In this section we first discuss the inter-relationship between developmental factors described above (see figure ) and then five recommended areas of strategy for policy makers. The core factors are clinical level partnership activities that clinicians undertake to develop linked service delivery. These partnership formation activities are ideally conducted in an organisational context with strong leadership support. Three other set of factors were found to enable partnership formation: having staff with the right attributes for collaboration in primary mental health care; the provision of supervision and peer support to staff involved in making linkages; and provision of office accommodation conducive to collaboration. Influencing all partnership formation activities and supports is an evaluation feedback loop that serves as a motivation enabler for sustaining collaboration.
From our analysis of these studies and our reference group discussions on policy importance, acceptability and feasibility, we identified five strategies for policy makers and service directors to promote partnership formation and hence build service linkages in primary mental health care:
1. Provide organisational level support for integration.
2. Facilitate joint clinical planning and problem solving.
3. Jointly develop local care guidelines (crisis plans, referral protocols and follow up arrangements) through regular meetings and the use of a common planning process.
4. Provide training, support and supervision of staff committed to work in primary care and mental health.
5. Feedback evidence about outcomes to service partners.
Our conclusion about organisational level support for integration comes from the study findings, but also from the observation that the research trials reported systematic interventions, with specific funding, leadership and change management support. Such organisational level supports are also required if the findings of this review are to be implemented successfully. This is supported by the intervention research literature, such as by Damschroder et al, who concluded that translation of effective models of care from research into everyday practice requires consideration of the intervention characteristics; the economic, social and political context; the structural, political and cultural contexts of the organisations involved; the agency and skills of the individual involved; and the implementation change management process at clinical and organisational levels [38
]. Hence, to address even some of these domains, specific organisational level supports are needed in non study settings.
Since greater role ambiguity is inherent in collaborative work, particularly in mental illness where a patient's condition can change between acute, chronic and recovery phases, attention is required to problem solving and the clarification of roles. Our findings indicate that a process to form linkages and deal with role issues, which is generalisable in different contexts, is joint clinical planning and problem solving. This is a large component of partnership formation activities as described in the literature. This planning and problem solving can occur between clinicians when they discuss patient care and as they consider linked service models, thereby developing ongoing personal links and professional relationships and building mutual trust. The immediate gains from such clinically grounded discussions could be the reinforcement needed to motivate staff to make a sustained effort to collaborate. The Australian Fourth National Mental Health Plan notes that dealing with role tension about activities, such as transporting patients with mental illness, access to in-patient care and management of people who are intoxicated, can be jointly resolved in this way [3
How such tensions are resolved will depend on the development of local solutions backed by good collaboration between sectors and recognition of roles, responsibilities and limitations. Patients and carers should routinely be involved in such deliberations. (2009:42)
Joint clinical planning and problem solving may help to form professional relationships between mental health and primary care services. This may counter service stigma and resistance that is evident in the finding that some GPs have limited interest in providing mental health care, feel under trained and do not see this as their role [39
]. In order to promote joint clinical problem solving between primary care and mental health their leaders will require skills, a clear remit and the necessary resources.
We also found that joint clinical problem solving should work on agreed service arrangements. Joint development of linked services arrangements is important to ensure that the model of care meets the needs of primary care and mental health providers, as well as patients and carers. Since contexts differ, local joint planning and problem solving must be flexible to account for these differences. Planning could cover such processes as documented referral processes (communication); care policies and procedures (guidelines); mechanisms for regular team leader and service-wide meetings; strategies for inclusion of patient and carer needs in decision making; and care coordination to ensure that the patients and services are linked. The finding that larger primary care practices were more amenable to collaborative care is relevant, since more staff requires that more attention be given to the development of agreed service arrangements. As a consequence larger primary care practices may have been able to negotiate referral and shared care arrangements with mental health services. Hence, local joint planning and problem solving is more likely to be relevant and sustainable if pitched at practices or collection of practices with four or more primary care physicians.
Our findings suggest that flexibility, commitment and skills to work in mental health and primary care, and motivation towards teamwork are staff attributes that help develop competence in collaboration. This is particularly the case when the workplace is receptive to change [14
], when staff have appropriate supervision from an experienced mental health clinician and peer support [24
] and when their work is supported by a care plan or guidelines [8
]. However, the ability to work in a collaborative problem-solving manner between primary care and mental health is a personal competency that has not been included in the formal training of primary care providers or mental health staff. While this competency might be achieved through "on-the-job" problem solving noted above, this would also be helped through inter-professional training at undergraduate and postgraduate levels. Our findings also support the value of expert supervision or mentorship [26
], as well as forums for mutual support for those staff undertaking linkage roles [24
]. These strategies could increase the mental health skills of these staff under expert guidance, as well as develop their role with others as they jointly identify role issues that require clarification.
Given the finding that feedback of evidence about service outcomes is an important driver of change, then the development of mental health data collection and systems for accountability are timely. Accountability can be articulated at the level of policy (for government and management) and clinical care (for service providers). Outcome data could be considered against national standards for mental health and primary care services, but these data must cover the key links between mental health services, primary care services and the wider human service sectors [41
]. The collection and reporting of data requires resources, has opportunity costs and may require new information and communication mechanisms. However, if communities are to have evidence-based and responsive primary mental health care services then such accountability must be resourced. Collection of such data across sectors would be aided by common patient identifiers, electronic health records and patient enrolment with a primary care provider [43
We did not conduct a quality assessment of the retrieved studies as they reported methods and results in different ways, with different theoretical perspectives and varying levels of detail. This range of studies in our broad review (over the two parts) would have made applying comparative quality criteria complex and outside our funded timeframe of one year. This is a limitation of our findings, as we cannot give weight to these findings beyond an estimate of importance of each factor based on the number of studies in which they were reported.
While the findings from this review are informative, about the factors that enable the formation of mental health service partnerships in primary care, the multifactoral and context dependent nature of these factors does limit the generalisation of the findings. This would particularly be the case when considering whether findings from one country apply to another.