Developing a U.K. protocol for collaborative care: a qualitative study

Abstract

Objective

This study aimed to explore the views of stakeholders including patients, general practitioners (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.

Method

We used semistructured interviews and focus groups with a purposive sample of 11 patients and 38 professionals from a wide selection of primary and secondary care mental health services, as well as framework analysis using a “constant comparative” approach to identify key concepts and themes.

Results

Regular contact for patients with depression is acceptable and valued by both patients and professionals. However, patients value support, whereas professionals focus on information. To be acceptable to patients, contacts about medication or psychosocial support must minimize the potential for patient disempowerment. The use of the telephone is convenient and lends anonymity, but established mental health workers think it will impair their judgments. While patients merely identified the need for skilled case managers, GPs preferred established professionals; however, these workers did not see themselves in this role. All involved were cautious about deploying new workers. Additional barriers included practical and organizational issues.

Conclusions

Although a telephone-delivered mix of medication support and low-intensity psychological intervention is generally acceptable, significant issues to be addressed include the values of the current mental health workforce, fears about new workers' experience and competence, the balance of face-to-face and telephone contacts and case manager education in nonspecific skills necessary to develop a therapeutic alliance, as well as the knowledge and skills required for education, medication support and behavioral activation. Qualitative research can add value to careful modeling of collaborative care prior to international implementation.

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.