Implementation of the Quebec mental health reform (2005–2015)

The objectives of the Quebec MH Reform were similar to those characterizing reforms undertaken in other industrialized countries. The Quebec reform aimed to improve: 1) access to MH services especially by reinforcing primary care; 2) quality of care through the development of shared care and best-practices and 3) continuity of care through better integration of primary care with specialized MH services. Overall, the results of this study demonstrate that the objectives of the MH Reform were not fully met. Concerning the first objective, i.e. access to care, standards for accessing treatment through the one-stop services, as well as quotas of psychosocial professionals and GPs in HSSC-MH adult primary care teams, were not attained in most networks. The fact that the Quebec MH Reform focused mainly on the implementation of new structures, and less on operational mechanisms, may explain the difficulties encountered in implementing the one-stop services or HSSC-MH adult primary care teams in some networks. This emphasis on structure seems to reflect the division of authority in the Quebec health system: while the Quebec Ministry provides the main orientations, regional agencies are responsible for budgeting and coordination in their networks, and local territories led by the HSSCs manage operational modalities. As a result, local territories with relatively few material or human resources or without strong leadership had greater difficulty implementing new services and practices. Furthermore, regional and local network regulations are generally more consultative than hierarchical or top-down [44]. Yet the literature highlights the need for centralized network structures, clear guidelines and benchmarks as well as stakeholder support in implementing complex interventions such as those advanced by the Quebec MH Reform [10, 45]. The focus on structure rather than implementation processes or outcomes was not unique to Quebec. MH reform in Belgium also required that networks implement several new services without providing detailed directives or outcomes to stakeholders responsible for implementation [10].

Efforts to implement shared-care in the Quebec MH Reform were hampered by the absence of GPs in most HSSC-MH adult primary care teams, as well as their general lack of interest in taking on clients with MHD. Moreover, while GPs in medical clinics ranked second in terms of frequency of interaction with HSSC-MH primary care teams, they were sixth in terms of satisfaction, which suggests something lacking in terms of continuity of care or quality of services. This could be explained by the fact that GPs are also solicited for health issues other than MHD. Also, GPs have little time to provide psychotherapy, as consultation time is severely limited in primary care [46, 47]. Moreover, while GPs did treat common MHD, most avoided taking on clients with severe MHD or co-occurring MHD-SUD, referring them automatically to MH specialized services [48‐50]. This finding corresponds to previous studies where the involvement of GPs with severe MHD or more complex cases was reportedly problematic [46, 51]. Recent MH reforms in Australia [8], and Finland [16]), reveal the central role of GPs as well as psychiatrists who were closely involved in the operation of multidisciplinary MH teams.

The HSSC-MH primary care teams treated common MHD, but also served an important minority of clients with severe MHD, personality disorders, suicidal ideation, and co-occurring MHD-SUD as well as chronic physical illnesses. The literature suggests a number of benefits accruing from primary care services for these clients: primary care is less stigmatizing than specialized MH services [52], fosters better community reintegration for individuals with severe and chronic MHD [33], and facilitates the treatment of chronic physical disorders often associated with MHD or SUD [53]. One may argue, nonetheless, that follow-up for some clients with severe or complex MHD may be more adequately provided by assertive community treatment teams, as highly specialized ambulatory services, rather than by primary care or intensive case management teams [54]. The referral of severe and complex cases, or less stabilized clients, to primary care may have resulted from the lack of specific eligibility criteria governing client referrals to primary versus specialized care, and the need to establish clear boundaries between the two levels of service.

Concerning the second objective (quality of care), the Quebec MH Reform prioritized the implementation of respondent-psychiatrists in order to enhance the expertise of primary care providers. The results show that respondent-psychiatrists collaborated more with HSSC-MH primary care teams than with GPs, however, and considered their impact higher on the quality of care provided by the HSSC teams. One likely explanation for this result was that respondent-psychiatrists had more previous contact with clinicians on HSSC-MH primary care teams, many of whom had been transferred from MH specialized services, than they had with GPs working in medical clinics. By contrast, according a recent Quebec study [49], 50 % of GPs had no previous contact with either psychiatrists or other MH professionals. Collaborative care is easier to implement when the providers involved have pre-existing relationships [47]. It should also be noted that respondent-psychiatrists were implemented late in the MH reform, suggesting the need for more experience with this strategy by both parties. Moreover, respondent-psychiatrists devoted very little time to GPs in terms of either telephone consultations or face-to-face discussions, which may explain their difficulties in building effective relationships with GPs. The implementation of successful innovation take time, especially initiatives like shared-care that entail a major shift in the MH system and in GP practices [55].

The Quebec MH Reform, unlike certain others [10], did not provide sufficient guidance on clinical processes, or on the use of clinical approaches or clinical/evaluation tools, which suggests why certain processes were underutilized. By contrast, MH reforms in countries like England [7], or Australia [8] provided clear guidelines around the implementation of clinical evaluation tools, best practices, and processes favoring the improvement of MH services, as well as performance assessment frameworks and specific indicators for MH system evaluation [15]. Curiously, certain strategies associated with co-occurring MHD-SUD services were more adequately implemented in the networks studied than MH strategies. For instance, screening and assessment tools for SUD were used more often than similar tools for MHD. Primary care teams often used motivational interviewing, which should be particularly effective for co-occurring MHD-SUD [56]. This may reflect the training offered to HSSC primary care teams by the Quebec Ministry from 2007, as part of its SUD program [57], that was generated by the high prevalence of co-occurring disorders in MH caseloads. Research suggests that half of individuals with a lifetime SUD may also have at least one lifetime MHD [58].

Concerning the third objective (continuity of care), referral procedures were the most successful integration strategy implemented. This result stands to reason as referral procedures represent the main form of inter-organizational collaboration, demanding the least amount of mutual dependence and organizational involvement [59]. Unlike referral procedures, service agreements formalize collaboration between organizations, and define their respective roles and responsibilities. Most HSSCs succeeded in formalizing service agreements with SUD rehabilitation centers for evaluation and collaborative treatment of individuals with co-occurring disorders, and with crisis centers for evaluation and follow-up of individuals at elevated risk for suicide. This seems to account for the high level of satisfaction among HSSC-MH primary care teams in their interactions with these organizations. In terms of liaison officers, participants cited their interactions with addiction specialist nurses as most satisfactory. The added value of liaison officers was underscored by the implementation of liaison teams to reduce the overflow of individuals with SUDs in emergency rooms in the context of the ministerial reform of the SUD program that was occurring simultaneously [57]. Working in partnership with emergency rooms and hospital units, the liaison teams systematically tracked clients with SUD or co-occurring MH-SUD and directed them to appropriate services [60]. According to a recent study, clients with SUD identified in emergency rooms by liaison nurses were 30 times more likely than others to enter a therapeutic program [61].

Another key network integration strategy, shared training, was moderately implemented, suggesting that the MH Reform did not view staff training as a priority, unlike reforms elsewhere [15]. While the training offered by the MH National Center of Excellence was important for implementation of intensive case management, other training opportunities for GPs and clinicians from HSSC-MH primary care teams were lacking. Yet good training infrastructure is essential to successful implementation of health reforms; training enhances provider competence and the appropriateness, quality and effectiveness of interventions [35], while also promoting a common vision [62, 63]. Unfortunately, training is too often perceived as a luxury, and may fall victim to budget cuts early on [64].

Finally, it is interesting to note that resource scarcity may be either a barrier or facilitator to reform, and to network integration [34]. According to resource-dependency theory, limited resources require organizations to work together [65]. The literature confirms however, that the extensive availability of MH services allows networks to introduce a greater variety of implementation strategies, such as standardized clinical evaluation tools, service agreements, shared-training, and the introduction of respondent-psychiatrists and liaison officers, all of which enhance service integration [34]. Other barriers to MH primary care consolidation and network integration reported by participants coincided with barriers described in the implementation literature [11, 38, 40‐42]. An accumulation of hindering factors may have resulted in service duplication or compromised service continuity. Among these, resistance to change on the part of psychiatrists and GPs, staff turnover and lack of leadership were the most important barriers encountered. Strong local leadership as well as sustained training would be required in order to reduce resistance [66]. Despite significant support from the MH National Center of Excellence there was insufficient momentum for real transformation of the Quebec MH system to occur.