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Idea In Brief
More mental health support is needed and Canada’s mental health system is under severe strain
Long wait times and a shortage of both mental health specialists and primary care providers mean many people cannot access timely support for their mental wellbeing, making prevention, early intervention and effective treatment increasingly difficult.
Primary health care workers can play a stronger role as the first line of defence for mental health
Just as family physicians play a central role in monitoring and managing long-term conditions, they must also be empowered to act as the first line of defence in mental health care. Stronger integrations between primary and mental health and adjustments to funding models are needed to enable success.
Domestic and international models show how integration can be achieved
Canada can learn from examples local and abroad to better equip family physicians with the capacity, supports and environment needed to build a more responsive, accessible and equitable mental health system.
In recent years, the conversation around mental health has gained significant momentum. Increasing public awareness, combined with the long-term impacts of the COVID-19 pandemic, has highlighted the urgent need for comprehensive and accessible mental health support. In Canada, patient wait times, access to generalist and specialist mental health services, and retention of a sufficient primary care and mental health workforce have become common challenges. People in Canada are struggling to find and get access to the mental health help they need.
Collaborative mental health care practices and incentives, connecting the primary care workforce with the mental health system, must become a priority if Canada is to effectively meet demand.
What challenges does our mental health system face?
The strain on provincial mental health systems can no longer be ignored. Wait times to see mental health specialists, including psychiatrists, psychologists and psychotherapists, can stretch from months to more than a year, leaving patients in the lurch. For many, by the time they reach a specialist, their condition has deteriorated, making treatment more complex and recovery slower. This is particularly concerning given that early intervention is one of the strongest predictors of positive mental health outcomes.
This reality necessitates a fundamental shift in our health system’s management of mental health conditions – provide support early and focus on prevention, before needs become acute. The comparison to chronic disease management is instructive: just as family physicians play a central role in monitoring and managing long-term conditions, they must also be empowered to act as the first line of defence in mental health care. This doesn’t mean replacing specialists, but rather ensuring that care is provided to all patients through an appropriately equipped and supported general practitioner workforce.
This is where a second challenge rears its head: the ongoing difficulty to recruit and retain a sufficient health workforce. Canada is facing a shortage of family physicians at a time when demand is rising. Recent studies estimate nearly 22 per cent of Canadian adults (6.5 million people) do not have a family doctor or nurse practitioner they can see regularly.
These challenges are exacerbated by several factors, including a growing population, limited number of family medicine graduates entering the profession, and family physicians increasingly pursuing more focused specialties. Policy based changes also contribute. For example, in Ontario, changes such as designated focused practice billing codes, and reduced team-based models (where most family medicine residents train) have created a less attractive and accessible career path for family physicians. Data shows family physicians have moved to other specialties, such as emergency or hospitalist medicine, with potential benefits of better remuneration, and quality of life with reduced stress.
Despite workforce constraints, family physicians see a larger proportion of patients with mental illness than specialized mental health services. Up to 80 per cent of Canadians rely solely on their family doctor for their mental health needs. This is not to mention access barriers, with specialist services not always covered by public health insurance plans, and approximately one third of Canadians without any third-party health insurance. These barriers position family physicians as the go to for care that would have previously been delivered by specialist colleagues.
Lessons to support family physicians and their workloads can be seen locally and abroad
The role and importance of family physicians in connecting those in need with mental health services and providing initial supports is well documented. Where systems fall short, however, is providing family physicians with the wrap around connections and supports needed to give vulnerable Canadians the help they need. Some examples of best-practice can be seen in Canada, and abroad.
Case study #1: The Hamilton Family Health Team (HFHT) Mental Health Program, Canada
In Hamilton Ontario, an embedded primary care approach to mental health has been delivered since 1995. The HFHT program has 180 participating physicians, spread across 83 practices in Hamilton. These practices deliver mental health services, often within family physician offices, through a collaboration based model (leveraging physicians, nurses, mental health counsellors, visiting psychiatrists and other part-time specialists). The HFHT delivers supports across the mental health continuum, supporting patients with initial assessments and information, to treatment and therapy services and further specialist referrals.
This model – and other collaboration approaches based on this model – have demonstrated consistent improvements to patient outcomes and wellbeing. The model has been connected with improved patient adherence with preventative practices, increased levels of patient and provider satisfaction, and enhanced care continuity and coordination. The model has helped to increase capacity of family practices and mental health services, with more people seen and provider skills augmented.
The model is not without its challenges, however. Space is in high demand, and often mental health professionals have to adjust to challenging and tight working environments (that is, within a family physician’s office or practice). Finding time to effectively collaborate can also be a challenge. Mental health professionals in the primary care environment can find themselves assigned to too many patients, leaving limited flexibility to take on new patients, or provide time for those that needed more therapy. Conversely, family physicians in this model are fronted with increased administrative workloads and internal meetings, causing them to struggle to find space to effectively collaborate and coordinate care.
The HFHT program has inspired establishment and delivery of similar models internationally, although fitting collaborative practices within existing health system funding models posed significant sustainability barriers.
Case Study #2: Practice Nurse Mental health (PN-MH), Netherlands
In the Netherlands, general practitioners play a ‘gatekeeping’ role to the specialist mental health system. Notably, patients in need of mild psychological or social supports are encouraged to be treated in general practices. The PN-MH enables physicians to realize this role, supporting all patients in general practice care with psychological, psychosocial or psychosomatic symptoms (under the supervision of a general practitioner). Working in partnership with a general practitioner, the PN-MH supports, coordinates and manages care pathways for patients.
PN-MHs were introduced in 2008, and have slowly become more prevalent across general practice services (following increased government investment). The PN-MH provides support for all forms of mental health needs, and alleviates general practice burdens by taking responsibility for diagnoses screening, short-form consultations, patient education, and referrals. They work as embedded staff within the general practice, allowing them to be easily reached and referred to as a low-threshold service.
The PN-MH model plays an important role in realizing efficiency for the Dutch health system. Services with PN-MHs have shorter wait times, improved service provider experiences, faster referrals, and reduced treatment costs for patients. PN-MH clients also have lower levels of broader mental health system use. While the model improves access and efficiency, however, it is important to note that it does not guarantee better clinical outcomes over another practice once care begins.
Prevalence, use and scope of the PN-MH role has steadily increased since its introduction. While initially focused on supporting general practice delivery of mental health supports, policy changes now enable senior PN-MHs to act as coordinating practitioners, responsible for analysing, diagnosing and developing a client’s treatment plan, and coordinating care.
These changes to the scope of PN-MH roles, and continued investment, show the important role PN-MHs make in realizing collaborative efficient mental health care in the Netherlands.
How can Canada build upon these learnings to better help those in need?
Family physicians already face overwhelming workloads, and recruitment and retention of clinical professionals is a challenge being confronted internationally. Increased service integration, and role sharing mental health services and supports, pose an opportunity to address these challenges. While many decisions rest in the hands of service providers, policy-makers can set the stage for the change.
Lessons learnt abroad and locally show:
- Fit-for-purpose financial and clinical remuneration models are critical to realize sustainability for integrated services. While there are existing examples of collaborative care in Canada (including and beyond HFTH), Canada’s predominant fee-for-service model of physician remuneration incentivizes quick service delivery and volume over collaboration. Collaborative care tends to take longer. Funding models that encourage integrated practices, and close ways of working between physicians and other health workers, underpin success. Examples can be seen across provinces, such as Alberta’s Blended Capitation Clinical Alternative Relationship Plans.
- Services must be co-designed with primary care and mental health providers, and the patients they serve. Integrated services are most successful when they reflect local patient needs, and the ever-changing nature of their mental health. Health systems (and local services) should be organized acknowledging the significant impacts low acuity and easy-to-access services can have on a patient’s trajectory, and broader health system use.
- Technology and systems supporting efficient administration, communication and coordination underpin positive provider and patient experiences. Six in 10 physicians report a high or excessive amount of time working on EMRs at home, and physicians already have burdensome administrative loads. Integrated practices pose a risk of increasing internal and administrative tasks. Change must be accompanied by investment in fit-for-purpose systems, allowing among other things, quick and easy sharing of patient data (e.g. through EMRs) and communication (e.g. through shared secure messaging).
Integrating services is not just about bringing workforces together, but creating a system where clinical and non-clinical professionals can thrive without burning out.
Where to from here?
Realizing greater integration between the mental health and primary care systems won’t be easy. Wholescale change begins with the system, but there are also opportunities for family physicians and their practices to make small adjustments for the better of all people in Canada.
System led change: Revise how family physicians are renumerated and funded
It is clear the current pipeline of family physicians and specialists cannot meet the current or future needs of Canadians. Collaborative practice must be endorsed.
Across provinces (and internationally), collaborative on-site practice tends to fall to the side in standard funding models. Collaborative models, including community health centres, only succeed where funding models reflect the joint working environment needed to deliver best practice care for patients (see, for example, Norway, where a successful adaptation of the HFHT model was closed due to a failure to fit the model within current funding models).
Collaborative care models must reflect:
- The time taken to collaborate across professions (i.e., increased meeting and administrative time to coordinate services)
- Potentially longer service times, with patients seeing multiple health professionals in one visit
The role collaborative care plays in the broader health system (that is, in addressing primary and mental health needs early, before they become more complex and costly). Innovative funding models seen at home and abroad. These pose opportunities to foster collaboration, and build the health workforce’s capacity.
Family physician led change: Make small adjustments to support prevention and early identification
Small changes can be made in how services are provided to patients. Some of these are all practiced by family physicians across the country, and represent small adjustments that can help people in need.
| Normalize mental health as part of overall health | In everyday practice, ask patients about their wellbeing | Share existing online resources to patients that may be interested in learning more |
This may include framing mental health discussions in the same way a routine physical check would be undertaken. Let patients know about the potential help you as a family physician can make (in connecting them with resources, or undertaking a more fulsome mental health and wellbeing assessment). | These questions could be simple and exploratory, such as (drawing on existing resources like PHQ-2): "Over the last two weeks, have you had any changes to your energy or mood?" Or be focused on prevention: "Are there any pressures in your life right now like money, housing, work, or caregiving that are weighing on you?" "Are the support systems you have feeling enough at the moment?" This may prompt opportunities to ask more fulsome questions. | We find people often have trouble navigating or accessing supports and there are many available. Support may include sharing existing community resources, such as those made by community, or national organizations (e.g. CAMH). |
All change starts with a simple recognition: mental health is health. No person experiencing mental ill health deserves to be left without the supports they need.
Get in touch to discuss the future of the Canadian mental healthcare system.
Connect with Tessa Dehring, Emma Kenyon, and Matt Guilding on LinkedIn.
Authors
Tessa Dehring
Principal
Tessa co-leads Nous' organizational performance and leadership and capability work globally.
Emma Kenyon
Director
Emma supports organizations to assess performance, develop strategies and improve outcomes.
Matt Guilding
Manager
Matt is an experienced strategy and public policy manager, working across the health, human services and education sectors.