Psychiatry and Primary CareDeveloping a U.K. protocol for collaborative care: a qualitative study
Introduction
Despite the availability of effective pharmacological and psychological treatments for depression, patients often receive a less-than-optimal treatment program. In international primary health care systems, patient concordance with pharmacological treatment is poor [1] and problems are exacerbated further by organizational barriers between generalist and specialist mental health professionals [2], [3]. Generalist primary care physicians often have very limited support when helping patients with both pharmacological treatment and psychosocial interventions. Such support may be critical given that in systems such as that in the United Kingdom and elsewhere, the general practitioner (GP) is the sole responsible medical clinician for 90–95% of patients [4].
Attempts to improve this situation have seen the development of organizational strategies including increased resources to specialist services, education of primary care clinicians, consultation liaison services and stepped care [5]. A systematic review of 36 organizational intervention studies concluded that simple care models such as guidelines and education were ineffective in managing depression [6]. Effective interventions involve complex combinations of screening, clinician and patient education, consultation liaison between primary and secondary care clinicians and case management [7]. One such complex model is known as collaborative care and involves (a) the introduction of a new case manager role into primary care, (b) liaison and educational mechanisms between primary care clinicians and mental health specialists and (c) mechanisms to collect and share information on individual patients [5].
While collaborative care improves outcomes over usual care [8], [9], [10], the vast majority of models have been developed and evaluated in the United States [11]. Given this, it is necessary to establish the international generalizability of collaborative care to determine if these outcomes can be replicated beyond the US, where the nature of patient populations and patterns of service utilization may differ. The feasibility and acceptability of implementation in the U.K. National Health Service (NHS) is likely to be shaped by funding arrangements, deployment of staff and the structure and organization of component parts of the NHS (particularly primary care). This may make it difficult to implement collaborative care and may even render it ineffective.
In order to investigate collaborative care in the UK, we adopted the modeling phase [12] of the strategies recommended by the U.K. Medical Research Council (MRC) for investigating complex interventions [13] (Fig. 1), which is defined as:
“… unravelling and distinguishing the key components in a complex intervention. A variety of methods may be used at this stage from purely paper and pencil informal modelling through more formal simulation and computer modelling through to primary data gathering via structured survey or qualitative interviews, focus groups or field work” [13] (p. 7).
Firstly, therefore, we identified prototype collaborative care components using a systematic review and meta-regression [11] to establish the critical determinants of collaborative care outcomes (paper submitted elsewhere). Secondly, discussions with teams of U.S. collaborative care model originators elicited the factors they considered most important for clinical practice. Thirdly, we used the qualitative methods reported here in order to provide a contextualized picture of the views of patients, primary care clinicians and mental health specialists on the acceptability, feasibility and barriers to collaborative care in the UK. We were particularly interested in stakeholders' views on two issues that emerged from our theoretical development stage: the nature of the patient/case manager consultation and the experience and expertise required of case managers, since the UK has recently introduced a new group of masters-prepared workers into primary care mental health — “graduate primary care mental health workers” — who might fit into this role.
This study aimed to explore the views of stakeholders including patients, GPs and mental health workers on the feasibility, acceptability and barriers to a collaborative care model for treatment of depression within the context of U.K. primary health care.
Section snippets
Sample
A purposive sample of stakeholders was recruited from primary care organizations in the north of the UK. Purposive sampling involves sampling informants according to a preconceived set of dissimilar respondent characteristics [14]. In the current study, informants with different experiences and perspectives on the treatment of depression in primary care were recruited, who might therefore be expected to have potentially different views of collaborative care [15]. GPs and practice nurses were
Results
We interviewed 49 respondents. All 38 professional respondents who were asked to participate in the study agreed to do so: 12 GPs, 4 psychiatrists, 4 psychologists, 4 practice nurses and 14 mental health workers (7 mental health nurses, 2 counselors, 3 graduate workers, 1 social worker and 1 unqualified support worker). Of the 17 consenting patients from 80 letters, 11 were interviewed, 5 subsequently declined or could not be contacted and 1 became so highly distressed that the interview was
Discussion
This study has shown how patient and professional perspectives coalesce around the basic premise of collaborative care case management — that, in general terms, regular support to patients with depression is acceptable and valued by both patients and professionals. Respondents thought that pharmacological and psychological interventions could be enhanced through contact between mental health workers and patients. However, our analysis revealed several areas where differences of opinion were
Study strengths and limitations
In qualitative research, auditable analytical processes are important and findings need to be articulated so that the logical process by which they were developed can be followed. It is vital to make the relationship between the actual data (i.e., transcribed texts) and the conclusions explicit, credible and believable [22]. In this study, we have addressed this issue through presenting plentiful quotations in both the text and in Table 1, where the logical process of analysis can be followed
Conclusions
The data from this study have enabled us to balance the original theoretical development of our collaborative care protocol, drawn from existing empirical literature and advice from model originators, with the views of patient and professional stakeholders in the UK. The study has highlighted the difficulties likely to be experienced in the implementation of collaborative care in the UK, the most obvious areas of contention being produced as a consequence of the different starting values of
Acknowledgments
This work was funded by the U.K. MRC Grant Number ISRCTN63222059. We would like to thank the professional and patient participants for their willingness to share their views with us and Greg Simon for advice on the content of case management.
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