The impact of organisational culture on GP-mental health service shared care
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Presentation to the Interdisciplinary Learning for Interprofessional Practice Conference, Adelaide November 2006. Based on my Masters Thesis, this slideshow looks at the logistical, cultural and communication barriers in an interagency interdisciplinary model of mental health care.
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The impact of organisational culture on GP-mental health service shared care
- 1. The impact of organisational culture on GP–mental health service shared care models. Presentation to the Interdisciplinary Learning for Interprofessional Practice Conference, Adelaide, November 2006 Louise Miller Frost John Moss
- 2. Objective of Presentation • Examination of some of the organisational cultural aspects that impact the development and sustainability of shared care between GPs and Community Mental Health Services • Implications of how these barriers are overcome.
- 3. Defining some terms… • Divisions of General Practice (Divisions) • Community Mental Health Services
- 4. Rationale for Shared Care • Addresses the Commonwealth / State funding split • More effective / efficient use of resources • Addresses gaps and duplications in service in multi-provider environment • Better (safer) outcomes for consumers
- 5. The literature says….. • A positive organisational culture is a requirement for shared care to work • Lack of a positive organisational culture is a barrier to shared care working
- 6. Organisational Culture • Edgar Schein (b 1928): shared reality of participants • A metaphor enabling examination and analysis of symbolic aspects of organisational life… shared systems of meaning, values, norms and belief systems, relationships within the organisation and with external entities • Three distinct levels: artefacts and behaviours, espoused values and assumptions
- 7. Research Questions • What is it about the cultures of community health services and GPs that doesn’t automatically enable shared care? What are the barriers to shared care? • What are the cultural and other factors that make the difference between whether a shared care model works or does not work?
- 8. Common models of care
- 9. Are they really so different? GPs… • Medical paradigm • Generalists / Holistic • Longitudinal view • No geographical boundaries • Often business owners • Individual practitioners • Fee for service (Commonwealth Government funding) Mental Health Services… • Psychosocial paradigm • Mental health specialists • Crisis intervention view • Geographical boundaries • Employed • Team structures • Salaried (State Government funding)
- 10. And the similarities? GPs… • Autonomous decision makers • Have a case management role • “gatekeepers to the health system” • Best interests of patient at heart Mental Health Services… • Autonomous decision makers • Have a case management role • “gatekeepers to the public system” • Best interests of the consumer at heart
- 11. Shared Care - barrier categories • Organisational barriers : funding, structures • Trust, respect • Paradigm / perspective • Roles - clash of roles / uncertainty about roles • Knowledge • Power • Perceptions of each other
- 12. How are these shared care barriers addressed in working models? • Maps (pathways) } • Defined roles } • Shared records • Face to face options* • Coordinator* } MOU
- 13. Face to face options Care components • Regular care planning meetings • Case discussion / peer support • Joint assessments Relationship building • Site visits (GP surgery / MHS) • Joint training / meetings
- 14. Role of the coordinator…… • All SA models have a coordinator role • May sit with Division or with MHS, depending where the funding came from • Role seems to be to be a buffer between the cultures • Sometimes administrative role only • May have a clinical role as well (triage, assessment or ongoing care)
- 16. Or in another way……. GPs CMHS GPs CMHS With coordinator Without coordinator
- 17. Coordinator pluses and minuses Plus • It works • Neither side has to compromise • Relatively simple and quick to implement • Problem-solver and flexibility built in • Improves relationships superficially • Gives each side a ‘face’ to relate to Minus • Neither side learns to accommodate or understand the other • No fundamental systemic change occurs • Sustainability dependent on funding • Size dependent on funding and number of coordinators • Level of functioning dependent on capacity of coordinator
- 18. Conclusions • Organisational culture, often a throw-away line in mental health shared care reports, is a fundamental barrier to coordinated care • Specific funding may be required to fund coordinators to enable mental health shared care to occur • Success will be limited by funding……
- 19. Where to from here • Semi-structured qualitative interviews - GPs - CMHS staff - Senior MHS managers - Shared care coordinators • Relationships / perceptions of each other / understanding of roles • Shared care and non-shared care • SA and WA
Editor's Notes
- The integration of the various primary care services in Australia into a coherent system of care that delivers for patients, providers and funding bodies remains a major problem. In the past decade, shared care has been seen as one solution. It was a major item in the Second National Mental Health Plan in 1998 and in 2005, the SA Government put $2.75 million into shared care which has created a variety of models across the fourteen Divisions of General Practice in SA, which I was involved in setting up. (refer slide) - Commonwealth = GPs, State = mhs resources - for example avoiding constant assessments, coordinating one plan A brief survey in the beginning of 2006 found 18 moels of mental health shared care operatin inmetroolitan Adelaide and at least another nine in rural SA. From these models which are very different from each other, I started to look what was shared care, and if it is so obvious to everyone that it needs to happen, why doesn’t it already happen, why did it need to be specifically funded?
- So using a detailed search algorithm on the Cinahl database, as well as some well-known literature reviews, policies and Government reports, I looked at what the barriers on why this doesn’t happen. Analyses of shared care models tends to focus on patient outcomes (as it should) and on benefits to clinicians and often mention the need for a positive culture. (refer slide) What the literature doesn’t say is what a positive organisational culture for shared care IS.
- So using Schein’s concept of organisational culture (slide) I looked at organisational culture between GPs and mental health services
- The blue circles represent the provision of care. (talk through slide) The idea of shared care is that the care is truly seamless from the point of view of the consumer, so that it feels like one unit of care. Now given that there are about 1800 GPs in SA and many fewer community mental health services, it is not feasible to have a true one on one partnership like this. So I next looked at how they were organised and what the literature says about the barriers to shared care occurring spontaneously in any significant size.
- So actually they are both trying to do the same thing for the same reasons but it is clear from this small sample of characteristics that there are clashes in roles here – practitioners from both camps are used to making autonomous decisions regarding their own care for the patient, both are used to coordinating the care of the patient, and they are, on the whole, acting in what they believe to be the best interests of their patient / consumer.
- Then I looked at the literature for barriers that were culture-based falls loosely into 7 categories: Organisational barriers refer to how the organisations are set up, the different funding with service-based funding for GPs whereas community mental health service staff are salaried – so GPs are not paid to discuss cases. Care planning and case conferencing MBS item numbers address this somewhat. Trust and respect refers to a number of factors. GPs tend to refer to specialists they know, and have confidence in the ability of. In shared care they refer to an organisation where they don’t actually know who will see their client. Relationships between GPs and community mental health services described as one of apprehension, the ‘high degree of suspicion and animosity’.Paradigm / perspective refers to different ideologies and goals, differing maps of the worlds, different clinical paradigms, and a distrust of other groups’ perspectives. There are also the paradigms of the GP as a generalist versus mental health services as specialists, and the GPs as a longitudinal view of the patient, whereas specialist mental health services often have a time-limited or crisis intervention view. Roles refers to the intersection of roles represented in shared care, and particularly the idea of case management – who has control over the consumer’s whole care. Links closely to power. Knowledge refers to a profession’s body of knowledge as key to defining professional identity, and lack of understanding of other professional knowledge bases leads to a lack of trust in professional ability and concerns about the ability of other partners to manage particular clients or conditions. Links closely to trust. Power refers to fear of losing the overall management of consumers’, loss through removal of power and responsibility. Shared care is largely about sharing power and responsibility in a negotiated model. For clinicians used to having autonomous decision making power, entering into the shared care agreement might represent a compromise, and if they are losing power to a clinician whose perspective they do not fully understand or respect, this can be a significant barrier And finally, perceptions further complicate all of these factors – not only is there how one side is feeling about the other, there is also what they think the other is thinking about them. Participants report the perception that GPs did not want to walk to the mental health nurses because they ‘aren’t good enough’, that GPs did not have the time, interest or skills and do not ask for help from nurses (ie: don’t recognise their skill level).
- Maps of the consumer journey may include referral criteria, communication points and methods etc. Agreed defined roles address a number of the issues mentioned on the previous slide such as power, roles intersection. These two items may be formally recorded and agreed in a Memorandum of Understanding or less formally in some form of working agreement . Shared records are an ideal that is currently not being taken up much due in part to the barriers of , ownershp of records and also issues regarding the Privacy Act. Shared care planning occurs quite frequently with each provider getting a copy of the plan. Face to face options include joint training, regular meetings and joint assessments, so are often less about the shared care model and more about trying to build relationships between clinicians. Of course this only works to the extent that they attend and actually engage with each other, not sit and talk to their own group, or stay away. And finally, the link that seems most promising, the coordinator, who is a central point of contact for both sides in engaging in shared care.
- NSPS example Level of knowledge appropriate for a specialist mental health service is not the same as for a GP or other service provider Unless people are specifically mixed up they will sit in their groups Timing – GPs want evenings, mhs want daytime, no-one wants weekends GPs often need a certain number of hours to get CPD points which might be too much for others
- All of the models I am aware of operating in SA have a coordinator, in part because many were funded in this manner through Divisions of General Practice. Some have the coordinator sitting in the Division, some have the coordinator sitting in mhs – depending largely on where the funding originated. One model had the coordinator moving between the Division and mhs.
- So the benefits of having a coordinator are that each side of the shared care agreement has to make the least possible change and still have it work. It also narrows the number of people each one needs to engage with down to one instead of a multitude. However, it does mean that there is a requirement for funding for this position in order for the model to be sustainable, and essentially it reinforces the idea that each side can continue as they are - there is no fundamental systemic change. What I would like to find is what sort of culture and accommodations need to exist in order to have shared care work without the coordinator, but to date I am finding that it doesn’t work, at least in an ongoing way to any large extent.
- Note on relevance to other areas Obstetric Shared Care GP – private allied health providers