Mental health policy and practice across Europe: an overview

Mental health problems in primary care 221
behavioural therapy (Scott and Freeman 1992), problem-solving (Corney and
Briscoe 1977), counselling (Ward et al. 2000) and interpersonal therapy
(Schulberg et al. 1996).
It should be noted that these models are not designed to capture the complexity
of actual service provision, but to provide broad categories which are of use in
prioritizing different methods of achieving mental health policy goals.
How do these methods assist in the achievement
of policy goals?
Access
Key goals of mental health policies (such as those in the United Kingdom and
other EU countries) relate to improvements in access and effectiveness. There
are two key criteria which determine the effect of each model on access.
The first relates to the impact of the model on the confidence and skills on the
primary care clinician. As noted above, the models differ in the degree to which
responsibility for care remains with the primary care clinician, or is passed to
the specialist. In primary care-led services, the primary care clinician acts as a
gatekeeper to mental health care, and thus interventions which leave responsibility
in the hands of primary care clinicians and target interventions towards
that group theoretically have the greatest impact on access, because changes in
the skills and confidence of primary care clinicians in mental health issues can
potentially impact on all patients with mental health problems in the community.
In contrast, interventions which require significant specialist involvement
to achieve their effects can only impact on the small number of patients to
which specialist assistance can be provided. Therefore, training of the primary
care team has the greatest potential impact on access, followed by consultationliaison
and collaborative care models. Replacement models have potentially
little or no impact.
Efficiency
The second criteria relates to the efficiency of specialist interventions within the
model. Within all primary care-led mental health care systems, the numbers of
specialist staff are insufficient to meet the demand for mental health care, and
thus specialist resources must be allocated efficiently. Thus, treatments (such as
medication from the primary care clinician) which may not need specialist
input at all are the most efficient because limitations in the availability of specialists
have no impact on access to this form of care. The consultation-liaison
approaches spread specialist resources efficiently, as most specialist time is spent
in training a large number of primary care clinicians, and only a small proportion
in direct patient contact. Collaborative care and replacement models are
least efficient because both require significant specialist time for all patients (for
case management and the delivery of therapy). Efficiency issues in these models