with 32 SMH & PMH work 22 Very limited GP -Different paradigms in SMH & PMHfunding to provie mild/mod 29 Narrow from different workforce capacity PMH options for GPs specialised focus in paradigms 3 DHB SMH have MH services history of saying 4 Individual efforts they will support to work alongside PMH & don't follow GPs but not 41 any development sustainable through 43 More and more incl training 40 Develop funding 34 Message from SMH people having consumes time and and service models that primary doesn't difficulty coping detracts from scarce 35 Systematic to make best use of know how to do MH with life hit road capacity deskilling in PMH the resources bump over many years available ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______161

Issue: Effective, equitable PMH, efficiently operating within constraints

46 Must approach PMH 42 Support empower, utilise the capacity 13 Provide access & within wider primary 27 More intergrated 33 Reduce variation 8 Increase access of people and their support for the 17% strategy care, more appriate in access for the 3% families setting 'severe/acute' 26 Need better access to nurse, allied health social Effective equitable, efficient PMH 28 Include wellness work & ACC services 11 Provide short strategies brief interventions 10 Provide more rigorous assessment for less acute needs -Provide access & support to the18 Work17% on joint 19 Better use of to focus service limited SMH capacity - People in stress, ‘bumps in life’individualised plans 36 Develop interdiciplinary 45 Adapt -Reduce variation in access interventions to skills & capacity 12 Both PHO & joint context & capacity -More integrated care/appropriate5 Need to have clear setting 37 Outsource PMH Spec Serv provided ... single standard thresholds for interventions, not model 15 Work with those different levels of require GP delivery -Increase options for GPs to meet needs 14 How do you get GPs have greatest service current reln 6 SMH thresholds may the PHOs in room to -Recognises their limited capacitynot be right provide leadership -Build options wider primary based support for coordinated 20 PHOs have very 30 Fear that there 9 Many SMH clients response? different 1 Variable usage of will be a dump of could be better populations & SMH services by GPs extra work on GP managed in PMH capacity -Optimise access/reduce variation of access -Assessment, inclusion/exclusion 39 Reduce inequity of funding acoss 7 SMH not building -Efficient17 Who is going models to of care 2 Dis illusionment PHOs capability in PMH so -Reducepay? inequities of funding 25 Spec MH - old in Primary over SMH 44 GP does not have needing to refer? 16 Many of Spec MH attitude "once support for PMH the time in short clients don't hace clients ours they consult to do much access to CarePlus & are ours for life" or know where to get BUT can't get time support -Severely limited GP capacity 21 SMH don't have -Variation in PHO population/capacity good reln with 31 SMH de-skilled in primary & PHOs 38 Use initiative -Integration withdealing wider with primary strategy 32 SMH & PMH work 22 Very limited GP funding to provie mild/mod 29 Narrow from different workforce capacity PMH options for GPs specialised focus in paradigms 3 DHB SMH have MH services history of saying 4 Individual efforts they will support to work alongside PMH & don't follow GPs but not 41 any development sustainable through 43 More and more incl training 40 Develop funding 34 Message from SMH people having consumes time and and service models that primary doesn't difficulty coping detracts from scarce 35 Systematic to make best use of know how to do MH with life hit road capacity deskilling in PMH the resources bump over many years available ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______162

Development of the action research agenda

From the second cycle of refinement of the local issues two potential areas for action research emerged which were tested with the local action research partners:

The first, driven from a primary health perspective was focused on the operational issues of managing the limited funding provided by the PMHI in the face of large un-met demand.

Without a process for targeting and prioritising the flow of people with mental health issues it was likely that available resources were not delivered in a coherent or consistent way. Demand was likely to exceed supply putting pressure on the sustainability of the models of care developed in the initiatives. It was feared that a waiting lists will develop for these services.

Potential primary mental health action research agenda: Develop a framework that provides layers of service with differing intensity and kinds of response, with a range of resource requirements. Identify tools that facilitate selection of service kind and intensity to match need with clear inclusion/exclusion guidelines, and criteria that take into account need and resource or capacity driven constraints. Develop ideas or specifications for the necessary infrastructure to implement and sustain this within the overall primary mental health system.

From both a planning and specialist service perspective the issue was that the current secondary mental health service model needed to change. Primary and secondary specialist mental health services should ideally operate in a complementary fashion across the continuum of mental health needs. However they had developed as silos in isolation with very different prevailing professional paradigms and histories.

Primary mental health depends on secondary to provide additional levels of support for those with severe/acute needs yet these services are stretched, overburdened and have limited capacity to be responsive to a wider population of people with relatively severe conditions who, by default, are handled in primary.

Secondary services have tended to assume an ongoing responsibility for people who have been users of their services since there is perceived to be inadequate capability/capacity to handle care and risk in primary/community settings. This consumes scarce secondary resource, further limiting support that secondary can provide to primary.

Integration is further constrained by funding silo’s and organisational boundaries that have ring fenced resources and make it difficult to create a whole population response.

There is a wide range of perspectives on the role and purpose of both primary and secondary serves at both DHB and PHO level. The current planning, funding and service frameworks are not robust enough to support the development of a whole population response to mental health needs that integrates the functions of primary, community and specialist mental health responses. Because of the network of organisations involved and the different professional paradigms efforts to create an integrated approach driven from one perspective, (for example secondary specialist services) run the risk of suspicion and misinterpretation.

Potential secondary mental health integrated action research agenda: Develop planning tools and models that facilitate joint planning, service design and resourcing by DHB Funders & Planners, PHOs, primary and secondary service clinicians and NGOs.

Action Learning Process

During the process of developing potential action research agenda’s it became clear that the there was limited energy and capacity from primary health to engage directly with a broader cross PHO initiative to develop primary mental health but there was continued energy and commitment from secondary services to develop an effective shared care system with primary care. It was recognised that this would require a programme of progressive partnership development; relationships, communication, trust building and service development.

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.

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

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______166 demand. Service selection was through self referral, GP filtering (supported by common assessment tools) and then eligibility criteria for more specialised services such as ACC.

Framework for engagement

The pathway to engagement was relatively straightforward with close collegial relationships between the respective PHO service and clinical leads and the DHB Funding and Planning portfolio manager who facilitated the engagement with the research team.

First cycle issues exploration

An initial issues exploration working session was held with a local working group to explore the issues.

Based on session notes and transcripts an initial set of concept maps was prepared as shown on the following pages:

Developing sustainable funding and resources

Issues of financial sustainability were topical in this research partner in the initial stages of the action research inquiry. There were a number of drivers for this: The area had been successful in augmenting health funding with social service and ACC funding sources to provide greater depth of treatment for complex constellations impaired functioning; mental health, social deprivation and unemployment. Some of these sources were at risk. Potential policy shifts on ring fenced mental health funding in an area with chronic DHB deficits raised questions over the sustainability of initiative funding. Combined with these issues was an awareness of the magnitude of demand and its relative severity.

“If we had more flexibility and we didn’t have a mental health ring fence, then we might make a strategic decision around investment in primary mental health. Since we last met I've had the discussions with the Ministry about whether we can use our mental health funding for primary mental health and they’ve explicitly said no. So that’s not going to happen. …. So strategically perhaps the ring fence might be removed. If it is, we need to look at total access to service, so acute services, community-based services, GP services, you would look at all of the funding we’ve

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

“[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?

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.”

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.”

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.”

Research Partner 3 cognitive maps from March 2009

52 We are achieving 12 Not clear what substantial overall outcomes 21 What is the fit reductions in seeking and what of PMH within wider stress, symptoms & resources would be 1 What mix of models 56 Addressing primary health dysfunction needed should we be working spirituality, belief strategy - with, how much & family support variety is necessary 24 How do we manage 44 Find right blend also works for referral pathways to 19 What happens to wairoa, sprituality Pakeha too & belief & Pakeha 15 We can provide other services? those we exclude? cognitive approaches good service to Don't meet threshold to MH for Maori 45 Requires time & those who manage to but still have high 10 Not clear how dedicated team to get access 38 Major issues with needs potentiual 11 Potential of different approaches 14 Wide variation in provide a wrap drug & alcohol use benefit shift to PBF fit or integrate nature & level of around to deal with with wider MH funding, will $ be intensity of complexity & services sustainable? service, use of entrenched issues 13 Most models 17 Once identified secondary packages how do we assess? producing good 40 Enable access and of care how much skill & $ 36 Huge differences results irrespective reduce DNA of Maori put into assess? 42 Enable whanau to 55 We don't know yet in resource of type or level of 22 Are we moving to PMH 7 Normal primary be part of process how to resource or utilisation intervention into concepts of care also supports support whanau 2 Diverse & stress, complexity outside of the MH restrictive funding 18 What resilience, wellness primary setting sources rather than 16 How do we inclusion/exclusion rather than just 20 What's the place coherent approach to identify, screen, criteria should we clinical labels? 39 Increasing of Rx? PMH 8 MoH controlled target within known use & how apply? awareness initiatives limited 9 PHOs evolved high risk popns? understanding of 41 Provide DHB PHO PMH models to suit mainstream in alernative, suitable 6 ACC funding for engagement population approach to Maori & safe venues in abuse community for Maori 58 Idea that at low 33 Need emerging for to access levels of need 4 MSD funding for 34 Can we apply GPs how to use community can take back to work 37 How do we tools, prioritise training to 3 SIA funding eg 26 PMH role in early care of itself programmes 5 MoH has small and 28 People are systematically learn with limited community support so 53 Need workforce post natal & child intervention & flow limited $ for PMH hurting out there at & respond to resources, choose people don't need capacity development attachment pilot through to SMH initiatives the moment, we have patterns of right Tx PMH especially Maori starting constrained 46 W&I access to raised community utilisation and disability support expectations, results? for crisis/severe 25 Can't utilise engagement 29 Right education & development for extended sessions blue print 3% $ for floodgates are open service providers, 54 Need educational developing PMH 27 Demand much 23 Connection to 35 Retrain right approach support for Maori & capacity greater than funding social services & therapists who are cultural course & capacity support? naturally fixated on development 51 Current funding their way of doing 32 What is the right will reduce as things? mode of delivery & initiatives wind up 57 Most people how get protected assessed in PMH have 47 High levels of 30 Training GPs just time? higher scores than complex stress in did not work were expected to be our populations 49 'My wairoa is handled >29 broken, my spirit is 31 Primary does know lost' creates a stuff, not different acknowledged 50 depression & 48 Work, understanding of anxiety relationship, social response pathway

What outcomes do we need? 21 What is the fit of PMH within wider 52 We are achieving primary health 12 Not clear what substantial strategy overall outcomes reductions in seeking and what stress, symptoms & 15 We can provide resources would be 1 What mix of models dysfunction 19 What happens to 11 should we be working good service to needed those- we exclude? those who manage to with, how much Don't meet threshold variety is necessary get access 44 but still have high needs potentiual 10 Not clear how 7 20 14 13 24 How do we manage benefit different approaches referral pathways to fit or integrate other services? with wider MH 34 22 services 17 Once identified 16 How do we how do we assess? 2 Diverse & identify, screen, how much skill & $ 9 restrictive funding target within known 8 put into assess? sources rather than high risk popns? What is the system that coherent approach to 18 What PMH inclusion/exclusion manages targeting & 26 PMH role in early 39 criteria should we intervention & flow use & how apply? inclusion while through to SMH 46 11 36 20 7 5 monitoring & responding constrained 4 MSD funding for 27 Demand much 33 to consequences of greater than funding 3 SIA funding eg back to work 38 Major issues with programmes & capacity exclusion?drug & alcohol use post natal & child 22 25 37 How do we attachment pilot systematically learn starting 51 & respond to 28 People are patterns of 6 ACC funding for hurting out there at utilisation and abuse the moment, we have results? raised community expectations, 47 High levels of 34 engagement complex stress in 14 floodgates are open our populations 23 Connection to 57 Most people 49 'My wairoa is social services & assessed in PMH have 9 broken, my spirit is support? 48 Work, lost' creates a higher scores than 50 depression & relationship, social different were expected to be anxiety handled >29 understanding of How would we focus and response pathway integrate our funding streams? Shift from diagnostic categories to recognition of stress & - Balance administrative needs for focus & accountability with breadth needed for complexity flexibility and PMH system development - Nature of need and demand is not just a less severe form of specialist MH

Developing sustainable funding & resources

Strategic Context - Being clear about what we are seeking to achieve in primary mental health 21 What is the fit - How this is integrated with wider mental 10 Not clear how 37 1 of PMH within wider health services in the district primary health different approaches 12 Not clear what - Fit of primary mental health within the strategy overall outcomes fit or integrate with wider MH 14 Wide variation in wider issues and outcomes of primary seeking and what health including LTC resources would be services nature & level of needed intensity of

26 8 9 service, use of secondary packages 1 of care Efficiency of use - How efficiently our models of care use 17 36 Huge differences 45 9 the funding available in resource 11 Potential of utilisation shift to PBF 16 How do we funding, will $ be identify, screen, sustainable? 9 8 target within known 2 Diverse & high risk popns? restrictive funding sources rather than 4 MSD funding for 5 MoH has small and coherent approach to 39 back to work limited $ for PMH PMH 37 programmes initiatives 23

6 ACC funding for 27 Demand much greater than funding abuse 26 & capacity 3 SIA funding eg 46 W&I access to post natal & child 47 28 disability support 25 Can't utilise attachment pilot blue print 3% $ for for crisis/severe 1 1 starting extended sessions developing PMH Efficiency of allocation capacity - How the resource we have is targeted 51 Current funding 20 What's the place 7 Normal primary will reduce as of Rx? care also supports initiatives wind up MH

Level and structure of funding mechanisms - Level and sustainability of resource - How structured ______- Leveraging non health resources © 2010 Toolkit for Primary Mental Health Care Development: Report ______175

Service Models 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?

2 53

37 12

36 Huge differences 45 Requires time & in resource 14 Wide variation in dedicated team to 56 Addressing 10 Not clear how utilisation Integrating self, nature & level of provide a wrap spirituality, belief different approaches intensity of around to deal with & family support whanau & community fit or integrate also works for with wider MH service, use of complexity & support with PMH 52 Pakeha too services secondary packages entrenched issues of care 58

12 8 44 Find right blend wairoa, sprituality 55 We don't know yet & belief & Pakeha 1 What mix of models how to resource or 28 cognitive approaches support whanau should we be working 2 to MH for Maori with, how much outside of the Function and fit of variety is necessary primary setting 9 PHOs evolved diverse PHO 53 models to suit 24 How do we manage 20 What's the place models with DHB population referral pathways to 2 of Rx? MH services other services?

5 42 Enable whanau to 52 7 Normal primary 38 be part of process care also supports MH 40 Enable access and 15 We can provide 13 Most models reduce DNA of Maori 58 26 PMH role in early good service to producing good to PMH 19 intervention & flow those who manage to results irrespective through to SMH get access of type or level of constrained intervention 22 Are we moving 17 Once identified into concepts of how do we assess? stress, complexity 35 57 25 39 Increasing how much skill & $ 41 Provide resilience, wellness awareness put into assess? alernative, suitable rather than just 16 How do we understanding of & safe venues in clinical labels? identify, screen, mainstream in community for Maori 18 target within known approach to Maori to access 28 high risk popns?

27 2

Developing sustainable approaches to primary mental health services for Maori - Balance of Maori & Pakeha approaches ______- Complementary Maori specific and mainstream © 2010 Toolkit for Primary Mental Health Care Development: Report ______176

Development of the action research agenda

From the initial exploration of the issues with the research partner the proposal from the academic team was to develop a research agenda focused on the depth/breadth issue.

The issue of depth is that primary mental health is addressing severe needs in terms of complexity, requiring both time to address and connections to whānau and community for support. The nature of this complexity is not well understood in conventional diagnostic terms or well represented by standard assessment tools. Yet complexity is seen to be a major driver of service demand and variability in resource usage, particularly for high needs populations. The nature of an appropriate service response for complex circumstances needs clarification, what mix of health, community, social services, education, justice, child and youth services should we be using and how do we mobilise this?

The argument for breadth comes from inequity and unmet need. Results from the PMHI evaluation suggest that effective symptom reduction is not necessarily dependent on intervention type or number of sessions, although in most initiatives there were people for whom either the tailoring of intervention or treatment intensity was important. This makes the distinction between the more straight forward anxiety/depression and the more complex situations an important issue for clinical practice, service design and resource requirements. Could better matching of need and intensity of response enable more people to be seen?

Increasing the range of populations served, e.g. post natal, child and youth asks questions about the rationale for service investments, what data, evidence and values inform those decisions? Is there a more thoughtful way of making allocation and development decisions? Would taking a more whānau /family oriented approach be another way of addressing some of these needs?

Possible ways of putting into action this research agenda were proposed:

1. Facilitation of a clinical conversation across the PHOs. What do we mean by the complex circumstances, can we better understand the practical judgement

dimensions that are being used to discriminate complexity and use that to guide better treatment or service responses? 2. Collaboratively explore the service model options that could provide a better response to the issues of inequity/volume and complex circumstances, including implications for work force and resources. 3. Work with the process of developing services for post-natal depression and child/youth to develop a planning framework that would assist in investment targeting decisions across primary mental health. 4. To articulate the lessons from this partner described positive experience in forming trusted collaborative network relationships and infrastructure in primary mental health, to enhance existing and future service delivery.

Action Learning Process

Unlike the previous two examples there was no formally structured action learning process in this partner region, rather the action research partners committed to meeting for two subsequent sessions to support the process of reflective learning within the informal PHO primary mental health leaders group.

Research Partner 4

This partner is unique within our research partners in having a formal strategic plan for primary mental health, developed just prior to the action research process by the two district PHOs, framed as part of a district wide, whole of system integrated mental health strategic plan.

The plan sought to provide a more strategic context for the services supported through the primary mental health initiative although at the time of commencement of our research process most of the action items within the plan were yet to be initiated.

The PMHI service model in this region used an extended GP consult for people with mild to moderate mental health, (with the PHQ9 used to support clinical judgement on severity/need). This provided access through a funded referral, to a wide network of providers who supplied packages of care of up to 6 sessions of talking therapy.

Framework for engagement

As the lead in developing the districts primary mental health plan the areas main PHO provided the engagement point for the action research process. Practically this was provided by the small two person PHO primary mental health team together with the DHB Funding and Planning mental health portfolio manager.

First cycle issues exploration

An initial issues exploration working session was held with a local working group to explore the issues. Based on session notes and transcripts an initial set of concept maps was prepared as shown on the following pages:

An immediate issue of financial sustainability

The first cycle of issues exploration became focused on an immediate issue of financial sustainability. Demand was higher than had been expected and, at the time of the action research process, providers were using more sessions per patient than planned.

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.”

“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

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.

Research Partner 4 cognitive maps from March 2009 Potential issues and opportunities for primary mental health development

12 What is the right 24 What is a good service model we planning and funding 38 Initiative should be using in evaluation shows investment model? the furture? benefits almost 27 Need alignment irrespective of type between PMH and Long 1 Need to reflect or length of Tx Term Conditions 26 Retaining money and learn from our approaches is critical to experience to date 11 Intl evidence of sustain service and 10 Pressure to cut 21 Tighten criteria minimum # sessions infrastructure back # sessions/cost for inclusion & - of packages of care exclusions & to gain benefit 48 Don't have enough referral to SMH financial resources 33 Once people 45 Opportunity to under current provide a different identified as having 28 We are cutting service structure to type or layer of a mental health down attention to provide cover for service that is less 5 Must rationalise issues tend to LTC to focus on the our population intensive the money we have, become ring fenced critical government delimna about how to 22 Are GPs gaming and isolated from prioities 37 Our use of full do that scores to use PoC as wider support needed 9 Depression packages of care is alternative to SMH guidelines BPAC higher than other waiting list? decision support initiatives (Timaru) 14 Demand exceeding 46 Trial in Golden PHQ9 tools Bay to triage what funding available , 29 PMH leading the people need, nurse 40 Counselors unsustainable way for us in assess & direction 35 Use of SIA FTE tending to keep engaging people could support people on 41 Maori health outside of practices assessment,short TX 13 Packages of care providers can also - role model for or referral 6 sessions access POC not very other areas reasonably costly 17 Target mild mod, tight criteria $500 no age, identified 30 Packages provided by GP by a total of 65 20 Patient self providers beyond generated request 31 Still working out practices for extended consult how our 34 Use of SIA funded 6 SIA funding 2 FTE FTE could fill gap 18 Demand arising relationships work 19 Demand arising clinical roles to in Motueka 39 Variability in from known issues for us all from newly augment programme, level of referral by with existing identified MH issues what best use? GPs, some heavy patients - referrers 36 Need to be 3 Invested in 2 We picked one careful not to 4 Expected a hump of cinical project particular model compete with demand but still management & network extended consult + existing providers continuing to grow support referred packages of 43 Gaps in some area care + case & flow such as Motueka coordination 47 Nelson made up of ______44 Our mission is large numbers of 7 PMH Initiatives not to provide small practices provide a range of services that are 23 How engage GPs in © 2010 options & models of otherwise provided upskilling & Toolkit for Primary Mental Health Care Development: Report in community capacity service development? ______183

5 Must rationalise Core sustainability issue the money we have, delimna about how to do that

14 Demand exceeding 37 Our use of full funding available , packages of care is unsustainable 41 Maori health higher than other providers can also initiatives (Timaru) access POC not very 40 Counselors tight criteria tending to keep people on 9 Depression guidelines BPAC decision support 13 Packages of care PHQ9 tools 6 sessions 30 Packages provided reasonably costly by a total of 65 $500 4 Expected a hump of demand but still providers beyond 17 Target mild mod, 20 Patient self continuing to grow practices no age, identified generated request by GP for extended consult 39 Variability in level of referral by 2 We picked one GPs, some heavy 44 Our mission is particular model referrers 19 Demand arising 18 Demand arising not to provide extended consult + from newly from known issues services that are referred packages of identified MH issues with existing otherwise provided care + case & flow patients in community coordination

47 Nelson made up of large numbers of 7 PMH Initiatives 43 Gaps in some area small practices provide a range of such as Motueka options & models of service ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______184

Options in choice of service model 38 Initiative 12 What is the right evaluation shows service model we benefits almost should be using in irrespective of type the furture? or length of Tx

11 Intl evidence of 45 Opportunity to 21 Tighten criteria minimum # sessions provide a different 10 Pressure to cut back # sessions/cost for inclusion & to gain benefit type or layer of exclusions & service that is less of packages of care referral to SMH intensive

5 Must rationalise the money we have, delimna about how to do that 22 Are GPs gaming 35 Use of SIA FTE scores to use PoC as could support alternative to SMH assessment,short TX 14 Demand exceeding waiting list? or referral funding available , unsustainable

34 Use of SIA funded FTE could fill gap in Motueka 6 SIA funding 2 FTE clinical roles to augment programme, - what best use? 36 Need to be careful not to 43 Gaps in some area compete with such as Motueka existing providers 2 We picked one particular model extended consult + referred packages of care + case & flow 44 Our mission is coordination not to provide services that are ______otherwise provided in community © 2010 Toolkit for Primary Mental Health Care Development: Report ______185

Action Learning Process

Given the urgency of the need to rationalise funding a fast cycle action research process took place during the exploration stage. This involved the academic research team sharing the emerging evidence and understanding on the options, benefits, risks and trade-offs of very short interventions versus norms that had been established through therapeutic traditions such as CBT.

In the short term the action research supported the local team to develop their case to the PHO Clinical Governance Group for reducing the funded sessions from six to four and to engage with providers who maintained that shortening session allowances would jeopardise care outcomes.

In addition an action research agenda was framed up based on a collaborative approach to modelling the two potentially competing service models described earlier. This recognised that the two service models had developed in an emergent process and operated under quite different assumptions, intervention models, resource requirements and organisational management structures.

The goal or the action research project was to develop a clear articulation of the two service models, PMHI and BIC; rationale, evidence base, key differences in terms of clinical and service model, population served, how they would operate under different inclusion/exclusion criteria and the consequent impact on resource requirements.

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.

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)

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

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.

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

______© 2010 Toolkit for Primary Mental Health Care Development: Report ______191 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. ______© 2010 Toolkit for Primary Mental Health Care Development: Report ______192

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;

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.

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.