Harnessing primary care to enhance recovery from severe mental illness

PATIENT PREFERENCES

Research does indeed suggest that people with SMI frequently report a preference for primary care as a favoured form of service delivery.⁷ Reasons given for such a preference include the capacity of primary care to deal simultaneously with mental and physical health issues. This is particularly important given that people with SMI suffer multiple physical health problems and a decreased life expectancy.¹,⁴ Other positive factors associated with primary care include the continuity of care and person-centred approaches inherent in primary care settings. Patients favourably report the familiarity present in treatment discussions, as well as the lack of necessity to retell painful stories.⁷ This is especially important given the high rates of staff turnover in secondary and tertiary psychiatric care.⁸ Finally, primary care has less documented association with stigma. In contrast, secondary and tertiary institutions are a source of fear and avoidance for patients and community members alike, contributing to high drop-out rates.⁹

While it is clear that general practice is a desirable arena for the delivery of recovery-oriented mental health care, there is a lack of empirical knowledge regarding the penetration of the recovery paradigm into general practice. This is an egregious knowledge gap given the potential for primary care to enhance recovery. That said, some knowledge can be extrapolated from other literature, particularly on patient-centred and holistic care, both of which are fundamental to the modern delivery of general practice.

PERSON-CENTRED CARE

In fact, there is considerable overlap between the philosophical and ethical underpinnings of progressive primary care and the recovery paradigm. Much of what is currently perceived as desirable standard procedure in general practice overlaps significantly with recommended recovery practice.

According to a seminal study on the topic, recommended primary care practice is premised on person-centred care which has three main elements:

1. effective communication between patient and physician, including understanding the patient’s story and context of illness and healing;

2. partnerships and shared decision making regarding treatments; and

3. a peripheral vision that looks beyond specific conditions towards health promotion and healthy lifestyles.¹⁰

These elements align with much of the literature describing the underlying principles of recovery. They overlap considerably with the principles of recovery-oriented care put forward in the Australian National Mental Health Plan, namely:

• recognition of the uniqueness of individuals;

• offering real choices;

• fostering appropriate attitudes and rights;

• treatment of people with dignity and respect;

• partnership to ensure effective communication for engagement; and

• evaluation of services and outcomes.¹¹

Such natural affinity between patient-centred primary care and the recovery paradigm could be better harnessed to advance the care of people with SMI. This can be advanced through further changes in domains such as training, funding, and competencies. Specifically, we outline below three proposals essential to building a lasting recovery orientation in primary care. These proposals are based on knowledge derived from studies in the psychiatric and general practice literature, and their degree of consistency with the recovery paradigm.

REDISTRIBUTION OF RESOURCES

Firstly, we call for a redistribution of funding and the restructuring of wider health systems. It has been noted that approximately 50% of mental healthcare funding goes towards tertiary hospital care.¹² Such a financial emphasis is inconsistent with the recovery paradigm, which emphasises community integration and the beneficial nature of normative life activities, for example, employment. If the recovery paradigm is to become a reality, we argue that some resources currently devoted to tertiary care should be reallocated to primary and secondary care. This implies expansion and wider investment in holistically-oriented community health care with a wide range of intervention options available, including psychosocial rehabilitation programmes such as supported employment.

EDUCATION AND TRAINING

Second, such a course of action would require further education and training of existing primary care staff, and a new generation of family physicians and nurse practitioners well-versed in the recovery paradigm. This could be done through incorporating the recovery paradigm into the medical curriculum, continuing medical education and targeted workshops to translate and implement the current conceptualisations of recovery. Primary care staff must be trained to ensure that they adopt a positive, strengths-based and hopeful stance when dealing with patients with SMI. Statements such as ‘schizophrenia is a chronic disease’, or, ‘you will need to be on medications all your life’ are not consistent with the evidence or a recovery orientation.

SHARED DECISION MAKING

Finally, there is a need for the continuance and consolidation of shared decision making in primary care for people with SMI. Shared decision making refers to a process whereby clinicians and patients openly discuss the variety of intervention options and associated risks and benefits to arrive at mutually-satisfying decisions. This can empower patients to play an active role in their own care, resulting in a strong therapeutic alliance that can enhance adherence and diminish drop-out. This would be building on solid ground, as much evidence suggests that many primary care clinicians currently encourage such choice and autonomy.¹⁰ The concept of autonomy is considered essential to notions of recovery, and has historically been denied to people with SMI due to paternalism and stereotypes over patient competency.