General practices are the main way many people first seek support for mental health and addiction challenges.140 They are a critical entry point to services, either in general practice itself or for referral elsewhere (for example, to counselling, psychological or community support services or to specialist services delivered through hospitals and community mental health teams). They should provide early intervention that is built on ongoing relationships and review of an individual’s mental and physical health. The linkages between physical and mental health, and the disparities in health outcomes for people with mental health and addiction issues, make the role of primary health care critically important.
In our view, general practices should provide first-level services and may also take a coordinating role where people are accessing other care. Furthermore, general practitioners (GPs) should continue to provide ongoing support, including medication management, to those who are discharged from specialist services.
Currently, responses from general practice to mental health and addiction problems are variable. Some people report valuable relationships with their GP, supportive responses and efforts to access specialist services on their behalf. Others do not have their concerns addressed and are ‘fobbed off’ with medication. Costs associated with general practice create barriers to access and result in some people with mental health and addiction challenges remaining attached to specialist mental health and addiction services, which are free, rather than being discharged to primary care services. This creates additional pressures on specialist services and bottle necks.
What GPs can do in 15-minute consultations is limited. Some GPs have gaps in their knowledge and training about mental health and addiction and have poor linkages with other social services (both NGO and government services such as housing and income support services). These factors contribute to an over-reliance on prescribing medication, rather than utilising a broader range of approaches, such as talk therapies, and broader social and cultural supports. GPs experience difficulty accessing specialist services for their patients, excessive time spent on referral processes, and long delays in receiving discharge documents from specialist services.
While, for most people, general practice is likely to be the first place they turn to when seeking professional help with mental health and addiction, it is not the only entry point for support. Many people will look elsewhere, because of cost or because general practices in their current form do not meet their needs and preferences. The role of other health care and social service providers, including NGOs, Whānau Ora providers, specialist youth services, and health services provided in school and tertiary education institutions, is critical to meet diverse needs. Again, this emphasises the need for services that are well connected so people can get the support they need through more than one ‘doorway’.
Nonetheless, responding appropriately to people’s mental health and addiction needs should be part of a core role of any general practice. GPs should be able to offer appropriate advice, interventions and support, and should know where and how to direct patients to other ongoing support.
As noted previously, some primary mental health initiatives are funded through specific and fairly minimal funding streams (for example, Youth Mental Health, Fit for the Future, and targeted funding for Māori, Pacific peoples and people on low incomes, such as extended GP visits and counselling sessions). Closing the Loop is a model the four largest primary health organisations developed to provide stepped care in primary and community settings.141 The model is being piloted in five Auckland practices, and preliminary independent evaluation shows early promise.142
Overall, however, little progress has been made in addressing mental health and addiction issues in primary health care in a meaningful way.
The lack of progress in addressing mental health and addiction issues in primary care needs to be seen in the broader context of overall primary care transformation.
The 2001 Primary Health Care Strategy (PHCS)143 set out a vision for a transformed primary health care sector that emphasised keeping people well, accessible services and coordinated ongoing care. It also had a strong focus on population health and reducing health inequalities between groups. The strategy was guided by the 2000 New Zealand Health Strategy,144 which included population health objectives directly relevant to mental health and addiction.145 Coordination between primary care and mental health services was mentioned explicitly in the PHCS as an area of focus for primary health organisations.
The overall vision for primary care in 2001 was transformative, but the goals of the strategy have not been delivered anywhere near the extent originally envisaged even 17 years on from the introduction of the strategy.146 There are likely to be initiatives we could all learn from, but a lack of research in primary care makes it difficult to know how services are developing and which ones could be encouraged to spread.147
Recent promising initiatives include Health Care Home, although this appears modest in its reach and ambition and adoption by general practices of the Health Care Home model seems to be voluntary. Overall, change has been slow and inconsistent.
A 2018 report found several factors supported and inhibited innovation in primary care such as Health Care Home. The funding model for primary care, in particular the ongoing reliance on co-payments by many practices, was identified as a barrier to innovation.148 As well as creating barriers to developing new models of care, co-payments and other charges create affordability barriers for many people149 – something we heard about during our consultation. This requires urgent attention so people can access primary care when they need it.
Building a mental health and addiction system with more supports in primary and community settings for people with needs across the full spectrum, requires a very different model than is still widely found. Innovation has been slow to take off with strong disincentives to change, especially in the current funding model.
The impetus to transform the primary care sector, including addressing affordability and cultural responsiveness, is not unique to mental health and addiction. Primary care is, appropriately, a focus of the recently announced Health and Disability Sector Review. In addition, an urgent priority must be a significant increase in the capacity and capability of the primary care sector to respond to mental health and addiction needs.
We assume that the primary care funding model will be a focus for the Health and Disability Sector Review, alongside broader consideration of commissioning of health and disability services, including the roles of district health boards (DHBs), primary health organisations and others. Our current arrangements seem to provide little mandate to DHBs in relation to primary care.150 This is likely to have had impacts for integration across primary, community and secondary services. Whatever the future structure of the health system, attention must be paid to the commissioning arrangements for primary care.
We emphasise, however, that New Zealand cannot wait for the wider transformation of primary care: a continuum of mental health and addiction services, including extended access to services to people in the middle ground, is urgent. The challenge is to start designing, funding and implementing these services without waiting for primary care transformation to be complete, but not to resort to ad hoc or short-term mental health and addiction initiatives and funding streams in the meantime. We recommended an approach to investment in chapter 4.
Attention should also be given to building the capability of the generalist primary care workforce, with additional mental health and addiction training for GPs, practice nurses, community health workers and others.
Transform primary health care
140 K Allan. 2018. Broadening access and ongoing support for people with mental health and addiction need: Rethinking the role of primary and community care. New Zealand Doctor (28 March).
141 The four primary health organisations are Procare, Compass, Midlands and Pegasus: Network Four. 2016. Closing the Loop: A person-centred approach to primary mental health and addictions support. www.closingtheloop.net.nz/#closing-the-loop. (external link)
142 S Appleton-Dyer and S Andrews. 2018. Fit for the Future: An evaluation overview for the enhanced integrated practice teams and Our Health in Mind Strategy (Business Case One) (report for the Ministry of Health). Sydney: Synergia. http://synergia.co.nz/news/fit-for-the-future-evaluation/(external link).
143 Minister of Health. 2001. The Primary Health Care Strategy. Wellington: Ministry of Health. www.health.govt.nz/system/files/documents/publications/phcstrat.pdf(external link).
144 Minister of Health. 2000. The New Zealand Health Strategy. Wellington: Ministry of Health. www.health.govt.nz/publication/new-zealand-health-strategy-2000.(external link)
145 For example, objectives included suicide reduction, minimising harm caused by alcohol and other drugs, and improving the health status of people with severe mental illness, as well as addressing social determinants (such as family violence) and general wellbeing (such as child and family health, nutrition and physical activity).
146 A Raymont and J Cumming. 2013. Evaluation of the Primary Health Care Strategy: Final report. Wellington: Health Services Research Centre. www.victoria.ac.nz/health/centres/health-services-research-centre/our-publications/reports/final-full-report.pdf(external link); J Smith. 2009. Critical Analysis of the Implementation of the Primary Health Care Strategy Implementation and Framing of Issues for the Next Phase (prepared for the Ministry of Health). www.health.govt.nz/publication/critical-analysis-implementation-primary-health-care-strategy-implementation-and-framing-issues-next(external link)
147 A Downs. 2017. From Theory to Practice: The promise of primary care in New Zealand. Wellington: Fulbright New Zealand. www.fulbright.org.nz/news/from-theory-to-practice-the-promise-of-primary-care-in-new-zealand/(external link).
148 L Middleton, P Dunn, C O’Loughlin and J Cumming. 2018. Taking Stock: Primary care innovation (report for the New Zealand Productivity Commission). Victoria University of Wellington. www.victoria.ac.nz/health/about/news/1664649-taking-stock-report-looks-at-the-state-of-innovation-in-the-primary-care-sector.(external link)
149 The New Zealand Health Survey reports that 14% of New Zealanders each year are unable to see their GP because of cost: https://minhealthnz.shinyapps.io/nz-health-survey-2016-17-annual-data-explorer/_w_da2f5c23/#!/explore-topics.(external link)
150 J Cumming. 2018. Brief of Evidence of Jacqueline Margaret Cumming in the Matter of the Treaty of Waitangi Act 1975 and the Health Services and Outcomes Kaupapa Inquiry, Waitangi Tribunal (Wai 2575, #A60), 7 September 2018. https://forms.justice.govt.nz/search/Documents/WT/wt_DOC_142252651/Wai%202575%2C%20A060.pdf(external link)