BackgroundPatients with comorbid depression and physical health problems have poorer outcomes compared with those with single long term conditions (LTCs), or multiple LTCs without depression. Primary care has traditionally struggled to provide integrated care for this group. Collaborative care can reduce depression in people with LTCs but evidence is largely based on trials conducted in the United States that adopted separate treat to target protocols for physical and mental health. Little is known about whether collaborative care that integrates depression care within the management of LTCs is implementable in UK primary care, and acceptable to patients and health care professionals.MethodsNested interview study within the COINCIDE trial of collaborative care for patients with depression and diabetes/CHD (ISRCTN80309252). The study was conducted in primary care practices in North West England. Professionals delivering the interventions (nurses, GPs and psychological well-being practitioners) and patients in the intervention arm were invited to participate in semi-structured qualitative interviews.ResultsBased on combined thematic analysis of 59 transcripts, we identified two major themes: 1) Integration: patients and professionals valued collaborative ways of working because it enhanced co-ordination of mental and physical health care and provided a sense that patients’ health was being more holistically managed. 2) Division: patients and professionals articulated a preference for therapeutic and spatial separation between mental and physical health. Patients especially valued a separate space outside of their LTC clinic to discuss their emotional health problems.ConclusionThe COINCIDE care model, that sought to integrate depression care within the context of LTC management, achieved service level integration but not therapeutic integration. Patients preferred a protected space to discuss mental health issues, and professionals maintained barriers around physical and mental health expertise. Findings therefore suggest that in the context of mental-physical multimorbidity, collaborative care can facilitate access to depression care in ways that overcome stigma and enhance the confidence of multidisciplinary health teams to work together. However, such care models need to be flexible and patient centred to accommodate the needs of patients for whom their depression may be independent of their LTC.

BackgroundMental-physical multi-morbidities pose challenges for primary care services that traditionally focus on single diseases. Collaborative care models encourage inter-professional working to deliver better care for patients with multiple chronic conditions, such as depression and long-term physical health problems. Successive trials from the United States have shown that collaborative care effectively improves depression outcomes, even in people with long-term conditions (LTCs), but little is known about how to implement collaborative care in the United Kingdom. The aim of the study was to explore the extent to which collaborative care was implemented in a naturalistic National Health Service setting.MethodsA naturalistic pilot study of collaborative care was undertaken in North West England. Primary care mental health professionals from IAPT (Increasing Access to Psychological Therapies) services and general practice nurses were trained to collaboratively identify and manage patients with co-morbid depression and long-term conditions. Qualitative interviews were performed with health professionals at the beginning and end of the pilot phase. Normalization Process Theory guided analysis.ResultsHealth professionals adopted limited elements of the collaborative care model in practice. Although benefits of co-location in primary care practices were reported, including reduced stigma of accessing mental health treatment and greater ease of disposal for identified patients, existing norms around the division of mental and physical health work in primary care were maintained, limiting integration of the mental health practitioners into the practice setting. Neither the mental health practitioners nor the practice nurses perceived benefits to joint management of patients.ConclusionsEstablished divisions between mental and physical health may pose particular challenges for multi-morbidity service delivery models such as collaborative care. Future work should explore patient perspectives about whether greater inter-professional working enhances experiences of care. The study demonstrates that research into implementation of novel treatments must consider how the introduction of innovation can be balanced with the need for integration into existing practice.

BackgroundPeople living in deprived areas are more likely to be overweight or obese, have poorer health outcomes, and tend to benefit less from interventions than those from more affluent backgrounds. One approach to address such health inequalities is to tailor existing interventions to low socio-economic populations, yet there is limited evidence to inform their design. This study aims to identify how best to tailor lifestyle interventions to low socio-economic populations to improve outcomes.MethodsFollowing direct observations of community-run weight loss groups, we interviewed 11 group facilitators and 14 service users from a health improvement service in a low socio-economic area in the North West of England. Audio-recorded interviews were transcribed verbatim and analysed thematically.ResultsWe identified two overarching themes within the data. The first theme, managing diversity, included challenges faced in delivering a generic intervention to a diverse population in terms of knowledge, language and literacy skills, and cultural diversity. The second theme incorporated all issues relating to the environment, such as cost, access and availability of food and leisure facilities, and ‘life gets in the way’.ConclusionsTailoring interventions for this population is necessary, and more attention is needed to develop ways to ensure service providers and users engage with behaviour change techniques such as goal setting, rather than focusing on information provision alone. Interventions should also be mindful of cost, cultural diversity, and language and literacy barriers, as well as potential for disengaging this hard to reach population.