Mental health policy and practice across Europe: an overview

Mental health problems in primary care 219
achieving those goals. The WHO suggests that all mental health policies are
anchored by four guiding principles:
1 Access: service provision should meet the need for services in the community.
In addition, the right to obtain treatment should depend on the need for
services, not ability to pay or geographic location. As outlined in Goldberg’s
‘pathways to care’ model, there are problems in access to care in primary care,
related to the fact that people do not consult as a consequence of stigma or
inadequate knowledge, and a significant proportion of disorders presenting in
this setting are not recognized by the gatekeeping primary care clinician.
Patients failing to pass the first ‘filter to care’ are unable to access effective care
from health services.
2 Equity: mental health care resources should be distributed fairly across the
population at large, so that patients with similar problems receive similar
services (horizontal equity) and patients with more severe problems receive
more care than those with minor problems (vertical equity). There are two
main sources of inequity in current services, which relate to the wide variation
in the ability of individual practitioners to recognize disorders, and
inequity in the provision of specialist services within practices. In addition,
the inherent under-investment in mental health services and stigma that is
associated with mental health problems means that allocation of resources is
inequitable compared to other disease groups.
3 Effectiveness: mental health services should do what they are intended to do:
improve health. Health may be defined in terms of health status, or broader
definitions may involve wider function and quality of life, and not just the
absence of disease (WHO 1948). Patient satisfaction with services is an additional,
if somewhat more controversial, measure of effectiveness. Current
management of mental health problems can involve the provision of ineffective
treatments or those of unknown effectiveness (such as some forms of
psychological therapy), or the ineffective delivery of effective treatments
(such as inappropriate use of medication).
4 Efficiency: given that resources for any health care system are limited, they
should be distributed in such a way as to maximize health gains to society.
Clearly, the problems with access, equity and effectiveness identified above
limit the degree to which current services can be efficient.
The relationships between these different goals are complex, and satisfying multiple
criteria requires a population approach to planning care, rather than a
focus on the particular patient which characterizes the philosophy of primary
health care (Sibbald 1996; Katon et al. 1997).
Models to improve mental health care in primary care settings
Broadly, there are four main models available to improve mental health care in
primary care (Bower and Gilbody 2005), which are described below. Additional
consideration should be given to the promotion of mental well-being and the
reduction of stigma associated with mental health problems is also important.
Mental health promotion is considered in Chapter 8 and is not considered