Model enablers and success: improved accessibility
When discussing the enablers and success of the adapted HFHT-model, the issues raised by patients, GPs and CMHC specialists surrounded improved accessibility. This was seen as resulting from two main model components: co-location and having experienced mental health specialists in the team, each with related sub-themes, as we describe next.
GPs and CMHC specialists being accessible to each other facilitate detailed, patient-centred case collaboration
Being present two full working days each week helped to embed the psychologists into the working life of the clinics. Some GPs pointed out how the social and professional skills of CMHC specialists enabled them to fit in and forge new working relationships. Working in the same environment facilitated close ongoing collaboration based on individual patient needs. In practice, this often took place as unplanned, opportunistic meetings as and when issues arose, such as “5 minutes in the corridor” or over lunch:
There has been very close cooperation around these patients, and I have to say that’s the most striking thing about this project … Yeah, and there has been a lot of, like, informal discussion with the GPs after appointments, like, 5 min here and there, just to clarify things, divide up tasks … We maybe haven’t had the long case discussions that we have at the CMHC. (CMHC 4).
Most of the patients experienced that the close communication helped their GP to be more involved in their mental health care:
I feel my GP has been – maybe to a greater extent – involved in that. Not like, not because she’s been present or anything, but because I know that [the psychologist] and definitely that the psychiatrist and my GP have been in regular contact. And I went to her pretty – or much more – regularly the year I saw [the psychologist] so I experience that as positive. (Patient 9).
While close collaboration was seen as positive by most patients, one said that it “felt strange” to talk to the psychologist with his GP present, possibly out of fear it would impact their existing relationship.
Most patients emphasised that it was important to them that all those involved in their care had access to their records. Sharing the electronic records system gave the psychologists instant access to historic and contextual information about the patients. They could add detailed notes about treatment activities and medication regimes, which then helped GPs to maintain them. Many of the GPs, who were used to lengthy referral processes to access specialist input, found that having “instant access” to the CMHC specialists was invaluable. In some cases, it made GPs refrain from prescribing antidepressants:
There was maybe less talk about medication, which I think is good. You know, that you can, because if, the GP is often very much on his own [in decision-making] so in a way I think it’s … it’s medication that you end up with maybe, during a busy working day. (GP2).
Several of the clinicians expressed the view that the complementary skills in the team made them better able to deal with co-morbidities. For instance, if a patient suffered from both panic attacks and heart disease, they could jointly arrive at an appropriate level of exercise that could alleviate psychiatric symptoms while not endangering cardiovascular health. There were also cases where it was agreed that depression treatment should be paused for a period while a patient was assessed for somatic illness.
Lowering the threshold makes mental health services more accessible to patients
The patients particularly valued that they could access mental health services without having to “fight” for them. As GPs could book consultations directly into the psychologists’ diary during patient consultations, treatment by a specialist could commence within days. Patients, GPs and CMHC specialists all agreed that patients benefitted from getting help for their mental health problems close to where they lived and at a place they were familiar with. Some patients expressed relief that they could get help without attending the CMHC where they risked being recognised as someone with a mental health problem. This fear of stigma was echoed in some GPs and CMHC specialists' impressions of patients’ concerns. Other patients stated, however, that location was secondary to the personality of the clinician and the only patient who had previously been treated at the CMHC said he had not experienced this as stigmatising.
The very different ramifications surrounding the usual practice of both GPs and CMHC specialists was acknowledged, including the nature of the time pressures they were under. Moving some of the flexibility from the specialist service into the GP practice was recognised as another way in which the model lowered the threshold and facilitated early access and intervention:
There’s really a difference between the boundaries that a psychologist and a GP work within […] You can’t expect a GP to achieve in 15 min what a psychologist achieves in 45 min. That’s not possible. If they worked under different conditions, then maybe the GPs could address much of this [mental disorders] themselves. But they can’t. They can spend 30 min once, but they can’t do that, like, regularly, 12 times, twice a week. (CMHC 2).
Having experienced mental health specialists in the team
Mental health specialists on the front line can shorten and improve pathways through care
The lowered threshold meant that mental health specialists could intervene while symptoms were relatively manageable. This, several GPs commented, helped patients just below the eligibility threshold to specialist care, for whom they often experienced they did not provide the best service. Participants from all stakeholder groups emphasised that getting in early could prevent conditions from deteriorating:
In that situation I think it worked like, sort of firefighting really, that I was in contact with that psychologist instead of, because then I could vent things. But that could perhaps have built up if I hadn’t had that contact in that situation, and then maybe, you know, it could have, hypothetically, been harder to handle. (Patient 7).
Getting in early was also thought to have positive knock-on effects on patients’ wider situations, such as shortening the duration of sick leave:
They get an appointment the following week and have weekly sessions with the psychologist. After 4–5-6 sessions they’re better and ready to get back to work. And then [they can] use the tools and the knowledge they’ve accumulated with the psychologist, to continue. (GP7).
A significant part of the psychologists’ work involved “sorting”, as they described it, patients in terms of the type of treatment and service they required and were entitled to. Their specialist experience enabled them to, for example, conduct screening assessments to see if a full specialist assessment was required, or to identify what type of service would be most beneficial to them:
Certain things are easy for me to do that the GP can’t get done. I can offer a brief assessment with a structured interview, just to clarify, should this go further to a referral for trauma treatment, or can we deal with that here, or refer to the borough’s [name of service]. And do a brief assessment of Asperger’s, which really is very complex, but when you can do it kind of ‘light’, plus [potentially] a referral to a neuropsychologist for confirmation, then you could get these cases dealt with at the GP practice. So I feel that, you know, I can use my specialist expertise and remove some really, like, barriers and potentially long and painful cases, at the GP practice. (CMHC 4).
CMHC specialists thus advised the GPs, on a case-by-case basis, on whether a patient should be treated at the practice or be referred to the CMHC or to other local services. This was described as increasing the likelihood of the patient’s pathway pointing in the right direction from the outset, avoiding detours or spending time waiting for services for which they would not be eligible. Also, at the GP practice, the psychologists were able to start treatment activities at the patients’ first or second appointment, sometimes without any clear diagnostic picture. At the CMHC, in contrast, patients were, after a few months on a waiting list, subjected to a raft of diagnostic and risk assessments before treatment could commence. Several of the CMHC specialists described this more rapid way of working as “liberating” and that it kept treatment episodes short: most patients were seen 5–10 times. Moreover, given that most of the cases were considered less severe than those they were used to at the CMHC, it was manageable for the CMHC specialists to see substantially more patients per day at the GP practice.
These factors resulted in increased throughput that was pointed out as beneficial by several of the GPs and CMHC specialists. The patient group expressed more mixed views. While they were all grateful for getting into treatment quickly, some experienced the pace of these short treatment episodes as a bit “hectic”, that the clinicians kept “an eye on the clock” or that the treatment seemed a bit simplistic:
But that gets a bit, like, a “quick fix” for me, really. And then sometimes – and I did let them know – it’s too simple just to come up with “just think differently”. You know, the world isn’t always quite like that. (Patient 7).
Almost all would have liked to have seen the specialist for longer:
I wish I had more sessions with [the psychologist]. I don’t think it’s enough with six sessions. Because it took two sessions just to get to know each other. (Patient 2).
Some patients suggested that follow-up appointments after a few months should routinely be offered to monitor progress.
The involvement of specialists can improve referral practices
Many patients were of the opinion that psychological help normally was exceedingly difficult to obtain and that GPs should learn to write more detailed referrals that could help them access it. The clinical participants also recognised referrals from primary to secondary services as potentially problematic and often frustrating, both at the sending and receiving end. Most believed that the collaborative care model would have impact on referrals in different ways. While treating more patients in primary care could reduce the number of referrals, an improved identification of need could lead to more referrals. However, most participants were concerned with how collaborative care could improve processes to ensure timely and comprehensive referrals to the appropriate service for which the patient is eligible. Several contributing factors were described. First, the CMHC specialists often wrote detailed notes that the GPs could consult when writing referrals
I [usually] wrote a pretty comprehensive note that the GPs could use as part of the referral. So I didn’t write the referral to the CHMC, but they enclosed my notes with [my] assessments and background and, like, why we think, or thought, they ought to be referred to specialist services. (CMHC 5).
Second, these notes could demonstrate that the GP’s view was shared by a specialist, and a few GPs described that this added weight to their referral. Third, the specialists often advised GPs not to refer patients if the underlying problem was one that specialist services could not solve (such as housing or family relationships). In such cases, a referral could create unrealistic expectations and lead to disappointment and depression. Support for the decision that a referral was futile was sometimes all that was required:
I noticed pretty soon that they [GPs] just needed a kind of confirmation that in this case we’ve done everything. You know, all we can do, and we don’t expect things to improve. But, you know, they referred simply out of desperation. (CMHC 6).
Some of the GPs said these ways of working together made them better able to write more focused referrals that included more of the information needed at the receiving end, and that they now were also better able to await situations or explore issues further:
Now we’re better at, or I am better at, having conversations with [patients] and making my own evaluations before passing them on. That’s after we’ve learnt, you know, understood more of how things are done with regards to referrals, what can be expected from the CMHC. So you think that, OK, here is a patient who doesn’t necessarily need a specialist assessment or something from the CMHC to get any help. This I can handle, so I do it myself rather than referring like [I did] before. (GP7).
Learning through access to complementary skills
Many of the GPs expressed the view that working alongside specialists had increased their ability to detect mental health problems. Several of them said that they had become more targeted in terms of assessing severity and treatment options and that they felt more confident in their own judgement, including the use of screening tools and selection of therapeutic approach but also medication use, dosage and associated blood tests.
For their part, the CMHC specialists had gained a better understanding of how co-morbidities impact mental health. Also, they now had more realistic ideas of the pressures on GPs and their capacity to follow up patients after discharge from specialist services:
Especially those Monday mornings that are simply chaotic and patients are pouring in, like, completely crazy […] I have maybe got a more realistic view of what a GP can help patients with once they've finished at the CMHC. For example, you don’t need to write in the discharge note that “the patient should receive regular supportive therapy from the GP”, because in reality maybe it will be more of a health check than a proper therapeutic session. (CMHC 2).
The new relationships that were forged were described as an important outcome of working as a collaborative care team. They made it easier to pick up the phone to talk to someone to discuss specific cases or seek advice more generally
Things go a bit more smoothly when you know each other: you can be bothered to pick up the phone, you know. You prioritise making that phone call a bit sooner when you know who the person is. And [you know] what to expect. (CMHC 6).
Barriers to the collaborative care model: the organisation of care
When discussing issues that had either prevented the model from reaching its potential or that could impede its sustainability, most of the issues revolved around the organisation of care. Sub-themes included that logistical issues must be thought through; different modes of working can impede practices and learning, and; that the funding of health care works contrary to collaboration.
Logistical issues must be thought through
There was a range of practical issues that made project-based collaboration problematic. For GPs, hosting additional members of staff presented logistical issues to make sure there was office space available on the days the CMHC specialists were present. Patients commented that the rooms used were not always ideal as they could be cramped or not provide sufficient privacy. There were also cost implications in terms of rent, IT and other technical equipment, and increased workloads for support staff. For the CMHC, lending out senior clinicians put pressure on other members of staff and on budgets. The clinical participants were clear that for the collaborative care model to be sustainable, permanent solutions to logistical issues must be identified.
Different modes of working can impede practices and learning
Almost all the clinical participants recognised that, at the outset, they had insufficient knowledge of the practicalities of each other’s everyday working life, and this had led to unrealistic expectations. For example, some GPs initially expected the psychologist to see 12 patients each day. This was soon adjusted to a more realistic level, and the load was settled on 5–6 consultations daily.
During the intervention period, there were situations where the different ways of working could compromise professional practices. One example was how GPs in effect could become gatekeepers for the follow-up of psychotherapeutic treatment:
And [a GP may say] “Well, the patient just said he didn’t need that appointment”. And that makes us therapists think, well is that avoidance or, like, what is happening to that patient now? And then it’s like, “Oh, that’s a shame because I really wanted a final session.” So, professionally we think very differently. (CMHC 2).
There were also other difficulties related to the psychologists not being entirely in charge of their own diary. For instance, if they believed a patient would benefit from 5 to 6 consultations in rapid succession over a couple of weeks, their diaries might already be filled up, and individual patients’ pathways could be prolonged.
As shown above, much of the practical case collaborations happened “in the corridor” due to the time pressures GPs work under. However efficient in daily practice, this ad hoc dimension to the collaboration could limit potential learning on both sides:
Maybe sometimes, rather than the patient being “mine,” Maybe, together with the GPs, I could have shown a bit of how we talk and work with, for example something as simple as exposure [therapy] for a panic disorder, or, you know how a patient can become less scared of their symptoms, and then maybe the GP could have a go on their own the next time. (CMHC 2).
The funding of health care works contrary to collaboration
The ways in which health services are funded was emphasised as the most fundamental barrier to collaborative care. Many GPs mentioned how the regulations surrounding fee-for-service reimbursements and patient co-payments, both central to their income, created problems: GPs could not charge for treatment he or she did not take part in, and CMHC professionals could not bill on behalf of the GP practice. In some cases, the normal GP fee or fees for collaborative work applied, but in a substantial number of cases no fee was reimbursed and patients were not charged. Similarly, the CMHC specialists could not be reimbursed for treatment not provided within their own service, and the CMHC therefore used significant resources with no immediate return. It was described as ironic that services in effect would be disadvantaged by improving services to their patients. Some of the GPs found it problematic that the GP system – designed to “run like a business” – in effect prevented collaborative work, leading some to express doubt in the wisdom of organising services this way:
I’m thinking that lots could be done with the GP system [laughs] because I think sitting here and everyone running their own business isn’t really very expedient. And I’d rather be on a regular salary than the way it is now. And maybe have more time, with fewer patients on my list, and more time to work together with other services. (GP1).