La réforme des soins primaires de santé mentale au Québec et le rôle et les stratégies de coordination des omnipraticiens Primary Mental Healthcare Reform in Quebec and the Role and Coordination Strategies of General Practitioners

Résumé

Les systèmes sociosanitaire et de santé mentale au Québec ont été substantiellement transformés dans les dernières années. Au coeur des restructurations, les réformes ont visé la consolidation des soins primaires et une meilleure intégration du dispositif de soins, tendances centrales des réformes sur le plan international. Cet article résume les principaux axes de transformation des réformes du système sociosanitaire et de la santé mentale au Québec. Il présente aussi le rôle clé des omnipraticiens dans la prise en charge des troubles mentaux et les stratégies de coordination déployées. Les réformes visent principalement l’intensification du travail en réseau des omnipraticiens avec les intervenants psychosociaux et les psychiatres. L’article conclut sur l’importance d’optimiser le déploiement de réseaux intégrés de soins et de bonnes pratiques en santé mentale. Par ailleurs, les réformes devraient toujours être accompagnées de mesures et de stratégies d’implantation à juste titre aussi ambitieuses que les changements planifiés !

Mots-clés :

• troubles mentaux,
• soins partagés / soins de collaboration,
• omnipraticiens,
• intégration,
• collaboration interprofessionnelle,
• réforme de la santé mentale

Abstract

Objectives: The health and mental health systems in Quebec have recently been substantially transformed. At the heart of this restructuring, reforms aimed to strengthen primary care and to better integrate services, which are central trends internationally. This article summarizes Quebec’s primary health and mental health reforms. It also presents the key role of general practitioners in the treatment of mental health disorders and their coordination strategies with the mental health care resources in the province.

Methods: Numerous documents on the Quebec health and mental health reforms and the international literature on primary mental health care were consulted for this study. Information on general practitioner roles in mental health were based on administrative data from the Régie de l’assurance maladie du Québec (RAMQ) for all medical procedures performed in 2006. The data was compared with the results of a survey realized in the same year with 398 general practitioners in Quebec. Complementary qualitative data was collected through one hour interviews on a subsample of 60 of those general practitioners.

Results: The central aim of the Quebec healthcare reform was to improve services integration by implementing local healthcare networks. A population health approach and a hierarchical service provision were promoted. For a better access and continuity of care, family medicine groups and network clinics were also developed. The mental health reform (Action Plan in Mental Health, 2005-2010) was launched in this general context. It prioritized the consolidation of primary care and shared-care (i.e. increased networking between general practitioners and psychosocial workers and psychiatrists) by reinforcing the role of general practitioners in mental health, developing mental health interdisciplinary teams in primary care and adding a psychiatrist-respondent function in each Quebec local healthcare network. In mental health, general practitioners played a central role as the primary source of care and networking to other resources either primary or specialized health care services. Between 20-25% of visits to general practitioners are related to mental health problems. Nearly all general practitioners manage common mental disorders and believed themselves competent to do so; however, the reverse is true for the management of serious mental disorders. Mainly general practitioners practiced in silo without much relation with the mental health care resources. Numerous factors were found to influence the management of mental health problems: patients’ profiles (e.g. the complexity of mental health problems, concomitant disorders), individual characteristics of the general practitioners (e.g. informal network, training); professional culture (e.g. formal clinical mechanisms), the institutional setting (e.g. multidisciplinary or not) and organizations of services (e.g. policies).

Conclusion: Unfortunately, the Quebec health and mental health care reforms have not been fully implemented yet. Family medicine groups and networks clinics, primary mental health teams and psychiatrists-respondent are not optimally operational and therefore, are not having a significant outcome. Support mechanisms to help implement the reforms were not prioritized. Hindering factors should be identified and minimized to increase positive changes in the health and mental health systems. This article concludes on the importance of implementing continuums of care, especially local healthcare networks and best practices in mental health. Furthermore, strong strategies to support the implementation of changes should always accompany sweeping reforms.

Keywords:

• mental disorders,
• shared-care,
• general practitioners (or family physicians),
• integration,
• inter-professional collaboration,
• mental health reform