Primary care mental health - A new direction?

Abstract

Current health policy in Ireland, as articulated in the HSE’s Transformation Programme (2007-2010), has a focus on the health and wellbeing of the whole population and demands a shift from the hospital system to the primary care setting as the central locus of service delivery.1 The main vehicle for this change is the Primary Care Strategy (2001) which recommended the establishment across the country of primary care multidisciplinary teams (PCTs) supported by specialist services in primary care networks (PCNs).2 The Primary Care Strategy and Transformation Programme documents both emphasise that successful implementation depends on close liaison and integration between PCTs and networks and secondary care services so that the patient journey from one service to the next is “seamless and delay free”.1 Consistent with the broad thrust of the national health strategy, the Vision for Change (2006) policy framework for mental health services makes the ambitious statement that it is not enough for a comprehensive mental health policy to make recommendations relating solely to specialist mental health services – it must also deliver mental health activities capable of improving the wellbeing of the population as a whole.3 However, while Vision for Change recommends that links between specialist mental health and primary care services should be enhanced and formalised, most of its recommendations relate specifically to specialist mental health service provision. It envisaged that multidisciplinary community mental health teams (CMHTs) occupy community mental health centres in proximity to other community services, but did not go as far as to recommend the actual co-location of CMHTs and PCTs. In a significant recent development, the HSE has now committed to the provision of physical space to accommodate community mental health teams (CMHTs) and day hospital services within all primary care health centres as the Primary Care Strategy is rolled out nationally. This decision represents a potential milestone in the evolution of mental health service delivery. It presents particular challenges to the historic relationship between primary care and specialist mental health services both of which have been relatively underdeveloped in Ireland, have evolved separately and between which deficiencies in communication and collaboration have been reported by service users and providers alike.4,5 While the health strategy documents describe overall structures designed to increase primary care capacity and improve integration between primary care and secondary care services, other than the inclusion of a clinical psychologist in the envisaged networks, no detailed working arrangements are described. The Vision for Change document identifies the need to build mental healthcare capacity within primary care through enhanced primary care mental health resources, as well as through education and training initiatives, and it recommends the consultation-liaison model in order to achieve greater integration with specialist mental health services. However, at present there is no specific guidance available to either the newly formed PCTs or to existing mental health services in how to pursue these goals. In a worsening economic climate both services can be seen as entering unknown territory without a road-map and both services may have an understandable anxiety as to whether the goal of improved mental health for the population as a whole can be delivered without compromising the quality of service provided to society’s most vulnerable individuals.6