Embedding effective depression care: using theory for primary care organisational and systems change

Abstract

BackgroundDepression and related disorders represent a significant part of general practitioners (GPs) daily work. Implementing the evidence about what works for depression care into routine practice presents a challenge for researchers and service designers. The emerging consensus is that the transfer of efficacious interventions into routine practice is strongly linked to how well the interventions are based upon theory and take into account the contextual factors of the setting into which they are to be transferred. We set out to develop a conceptual framework to guide change and the implementation of best practice depression care in the primary care setting.MethodsWe used a mixed method, observational approach to gather data about routine depression care in a range of primary care settings via: audit of electronic health records; observation of routine clinical care; and structured, facilitated whole of organisation meetings. Audit data were summarised using simple descriptive statistics. Observational data were collected using field notes. Organisational meetings were audio taped and transcribed. All the data sets were grouped, by organisation, and considered as a whole case. Normalisation Process Theory (NPT) was identified as an analytical theory to guide the conceptual framework development.ResultsFive privately owned primary care organisations (general practices) and one community health centre took part over the course of 18 months. We successfully developed a conceptual framework for implementing an effective model of depression care based on the four constructs of NPT: coherence, which proposes that depression work requires the conceptualisation of boundaries of who is depressed and who is not depressed and techniques for dealing with diffuseness; cognitive participation, which proposes that depression work requires engagement with a shared set of techniques that deal with depression as a health problem; collective action, which proposes that agreement is reached about how care is organised; and reflexive monitoring, which proposes that depression work requires agreement about how depression work will be monitored at the patient and practice level. We describe how these constructs can be used to guide the design and implementation of effective depression care in a way that can take account of contextual differences.ConclusionsIdeas about what is required for an effective model and system of depression care in primary care need to be accompanied by theoretically informed frameworks that consider how these can be implemented. The conceptual framework we have presented can be used to guide organisational and system change to develop common language around each construct between policy makers, service users, professionals, and researchers. This shared understanding across groups is fundamental to the effective implementation of change in primary care for depression.

CollAborative care for Screen-Positive EldeRs with major depression (CASPER plus): a multicentred randomised controlled trial of clinical effectiveness and cost-effectiveness

“…Background Gunn et al 62 reported that GPs perceive patient engagement to be of fundamental importance in dealing with depression. Older people may be reluctant to define their distress as a mental health problem, with implications for treatment acceptance.…”

Patient centredness and the outcome of primary care consultations with patients with depression in areas of high and low socioeconomic deprivation

“…35 In previous studies, the measure of observed patient centredness used in the present study (the MPCC) has been linked to patient satisfaction, 27 reduced diagnostic testing, 18 and improved patient health status. 19 There is substantial evidence of the beneficial effects of practitioner empathy on the outcomes of consultations with patients with mental health problems.…”

Increasing equity of access to high-quality mental health services in primary care: a mixed-methods study

“…376 Improvement of primary care 'quality' and organisational change are both important. 377 Any initiative needs to be seen as relevant to practices' everyday work, and flexible enough to respond to the challenges posed by the needs of an individual practice. 378 As we explained in Chapter 2, the AMP programme assimilated evidence on the nature of access problems for underserved groups, and views of how access might be more equitable.…”

“…We used evidence gained from phase 2, together with our knowledge of and experience in the diffusion of innovation 377,399,400 to inform implementation strategies at three complementary levels:…”