Towards integrated mental health services in a rural community

As I write, the Australian media has been focussing in depth on drought in Australia for two weeks. It is as if those in metropolitan Australia have suddenly realised that rural farmers and communities are experiencing hardship and are at risk of psychological distress and mental illness. Much of the focus is on immediate aid such as government loans and charitable gifts towards purchasing and transporting hay bales to farmers in need.

While short-term responses are welcome they cannot be the whole answer. Rural people experience similar mental illnesses to those in cities, but they have poorer outcomes. This is usually attributed to the maldistribution of specialist mental health care, in particular psychiatrists, and to the limitations of primary mental health care in rural settings. In 2016 I published a perspective paper in the International Journal of Integrated Care proposing a simple 4-step model of integrated care comprising: self-care; primary care; specialist care in the community; and tertiary care. As always, the challenge is the integration of services or the movement between “steps”. In 2018, Scott Fitzpatrick et al published a case study of a rural community mental health service which has been on an integration journey for 10 years.

Located 2 hours by road from the nearest specialist mental illness hospital, the case study describes the development of a model of care in which the community mental health team and the group general practice have combined to provide increasingly sophisticated community-based services supported by psychiatrist support (0.2 FTE). The case study focusses on the link between steps 2 and 3 – primary care and specialist care in the community. There are a number of interesting features. Considerable progress has been achieved without additional project or pilot funding and despite the need to work with a fee-for-service system in general practice and different information systems which do not facilitate collaborative working.

The case study describes a shared and sustained ambition to provide better care for vulnerable community members with co-morbid mental and physical health problems; dual diagnoses of mental and drug and alcohol disorders; and those with severe and enduring mental health problems. This ambition has enabled important improvements in patient- centred care, better supervision and support for clinical staff and, better use of resources including the costs borne by a vulnerable group of patients.

Prof. David Perkins is Director of  IFIC Australia and the Director of Centre for Rural & Remote Mental Health, University of Newcastle, Australia