Access

Early intervention and support are evidenced to alleviate distress and improve outcomes (Bird et al., Reference Bird, Premkumar, Kendall, Whittington, Mitchell and Kuipers2010; McGorry and Mei, Reference McGorry and Mei2018; Read et al., Reference Read, Roush and Downing2018). However, the workshops showed that early intervention is not available in all countries. It was reported that people met barriers and received little or no help until they reach the threshold to meet the criteria to enter services. However, not all receive access to specialized treatment due to their diagnosis or having a comorbidity such as addictions or physical health problems. Access barriers leave people suffering on waiting lists, often unrecognized, misdiagnosed, misunderstood, or ending up in different parts of the system, notably the criminal justice system. Countries with a health insurance funding system reported that treatment was only available for those with symptoms that fitted specific ‘diseases’. Countries without health insurance reported a ‘lottery’ of health care with no consistency of services nor allocation of resources. All countries reported that funding for mental health services is not equal to physical health.

To get a better and fair access to mental health care in a primary care setting, there should be no artificial limits if you require care. Access needs to be at the right time, in the right place, by the right person with the right skills. Primary care can enable swift access at a low level and recognition stage (Dowrick et al., Reference Dowrick, Bower, Chew-Graham, Lovell, Edwards, Lamb and Waheed2016). Collaboration ensures that the patient can get the support they need when they need it, including housing, benefits, work, family, social support, therapy, and specialized mental and physical health services. Primary care offers a continuation of support that matches need, freeing up demand for specialist services. Specialist services need to be working collaboratively with communities that involve patient and caregiver voices, primary care, social care, and the voluntary sector in an integrated system to support the patient on their path to recovery (Woltmann et al., Reference Woltmann, Grogan-Kaylor, Perron, Georges, Kilbourne and Bauer2012).

Co-creation

Throughout the workshops, it was voiced that there could be no improvements and decisions made without the patient at the heart of all that was done. Concern was expressed that co-creation is frequently discussed and is represented in international policy documents and is rightly best practice, but, is seldom delivered upon. A systematic review of the literature (Manikam et al., Reference Manikam, Shah, Reed, Santini and Lakhanpaul2017) evidences this view demonstrating the growth of published material from 6 to 150 papers from 2006. However, these are across all of health showing co-creation remains an under-resourced and under-invested area of Primary Care Mental Health. Evidence shows that language and access to some cultural communities are barriers in meeting their mental health needs and co-production could increase participation rates to improve the quality of services (Lloyd et al., Reference Lloyd, Johnson, Sturt, Collins, Barnett, DeSouza and Williamson2008; Minogue and Girdlestone, Reference Minogue and Girdlestone2010).

To do justice to co-creation patients and caregivers need to be at the heart of all we do, and their voices must be heard within any system change. Integrated pathways of care will work when patient and caregiver experiences are shared, and their world view is understood. The World Health Organization (Murray et al., Reference Murray and Lopez1996) emphasizes the need for people-centered health services, which sees people as participants as well as beneficiaries of health care services. Primary Care Mental Health services of the future need to be integrated, responsive, and compassionate in their response. Patients need the education and support they need to make decisions and participate in their care. (World Health Organisation, 2015). This will ensure that services are tailored to meet the breadth and depth of need from local community sources. Investment and mainstreaming of patient-led research and evaluation will benefit services, communities, and individuals alike.

Complexity in primary care

Mental health is individual with complex biological, social, spiritual, cultural, medical, psychological, existential, and economic factors interconnecting. Clinical guidelines and evidence-based medicine focus on single issues and the best treatment for a sample population that tends to exclude people by age, culture, and gender (Smit and Derksen, Reference Smit and Derksen2017). We need to acknowledge the individual, consider comorbidity, and the interconnectedness of all factors. It is time to change systems of care (Sturmberg et al., Reference Sturmberg, Martin and Katerndahl2014).

Building teams around primary care to link patients into the community and local mental health services is a good way of ensuring that every individual can be supported to meet their complex needs (Thota et al., Reference Thota, Sipe, Byard, Zometa, Hahn, McKnight-Eily and Gelenberg2012). The EFPC underlines that primary care practitioners are experts in complexity, acknowledging the individual, their surroundings, and the interactions between physical and mental health and the need to look after both (Kringos et al., Reference Kringos, Boerma, Hutchinson, Van der Zee and Groenewegen2010). They are rooted in their communities and in a good position to know about both the problems and the assets within the areas they work in.

Diagnosis of mental health disorders

The use of psychiatric diagnosis in primary care is problematic (Vanheule et al., Reference Vanheule, Adriaens, Bazan, Bracke, Devisch, Feys and Calmeyn2019). A psychiatric diagnosis misses the individual context of the patient, which is needed to weigh up the symptoms and to answer the request for help (Van Os, Reference Van Os2014). The complaints of the patient are often compounded. Moreover, there is a huge amount of overlap in symptoms resulting in difficulties with classification. A diagnosis does not tell us much about what kind of treatment the patient needs (Allsopp et al., Reference Allsopp, Read, Corcoran and Kinderman2019). The professional guidelines, linked to the DSM-5 diagnoses, tend to medicalize mental problems, whereas in primary care contextualized mental health problems are presented and managed.

Instead of focusing on the diagnosis regarding mental health problems, the focus should be much more pragmatic. This pragmatic approach allows recognition of individual experience and gives a better understanding of the distress of the patient (Allsopp et al., Reference Allsopp, Read, Corcoran and Kinderman2019). This could be as easy as asking four questions: what happened to you? What is your vulnerability and what is your strength? Where do you want to go? What do you need? (Van Os, Reference Van Os2014; Delespaul et al., 2017). From an integrated care perspective, we advocate for a centralized role for the patient based on their individual needs supported by a whole system approach including local caregivers. Primary Care Mental Health problems should be seen in a context where treatment will stimulate normalization and self-care in harmony with the patient.

Education

The views were that there is a lack of awareness and skills in communicating and managing well-being and mental health across the whole population, resulting in fear and stigma. The literature supports this view of stigma not just being at a population level but also across professions (Schulze, Reference Schulze2007), education (Martin, Reference Martin2010), disciplines including physicians (Wallace et al., Reference Wallace, Lemaire and Ghali2009), communities, and whole countries (Saraceno et al., Reference Saraceno, van Ommeren, Batniji, Cohen, Gureje, Mahoney and Underhill2007).

A workforce, fit for the future, requires education that is fit for purpose at all levels. There is a need for education that enables awareness of mental health and well-being from an early age to enable prevention, early detection and to address stigma, the entire population requires a level of knowledge. Research shows that contact combined with education seems to be the most promising avenue (Rüsch et al., Reference Rüsch, Angermeyer and Corrigan2005; Thompson et al., Reference Thompson, Dogra and McKinley2010). Professionally, mental health needs to be embedded across the curriculum of all disciplines starting at an undergraduate level and continuing through post-graduate training and continuing professional development. Co-production and a wider knowledge base that builds on the needs and experience of service users for their recovery journeys (Leamy, 2011; Stuart et al., Reference Stuart, Tansey and Quayle2017) is key, as is reflecting people’s cultural and spiritual needs.

Inequality

Mental health is not discriminatory. We know that certain areas are at higher risk of mental health problems because of greater exposure and vulnerability to unfavorable social, economic, and environmental circumstances (Barnett, 2012; Wilkinson and Pickett, 2017; Ribeiro et al., Reference Ribeiro, Bauer, Andrade, York-Smith, Pan, Pingani and Evans-Lacko2017). Nurture, love, support, and freedom to grow are necessary to develop into a healthy adult, but those born in poorer families and poorer areas have an increased risk of mental health problems in later life (Vannieuwenborg et al., Reference Vannieuwenborg, Buntinx and De Lepeleire2015; Tong et al., Reference Tong, Liaw, Kashiri, Pecsok, Rozman, Bazemore and Krist2018). There are fewer mental health problems in societies where the population feels they have control over their lives and are involved in decision-making. The poor have less choice and societies are happiest where inequalities are lowest. Poverty divides society and is a major factor for mental illness, the dispossessed lose hope and feel left behind whilst the rich fear losing the security of their wealth.

Inequalities caused by adverse life events, racism, and other forms of discrimination, abuse, violence, neglect, immigration, refugees, asylum seekers, illness, bereavement, relationship breakdown, contact with the criminal justice system and institutional care are all related to an increased risk of mental health problems. There is enough evidence that we should strive for fewer income differences to improve the health and well-being of populations (Pickett and Wilkinson, Reference Pickett and Wilkinson2015; Barnett et al., Reference Barnett, Mercer, Norbury, Watt, Wyke and Guthrie2012). We will not reduce the stigma associated with mental illness, unless we recognize this and focus on the causes and reduction of their impact, instead of blaming it on inherent weakness in the individual (Clement et al., Reference Clement, Schauman, Graham, Maggioni, Evans-Lacko, Bezborodovs and Thornicroft2015).

Information technology

Concern was shared regards the growing shortage of General Practitioners all over Europe. It was voiced that health care systems alone will not be enough to meet the growing need for treatment of mental health problems (Bodenheimer and Smith, Reference Bodenheimer and Smith2013). Social media can isolate and be the cause of deterioration of mental health through cyberbullying and social isolation, but it can also be used to benefit mental health by providing education and therapy programs. There is a gap in our knowledge as to the impact of these programs, this gap should be narrowed down.

Information technology has the potential to help those with mental health problems, alongside those who support them. We must make this information technology accessible for everyone, not only for people who can afford it (Allen and Christie, Reference Allen and Christie2016). E-health web-based health interventions have been shown to increase access to care (Hilty et al., Reference Hilty, Ferrer, Parish, Johnston, Callahan and Yellowlees2013). There is evidence of websites, apps and other technologies, which used wisely can be of benefit, particularly to those unable or unwilling to access health and social care services. Guided Internet interventions seem to be cost-effective (Donker et al., Reference Donker, Blankers, Hedman, Ljotsson, Petrie and Christensen2015).

Information technology cannot replace the human touch; however, it can be used to the benefit of many, either with or without therapist and clinician support. Further research and investment are needed in this area.

Leadership

To create change, there needs to be governmental, clinical, community, and patient ownership. Within these areas champions for mental health are needed. Like all other conditions presenting in primary care, the approach should be biopsychosocial and existential. ‘There needs to be an integrated approach which is case managed with a recognition that it corresponds with complexity sciences which have cohesion and dynamics in their focus’ (Smit and Derksen, Reference Smit and Derksen2015).

The process of change is one that needs guidance and understanding, which requires leadership at all levels. We know ‘one size does not fit all’, so it is important to recognize the uniqueness of each environment and tailor services to meet population needs with leaders to inspire that change. These leaders need to be visible throughout society in schools, faith centers, education, and medicine. Their role is simple to inspire others to create change and develop ownership. Therefore, to enable the rhetoric of national and international statements advocating a change in mental health to become a reality, we need transformational leadership to inspire the change (Hallinger, Reference Hallinger2003; Day and Harrison, Reference Day and Harrison2007; Plsek and Greenhalgh, Reference Plsek and Greenhalgh2001; Plesk and Wilson, 2001; Sturmberg and Martin, Reference Sturmberg and Martin2012; Sturmberg et al., Reference Sturmberg, O’halloran and Martin2012).

Model of care

Family doctors, from all countries, support people across society and at all stages of their life course. Good primary care provides compassion and cares for the individual, from conception to a good death. There needs to be the recognition that every child, man, or woman has their own unique needs when experiencing mental ill-health. There also needs to be a clear recognition of the families and caregivers, who also have distinct needs that are often not understood in the school, community, and workplace environments.

Therefore, the EFPC states that integrated working is a priority across community, health, and social care, with best practice examples needing to be understood and shared. Integrated care needs to be at a local level, with skill mix and holistic representation linked to primary care. For more complex needs a dedicated team around the person, offering available support twenty-four hours a day, was identified as key. Mental health needs a clear equitable model of care, which includes investment in prevention, early intervention, access, treatment, and recovery. There is evidence from the USA, Belgium, and the UK that approximately 50% of healthcare costs come from 5% of the population. These high costs, high need patients are often complex and involve multiple agencies (Blumenthal et al., Reference Blumenthal, Chernof, Fulmer, Lumpkin and Selberg2016; Rosen, Reference Rosen2018). Adopting a risk stratification model (Figure 1) as a framework to develop a fresh approach for mental health will ensure that investment and integration are key pillars of development. It will also address those more complex patients presenting with comorbidities (Thornicroft et al., Reference Thornicroft, Chatterji, Evans-Lacko, Gruber, Sampson, Aguilar-Gaxiola and Bruffaerts2017). Whilst increasing expenditure on mental health is important it is not the sole driver of change. Improved care and outcomes are equally as important. Reducing inequities in geographic coverage and meeting unmet need means using Primary Care as the first point of support and entry prevents the spiraling of distress and enables the reduction in avoidable hospitalizations. Kaiser Permanente, an American Health Organization, has developed a risk stratification model (Jadad et al., Reference Jadad, Cabrera, Martos, Smith and Lyons2010) which has been also used in the UK to categorize levels of care.

Figure 1. Proposed model of care for mental health based on Kaiser Permanente risk stratification pyramid

‘Case management’ ensures coordination for individuals with complex needs requiring integrated high health and social care support. ‘Care management’, at the next level, provides for high-risk individuals using peer support and education. ‘Supported self-management’ is the level of care for individuals with good control of their mental health in recovery needing only routine medical review. The ‘risk stratification’ allows a framework for both health promotions in the community and for identifying clients at risk.

Prevention

The European Forum for Primary Care recognizes that the mental health issues presented in primary care are often preventable and can be caused by external and environmental factors (Patel et al., Reference Patel, Lund, Hatherill, Plagerson, Corrigall, Funk and Flisher2010; Hughes et al., Reference Hughes, Bellis, Hardcastle, Sethi, Butchart, Mikton and Dunne2017). These factors are diverse and include global issues such as war (Lindert et al., Reference Lindert, Carta, Schäfer and Mollica2016; Miller and Rasmussen, Reference Miller and Rasmussen2017), disease (Scott et al., Reference Scott, Von Korff, Alonso, Angermeyer, Bromet and Fayyad2009), inequalities (Wilkinson and Pickett, Reference Wilkinson and Pickett2017), maltreatment in childhood (Angelakis et al., Reference Angelakis, Gillespie and Panagioti2019; Norman et al., Reference Norman, Byambaa, De, Butchart, Scott and Vos2012), poverty (Patel et al., Reference Patel, Lund, Hatherill, Plagerson, Corrigall, Funk and Flisher2010), and debt (Sweet et al., Reference Sweet, Nandi, Adam and McDade2013). Within affluent societies, despite policies and investment, mental health needs are not a priority, are not reducing and in some countries are increasing (Jorm, Reference Jorm2014). Current predictions indicate that by 2030, depression will be the leading cause of disease burden globally (World Health Organisation, 2011) The impact is far-reaching, going beyond a global economic issue, to one which, on a personal, family and community level, impact on people’s spiritual, social, economic, physical, and psychological well-being.

To enable mental and physical health to be of equal status and ensure parity of esteem requires research, evidence, and investment (Sabbe, Reference Sabbe2013). The use of education, including mental health promotion, would enable a population approach to manage this ever-increasing problem. Supporting this is the move toward social prescribing in primary care and the use of the community and third sector (Maughan et al., Reference Maughan, Patel, Parveen, Braithwaite, Cook, Lillywhite and Cooke2016). Therefore, a fundamental paradigm shift toward prevention (Jorm, Reference Jorm2014; Keet et al., Reference Keet, De Vetten-Mc Mahon, Shields-Zeeman, Ruud, Van Weeghel, Bahler and Pieters2019) and community-based services including primary care is required (Knapp et al., Reference Knapp, McDaid and Parsonage2011). This needs to be holistic and compassionate requiring both government strategic support and investment.