Collaboration between specialist and primary health services in psychiatry: Development and implementation of the Pomor model to Arkhangelsk County, Russia

Mental health problems are a global issue and are increasingly drawing headlines in modern society. Along with preventative measures, effective mental health care is needed to provide treatment and support for communities. Such care generally falls into two categories: primary and specialist. In most Western countries primary care is provided by a general practitioner (GP). They are the first point of contact for patients and are also responsible for continuing care. After assessment, a GP may decide that specialist care is required and will refer a patient to the appropriate service. The relationship between primary and specialist care providers is therefore integral to achieving positive patient outcomes.

Cooperation between the two services varies greatly between, and even within, countries. It depends on a number of variables such as geography, education, and political priority. For example, Norway has introduced a model for organised cooperation where it is intended that specialist care providers take an active role in communicating with primary care providers. However, the model has been implemented to varying extents across the country so that in many cases specialist care functions more as a reference point for primary care.

Mental health care in Russia
Vast changes to the economy following the collapse of the Soviet Union in 1991 led to Russia experiencing a substantial decrease in total population. This was exacerbated by public health problems including mental health, suicide, and alcohol abuse. This left some areas such as Arkhangelsk County, with a population of around 1.2 million sparsely spread across an area of 600,000 km². Issues with cooperation between primary and specialist care are particularly relevant in areas such as this where workforce numbers and capability are limited. While steps have been taken to improve Russian primary health care, there is still excessive specialisation whereby only 16% of physicians function as GPs, compared with 30-50% in Western Europe. Investment in improving the role of primary care givers in the treatment of people with mental health disorders has been insufficient to significantly change this. While institutional psychiatric care has declined considerably in Western Europe, it is still widespread in Russia. In cities such as Arkhangelsk, specialist care centres are stretched to provide primary care, while in rural areas primary care is often given by under-qualified practitioners. In other districts attempts have been made to integrate training on mental health into health sector reforms, but unfortunately the approach has been met with limited success. Furthermore, cultural and ideological traditions in Russia mean mental health stigma is strong, and economic resources are sparse.

Issues with cooperation between primary and specialist care are particularly relevant in areas such as Arkhangelsk where workforce numbers and capability are limited.

Collaboration between two countries
In an effort to address the issues described above, Russian and North Norwegian collaborators have been working on psychiatric research and mental health service development in Arkhangelsk for the last two decades. Through comparative assessments of psychiatric care, and time spent visiting primary and specialist health providers in both countries, the team has built up a good knowledge of how services function and the issues faced. In the last decade their focus has been mainly on how to improve mental health care by facilitating cooperation between primary and specialist services, through the development of a model.

The researchers were keen to follow several prerequisites for the model. Firstly, that it complied with federal and regional health policy guidelines that mental health should be integrated into primary care. Secondly, that the people involved in all stages of the project were closely affiliated with the relevant health services, so they had the necessary knowledge of local needs and resources and the authority to implement changes. Along with the Russian-Norwegian researchers, the project included collaboration from a primary health care centre near Arkhangelsk, and a group of Russian and Norwegian GPs. The project also had backing from Northern State Medical University (NSMU) in Arkhangelsk and the health minister for Arkhangelsk County.

Procedure for development of the model
An in-depth situation assessment confirmed failings in the existing cooperation between the two services, both in terms of literature review, and specifically at the collaborating primary health care centre near Arkhangelsk. Based on this, the Pomor model (named for settlers in the area known as Pomors) in psychiatry was developed.

In the model, GPs assess patients’ mental health needs into one of three categories: those with severe disorders, those with moderate disorders, and those in stable remission. The level of care and collaboration between the GP and specialists is determined by the category. For example, GPs will have closer input from specialists when treating patients with severe disorders, and less when treating those in remission. Regardless of the category, GPs will have access to specialist advice as and when needed, and are also provided with guidelines for diagnosis and treatment that can be used in daily practice. Additionally, GPs and specialists will have a yearly joint review to discuss diagnosis, treatment, and to reaffirm the cooperative approach of the model. The model is designed to foster long-term collaboration between both parties.

A key focus of the model is the integration of information and communication technology (ICT) to facilitate cooperation between the health care services.

A key focus of the model is the integration of information and communication technology (ICT) to facilitate cooperation between the health care services. This is particularly relevant to areas such as Arkhangelsk with large geographic distances between professionals. Also essential to the model is the ongoing training and competence building of GPs. Such was the success of the training programme developed, that it is now included in compulsory family doctor training backed by NMSU.

Administrative responsibility
The district psychiatric centre in Arkhangelsk, which has the participating primary health care centres within its area of responsibility, was assigned by the Minister of Health to implement the model. This meant that implementation of the model was not delayed by any existing reluctance to take responsibility for first-line mental health care. In many countries, as in Norway, specialist and primary services belong to different administrative levels. This often prevents the degree of mutually binding cooperation and prioritisation that was possible in this project.

Initial evaluation and implementation
An initial evaluation of the model showed positive feedback from both patients and professionals. Although both GPs and specialists had been sceptical about aspects of the model, they were pleasantly surprised. GPs found that contrary to belief, patients were pleased to discuss their mental health issues with them, and in fact found this less stigmatising than when dealing with specialists. Specialists who had doubts concerning GPs’ capabilities in dealing with psychiatric patients, found these were relieved after a relationship was built between the two services. This success has led to the model’s implementation in other districts, with a view to eventually rolling it out across the entire county. Indeed, requests have also been made for its use in other parts of the Russian Federation.

While Dr Sørlie and colleagues report that integration of the model has so far encountered relatively few obstacles, development of the model is on-going, and its roll out across larger parts of the county may present more of a challenge.

Summary
Close collaboration between the Russian and Norwegian teams has led to the development of a model that is unique in its approach. Psychiatric care is distributed cooperatively between primary and specialist services to improve diagnosis and treatment outcomes for patients. GPs have access to specialist assistance when it is needed and are provided with the training they need to be confident in treating patients themselves.