Experiences of barriers to trans-sectoral treatment of patients with severe mental illness. A qualitative study.

Abstract

Background Patients with severe mental illness (SMI) have shorter life expectancy than people without SMI, mainly due to overmortality from physical diseases. They are treated by professionals in three different health and social care sectors with sparse collaboration between them, hampering coherent treatment. Previous studies have shown difficulties involved in establishing such collaboration. As the preparatory phase of an intervention to improve physical health of people with SMI and increase collaboration across sector borders, we explored different actors’ experiences of barriers for collaboration. Method We collected qualitative data from patients, professionals in general practice, psychiatry and social psychiatry involved in the treatment of these patients. Data consisted of notes from meetings and observations, interviews, focus groups and workshops. Analysis was by Interpretative Phenomenological Analysis. Results The study revealed many obstacles to collaboration and coherent treatment, including the consultation structures in general practice, sectors being subject to different legislation, and incompatible IT systems. Professionals in general practice and social psychiatry felt that they were left with the responsibility for actions taken by hospital psychiatry without opportunity to discuss their concerns with psychiatrists. There were also cultural differences between health care and social psychiatry, expressed in ideology and language. Social psychiatry had an existential approach to recovery, whereas the views of health professionals were linked to symptom control and based on outcomes. Meanwhile, patients were left in limbo between these separate ideologies with no leadership in place to promote dialogue and integrate treatments between the sectors. Conclusion Many obstacles to integrated trans-sectoral treatment of patients with SMI seem related to a lack of an overriding leadership and organizational support to establish collaboration and remove barriers related to legislation and IT. However, professional and ideological barriers also contribute. Psychiatry does not consider general practice to be part of the treatment team although general practitioners are left with responsibility for decisions taken in psychiatry; and different ideologies and treatment principles in psychiatry and municipal social psychiatry hamper the dialogue between them. There is a need to rethink the organization to avoid that the three sectors live autonomous lives with different cultures and lack of collaboration.

Flexible assertive community treatment teams can change complex and fragmented service systems: experiences of service providers

“…A reason for this finding might be the way teams are described to collaborate. This is in line with findings of some studies suggesting that certain activities, such as building relationships across services [55,59,71], collaborating through regular meetings [54,55,59], being flexible [71] and accessible [50,55,59], enhance collaboration. Such ways of collaborating can also be a contradiction to often bureaucratic structures of mental health services in Norway [50,60] and challenges when attempting to contact the each other [50,55,59].…”

“…This is in line with findings of studies on similar models [35,37]. Lack of clarity with respect to roles is challenging [54] and might have negative effects on collaboration [58], while role clarity might reduce burnout among mental health professionals [73]. This finding implies that working to reduce some of these uncertainties can enhance the functioning of teams in service systems and make it easier to work as part of complex and fragmented systems.…”

“…This finding might make the described challenges even easier to understand, because patient records and information technology systems are not connected. Lack of supportive technology is considered a barrier in both innovations [20] and collaboration [54], and if information technology systems are not connected, then it might create unclear communication, which might in turn create risky situations for users [72]. By contrast, shared client records may enhance communication [40], implying that reducing such challenges may contribute positively when implementing innovative models, such as FACT as part of existing service systems.…”

“…The service systems in which FACT teams are implemented are described as complex [44][45][46][47] and fragmented [11,44,45,[47][48][49][50][51][52][53][54], with challenges in collaboration [50,54]. Complexity, fragmentation [55][56][57][58][59][60] and challenges in collaboration [58][59][60][61] are also found in the Norwegian system.…”

The SOFIA pilot trial: a cluster-randomized trial of coordinated, co-produced care to reduce mortality and improve quality of life in people with severe mental illness in the general practice setting

“…In the SOFIA study, an intervention was developed by combining state-of-the-art evidence-based clinical, and social knowledge, with the perspectives of all involved parties in a participatory co-design process [20]. Furthermore, barriers for trans-sectoral treatment of patients with SMI, and potential solutions for these, were explored in a series of workshops, focus groups, and interviews as part of the co-design phase to help guide the development of an intervention [21]. This intervention essentially aims to improve the treatment of comorbid somatic conditions in persons with SMI through an enhanced educational training of general practitioners and their clinical staff, and by implementing strategies to better accommodate patients with a psychiatric background in primary care.…”