The data can be understood using two over-arching major themes, which were distinct but complementary in illuminating how collaborative care was implemented and perceived by both patients and professionals. The first theme concerns how the model enabled integration, encouraging co-ordination of care for patients’ mental and physical conditions. By contrast, the second theme focused on division, with both patients and professionals emphasising a preference and perceived need for treatment spaces that separated out the management of physical and mental health problems.
Integration
When asked whether and how collaborative care impacted their clinical work, all health professionals (PNs, PWPs, GPs) emphasised how the new care model had enabled better liaison between themselves and supported signposting patients to a wider range of services. Expressions about “sharing care” (PN01), providing the care “side by side” (PN10), “well rounded care” (PN03), and “working as a team rather than as individuals” (GP06) were typical of health professionals’ perceptions about the benefits of integrated working. The framework offered by collaborative care was valued by professionals, especially by PWPs, because it increased opportunities for care co-ordination and information sharing with PNs, and also enhanced their confidence to manage mood problems in the context of complex physical symptoms:
PWP10: Working collaboratively…in terms of your practice it’s very helpful to get that reassurance that what you’re doing in the sessions is the right thing, is useful, and will be helpful for the person.
Patients were positive about the enhanced communication between the professionals, who typically had worked in isolation from each other:
PT06 (Female, completed): Basically the nurse is very good at what she needs to be which is checking things but a lot of it is that she's interested in your physical health… there could be that link so I think both professionals have got to have, you know, like an idea of what the other professional is actually doing and so they're not just working in silence they're working together.
Consistent with this, health professionals reported an increased awareness of patients’ multiple conditions. The PNs reported that the model helped them understand the patient in a more holistic way, and PWPs valued the broader understanding of the patient that they gained from the additional communication with the nurse.
PN01: I didn’t realise how much of that was to do with their disease, because generally the people I refer are depressed for some other reason, …and I didn’t put it altogether that, perhaps this is just a whole package of things, it’s not just one thing…So, yeah, it’s made me more aware really of how people think and the one problem they’re presenting with may not necessarily be the only one.
PWP04: One good thing about the joint meeting with the practice nurse, that it just gave us a lot more information and maybe a lot more background to the patient than what we would normally have in therapy.
The increased access to and availability of mental health care offered was considered much needed by both PNs and patients, who reported that routine management by the nurses was typically restricted to focusing on LTCs with no space to discuss their mental health problems, particularly the ‘everyday’ struggles of living with depression and chronic illness:
PT24 (Female, disengaged): [The GP and PN] haven’t got the time. No, it has to be people that are trained listeners and also have the time that they can devote to a session like that. I think there are counselling sessions but I think you’ll find it’s full of people with schizophrenia and that sort of depression, rather than us who just plod on, feeling very blue, not achieving as much as we could and not feeling our best, but we’re not going to kill ourselves tomorrow. I think the service as it is now could only cope with crises, rather than helping the everyday person, which is probably a much larger number of people, isn’t it?
Both PNs and PWPs also suggested that the collaborative care framework facilitated delivery of mental health care in a more acceptable, less stigmatised way. In this sense embedding mental health care in the context of patients’ physical health problems increased the accessibility of the mental health treatment for this patient group, as patients could work with PWPs without necessarily characterising their problems as ‘depression’:
PN10: If you mention mental health there is still that - yeah, another word for it is it’s still a stigma. People don’t like to address it, admit to it, or whatever. So maybe I think it needs to be addressed side by side as part of the whole care. At present it does, anyway, until people’s attitudes change.
PWP10: I had one person who wouldn’t even say the words, anxiety and depression, he didn’t see himself as being anxious or depressed at all, so we didn’t use those words. He still engaged, and still did the work, but we just kind of skirted round those words, yes! And he still really felt the benefits of it, and was really a different person when he finished.
The integrated working was emphasised to be between PWPs and PNs, with GPs having relatively little involvement, consistent with other studies of collaborative care in the UK [21]. Patients themselves felt GPs would be unable to contribute due to time restrictions and preferred the closer involvement of the PN and the low intensity PWP.
Division
So far we have shown how a collaborative care model that integrated depression care within primary care of LTCs was valued by PWPs, PNs and GPs because it facilitated greater coordination of mental and physical care and also enhanced their confidence to manage patients with a complex mix of physical and mental health problems. For their part, patients’ perceptions of what integration meant revolved around the sense that the collaborative approach granted them access to mental health care that had hitherto been out of reach, either because physical health problems had taken centre stage in routine primary care consultations or because seeking mental health treatment was stigmatised.
We now show that service level integration in the context of collaborative care for depression and LTCs did not necessarily equate to therapeutic integration. Indeed both PWPs and PNs maintained explicit role divisions around delivering mental and physical health care, often drawing on a narrative about the limits of their expertise:
PN10: We see patients in primary care and try to be holistic, [but] we have to realise that we do have limitations in what care we can provide and sharing patient care with other professionals…You have to realise that you have limitations and there comes a point where there are other better qualified people who are better able to care for that patient.
PWP04: I think, you know, as I say, my area is obviously mental health, and her area was more physical health … So there was no real, you know, crossover
This separation between what constituted physical and mental health care was reinforced by patients as well. In part, separation was seen by patients as a natural by-product of health professionals’ expertise, but it was also linked to treatment preferences. While patients recognised the value of seeing PWPs in the same geographic space as their nurse, (as co-location was seen to enhance care coordination and removed the stigma of accessing mental health treatment), they often stated a preference for discussing emotional health problems in a separate therapeutic space away from the nurse:
PT20 (Male, Completed): its two different things. I wouldn’t go to [PN name] and start crying my eyes out and saying I miss my dad and all that. She controls my medication. That [the mental health aspect] was emotional…Separate. Absolutely separate… I don’t think you’re ever going to get one person doing all that.
PT12 (Male, Completed): [The PWP is] more qualified in that sense [talking about emotions]. She’s… the nurse basically looks after your body, not your mind. Each one’s got a job to do.
Patients’ perceptions about therapeutic integration were also shaped by their experience of the joint consultation meetings between the PNs and the PWPs. These joint meetings may have reflected a sense of joined up working on the part of professionals and led patients to feel confident that their care was being more appropriately and expertly managed, but they did not lead to care that sought to treat both their physical and mental health problems synergistically. In fact for some patients the joint consultation meetings were deemed to be unnecessary and just about “comparing notes” (PT20), and several commented that it appeared to be more useful for the professionals than for patients. Patients appreciated that the professionals were now ‘working together,’ but with clear divisions in the work undertaken still emphasised:
PT21 (Male, Completed): Knowing somebody is depressed is a good idea, but I don’t think it’s [the nurses] job to…because as I say they’re medical people, they treat people come in with their toenails and whatever…. I think it’s a good idea that they should know that you’ve got a bit of depression because when I go in there and she says your blood sugar, I said well, I’ve been a bad boy, I’ve eaten this, that and the other, she shouldn’t start saying, oh, what are you doing that for?!
GPs and nurses were cast as ‘insiders’ who knew their patients and had responsibility for ‘controlling’ their medical conditions, whereas PWPs were cast as ‘outsiders’ which paradoxically granted patients freedom to talk emotionally about their life circumstances and medical conditions in ways that were not possible with GPs and nurses:
PT13 (Female, Completed): You do stop and you think to yourself how am I going to cope with it, but you don’t have anyone to say that to. You don’t have a professional to say that to … I mean I’m not saying a GP’s not qualified to do that. I’m sure they are. But at the same time they’re the ones who are controlling your condition…. I think with [PWP name], it is like because he’s an outsider, because he just let me talk.
In fact, attempts to explicitly integrate physical and mental health treatment were resisted by patients when it encroached on their freedom to talk about other factors, outside of their physical health, that might be linked to their mental health. Consistent with the previous excerpts, patients wanted the mental health treatment to be separate and distinct from their physical health management, and struggled with sessions that focused on dealing with their mental health condition only in the context of their physical illness.
PT03 (Female, Disengaged): When [the PWP] was asking me questions … he wanted me to say that I felt very depressed over my heart trouble, and that, and I didn’t and I couldn’t say I did, because it would have been dishonest
PT24 (Female, Disengaged): I think that was the problem for [the PWP], she kept coming back to just diabetes; now, we’re just talking about the diabetes, how does that affect you? If they could look at the wider issue, yes, it’s brilliant and it’s well needed for most people that are chronically ill.
These tensions between integration and division were keenly felt by health practitioners who attempted to implement the COINCIDE care model as per the trial protocol i.e., as an integrated psychological intervention for depression for people with LTCs. Both PWPs and PNs reflected on instances where they started with an integrated treatment philosophy but were often led away from a focus on LTCs by patients who valued a less specific discussion about the genesis and maintenance of their mood disorder.
PWP06: We tried to do a gated, boundaried piece of work… Some of them wanted to receive treatment on their mental health and talk about things that were nothing to do with their health condition
PWP02: Sometimes they [patients] will go off on a tangent so to speak and start to talk about other things… but it’s not so relevant in terms of the physiological condition that we had on the trial…it could be something that’s happened years ago and they’ll want to talk about that, but it’s not really relating to diabetes or chronic heart disease.
PN02: They thought it was to bring everything else in as well …. a lot of the issues weren’t just related to their long term condition. Their depression was related to things that were going on in their family life which was nothing to do with that actual condition, it was social things… we have to stick to what we were wanting to get out of this study when it was nothing to do with them
Notably this may have been an artefact of the trial (as the professionals refer to ‘the trial’ and ‘the study’), but it may also relate to the well documented prioritisation of physical health at the expense of mental health:
PN04: I think if you asked a patient what their agenda was a lot of patients would say, yes, the depression is outweighing everything else, but obviously for the healthcare point of view sometimes you look at results, and you have to put it holistically with the patient, you know, and think, golly, these results are diabolical, we’ve got to get your diabetes on track, and then the depression would take a second seat I think really
Some patients reported valuing the opportunity to discuss the emotional impact of their health conditions, but the data suggest that preference for this was varied, and patients who wanted to talk about issues beyond their LTC were not always given the desired space to do so. The joint meetings, which attempted to directly integrate the mental and physical health care received were consequently uncomfortable for some patients:
PT01 (Male, Disengaged): In many ways I was dreading it, because, I just couldn’t see the point in it. I thought it was just an embarrassment. An embarrassment for the nurse and embarrassment for me. We didn’t have anything to say.
This further supports the interpretation that patients valued access to mental health care outside of their typical LTC management, and with a professional not involved in their physical care. Explicit attempts to integrate mental and physical health care within joint therapy sessions was considered inappropriate or irrelevant, and potentially undermined the patient’s need for their mental health condition to be independently valued and explored.