The Work of Primary Care Physicians in the Field of Mental Health after the Reform
Yael Ashenazi, Yoav Loeff, Rina Maoz-Breuer, Hava Tabenkin1
Israel’s mental health Insurance Reform went into effect in July 2015 when the responsibility for the provision of mental health services was transferred from the Ministry of Health to the health plans. As part of the reform, the health plans developed or expanded their services for people with mental health problems.
Primary care physicians are generally the first professionals in the health system to see patients, identify problems, offer treatment or refer to specialists. Many people experiencing distress or mental problems do not turn directly to mental health services, and instead see a primary care physician. This encounter is sometimes the only opportunity to identify a problem and embark on treatment. Even prior to the reform, primary care physicians played an important role in identifying and treating mental health problems. To date, this component of their role, and how they cope with it, have not been subjected to in-depth study in Israel.
The goal of the study was to examine and describe the mental health-related work of primary care physicians, with particular attention to the following aspects: how they perceive their role and conduct themselves in this context; the nature of their interface with mental health care providers; the impact of the reform on their work; existing and desirable models of the provision of mental health care in primary care; and the difficulties the physicians encounter.
The study was qualitative, relying on semi-structured, in-depth interviews. It centered on 27 interviews with family physicians, and 12 with pediatricians. In addition, there were 10 preliminary interviews with managers of mental health services and primary care services at the health plans, and five interviews with psychiatrists. All the interviews were held from June 2016 to May 2017.
Physician’s role: All the interviewees regarded mental health as an integral part of their work. They distinguished between patients with mild to moderate psychiatric conditions prevalent in the community (such as anxiety and depression) and patients with severe mental illness (such as schizophrenia). Regarding the former – all the interviewees stated that they tended to diagnose and treat on their own; they begin with medication and sometimes also therapeutic conversations, and only if there is no improvement do they refer patients to mental health professionals. In the context of diagnosis, the physicians have to address the patient’s tendency towards somatization, i.e., physical manifestation of psychological concerns. In such cases, the physician’s role is to clarify whether the underlying cause is a mental health difficulty, and if so, to help patient recognize this. Helpful factors in such cases are the physicians’ ongoing acquaintance with a patient and sometimes also with the family; and the absence of stigma attached to the treatment since it is provided by family physicians rather than mental health professionals.
Regarding severe mental illness, all the physicians said that they transfer the main responsibility for diagnosis and treatment of mental health patients to psychiatrists. Nonetheless, most noted that they considered themselves responsible for providing the medication prescribed by psychiatrists and for ongoing monitoring: ensuring that the medication is taken, monitoring for possible side effects and, of course, monitoring a patient’s physical condition.. The interviews revealed that some physicians find it hard to talk to or treat patients with severe mental illness. Some cited difficulty and discomfort with these patients as expressed in their reluctance to have contact with them, mainly due to difficulties of communication.
Contact with mental health services: The physicians refer some patients to various mental health professionals, mainly psychiatrists and psychologists, in various treatment frameworks. Several problems were mentioned in this context::
- The nature of the relationship with professionals: Physicians complained about a lack of personal acquaintance with these professionals, which made contact and dialogue with them difficult. The lack of contact was especially conspicuous in the case of psychologists.
- Availability of appointments: The estimated waiting times for an appointment with psychiatrists varied greatly, from a week or two to some months. The availability of an appointment with psychologists in non-payment frameworks at the health plans was low. Therefore physicians often refer patients to self-employed therapists working with the health plans (with whom visits entail co-payments). Some, physicians said they were uneasy about referring patients to a service for which the health plan charges a fee.
- Information exchange: The evaluation of the adequacy of information received from the system of mental health care varied greatly.
- With respect to psychiatrists – some physicians described a favorable change since the reform took effect. Others said that the information transmitted by the computerized system was inadequate, and others still said that they received information only if a patient brought a letter from the psychiatrist.
- For patients either visiting emergency services or hospitalized, the transmission of information was not always orderly.
- There is no orderly transmission of information from psychologists.
Contact with social workers: Many physicians noted their occasional contact at primary care clinics with the health plan’s social workers. They consult with them and can benefit from their involvement in treatment; according to the interviews, the physicians were highly satisfied with this model of a familiar, available resource to turn to.
The possibility of consulting with psychiatrists: Following the reform, the health plans established professional mental health consultation mechanisms to assist primary care physicians. These mechanisms include virtual and telephone consultations with psychiatrists. Some interviewees noted that this practice of consulting with an unfamiliar psychiatrist did not suit them or meet their needs. They needed a personal acquaintanceship and felt very uncomfortable with the idea of consulting someone they did not know.
The impact of the reform:The interviews revealed a complex, uneven picture of the reform’s impact on the work of family physicians: some cited mainly favorable changes; some cited unfavorable changes; and others said that they had experienced no significant change in their work since the reform. Among other things, these responses appear to depend on local changes in the supply of services. The main favorable changes cited were the opening-up of new clinics, and improved transmission of information from the mental health system (as said, however, some physicians said they had experienced no improvement). One unfavorable change cited was that it was no longer possible to turn to services previously accessible, such as the mental health clinics of the Ministry of Health in certain localities.
Models of joint work between primary care physicians and mental health professionals:All the suggested models shared a need for closer, more direct contact between primary care physicians and mental health professionals as a basis for ongoing contact: the permanent integration of mental health professionals into primary care clinics or periodic visits by psychiatrists to primary care clinics.
Physicians’ role: All the pediatricians spoke of their role of identifying and diagnosing problems. In many cases, it was the parents who broached a problem to physicians. Pediatricians mainly treated behavioral and other problems that can be dealt with by guiding parents. In more complex cases, they referred children to mental health professionals. They do not prescribe psychiatric medications themselves as they feel that they do not have sufficient knowledge to do so. Some pediatricians expressed regret that in complex cases, their main role was to renew prescriptions and monitor patients.
Contact with associated systems: While parents are the main providers of care to children, children’s lives proceed in additional circles as well: the extended family, the school system, the community and occasionally other systems, such as social services. In these systems, various parties suggest responses to a child’s needs and it is important to stay in contact and coordinate with them. According to the interviews, there is hardly any contact of this type.
Contact with mental health services: Pediatricians refer children to a variety of professionals, including psychiatrists, psychologists and neurologists, as well as child-development clinics. In this context, the following problematic aspects emerged:
- Nature of contact: Most of the interviewees said that they had no direct contact with the mental health care professionals and, if there was contact, it was usually in one direction only (i.e., physicians contacted therapists, not vice versa). This situation was perceived as problematic and an obstacle to treatment.
- Availability of appointments: The different assessments ranged from 1-2 weeks to several months. Furthermore, accessibility was cited as a problem since certain localities lacked services within a reasonable distance.
- Information exchange: Pediatricians were not clear about the exact type of information that they were to receive from mental health professionals. Their sense was that most of the information in the computerized system was blocked to them and, if information was passed on, it was mostly by parents.
Possibility of Consulting Psychiatrists: Most of the interviewees do not use the consultation services placed at their disposal by the health plans, either because they are unfamiliar with them or because, on sensitive topics, they prefer to consult with professionals whom they know.
The impact of the reform: Most of the pediatricians said that they had not felt any significant change in their work following the reform.
The interviews revealed that family physicians perceive the treatment of the more common and less complex mental health problems as an integral part of their work. With respect to patients with severe mental illness, family physicians do not regard themselves as the main care providers although they b do still play a role in the provision of care. Pediatricians regard the identification and diagnosis of problems as part of their work, and they intervene and treat in cases that could be improved by guiding parents. They refer more complex cases to mental health professionals.
One objective of the reform was to break down the barriers between physical and mental health. Conceptually, many physicians consider the two to be related, believing that many physical complaints have a psychological basis and these aspects should be taken into account in treatment. However, on the system level, the service structure still maintains abundant separation between the two, as reflected in the paucity of information passed on, the little use of consultation, the lack of mutual acquaintance and, in general, little cooperation between the fields. mental health professionals do not appear to take advantage of the primary care physician’s acquaintance with, or knowledge on, a patient, their surroundings and family; nor do they generally tend to involve primary care physicians in treatment beyond technical instructions about giving medication, which some interviewees found frustrating. To overcome the separation, there is a need to define both the desired model of cooperation and the latter’s potential benefit to treatment.
The flow of information between primary care and the mental health system is neither orderly nor even; in certain cases, it impedes continuity of care. Moreover, primary physicians do not always know what information is available to them. Where deficiencies exist, it is incumbent on the health plans to handle them.
Apart from the channels of consultation with psychiatrists developed by the health plans, non-virtual channels should also be developed to suit the needs of physicians, and ways should be found to reinforce the acquaintanceship, contact and joint work of primary care physicians and mental health professionals.
The common denominator of ideal work models suggested by the physicians is direct, available contact with mental health professionals. One model used in many clinics and satisfactory to most physicians speaks of the presence of a social worker at their own or a nearby clinic. While the social worker may not necessarily be a mental health professional, she is connected to the field and can contribute considerably. It is recommended considering expanding this model.
The specialization in pediatrics does not include the topic of mental health and it is recommended that it be added to the training.
For children, it is very important to connect the various systems enveloping their lives. The interviews revealed disconnectedness, except in cases of personal initiative. The ministries of education, welfare and health, along with the health plans, should find a way to formalize communication channels between all the relevant parties.
The study was funded by a research grant from the Israel National Institute for Health Policy and Health Services Research
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