Denise Aubé , Community Medecine Physician, Researcher

1. How Mental Health Ministerial Orientations Generate Change in Public Health System: Lessons from The Quebec Experience with Regard to New Practices Implementation Denise Aubé , Community Medecine Physician, Researcher Quebec National Institute of Public Health / Research Group on Social Inclusion, Service Organization and Evaluation in Mental Health 2009 12th World Congress on Public Health, Session#24, April 28, Istanbul, TURKEY

2. Research Program (2006-2010) • Aim: • To support Mental Health Primary Care transformation in Quebec following introduction of Quebec Action Plan in MH • Funding: • From Canada: Canadian Health Services Research Foundation • From Québec: FRSQ, INSPQ, MSSS, GIRU • From 15 participating organizations • Main team members: • Vallée C., Poirier LR, Fournier L., Roberge P., Lessard L. • Total of 14 researchers and 16 decision makers

3. Quebec Ministerial Action Plan in Mental Health (June 2005) • Mechanisms: • Creation or consolidation of primary mental health care teams • Development of unique access for all referral needs when additional mental health services are required • Mentorship to support mental health professional and enhance mental health expertise development • Aims: • To upgrade service quality • To optimize existing resource utilization • To reinforce service coordination by fostering dialogue between main mental health actors

4. Research Program (2006-2010) • Main components: • A contextual survey • An organisational assessment of medical PC models • A medical PC user’s survey (anxious and depressive disorders)

5. Methodology Overview • Multiple case study: 15 local networks • Regional and local respondents • Data from: • Documentary sources • Individual interviews • Focus groups

6. Agenda • What do we learn from compliance analysis for desired changes? • Could we link results with collaborative process analysis to add meaning? • How ministerial input sustain changes implementation? • What’s next to deepen change understanding in 2009 data survey?

7. Selected Attributes for Compliance Analysis • Capacity of CSSS MH teams to act on various MH disorders and to provide multidisciplinary service supply optimizing local network potential • Availability of medical back-up from family physicians as well as from psychiatrists • Access to clinical advisors when needed • Presence of flowing MH services pathways for users

8. Results • Three groups with • Good / Moderate / or Poor compliance • But … differences between and within each group cannot be explained by : • Rural, urban or semi-urban area • Population socio-economic status • Development level of psychiatric services • Family physician shortage

9. Positive dynamic factors • Previous successful changes in the last 10 years with trends similar to those recently introduced • Well established collaborative mechanisms with various partners • Successful organization merging

10. High compliant group attributes • Successful dialog mechanisms with formal mutual agreement • Commitment from territory FP • Presence of fluidity and coordination • Relatively low turn-over of key personal members, with functional stability

11. Poor Compliance Group Attributes • Cohabitation of mixed pitfalls: • Non assumed cultural clash from relatively recent merging (with CHC or CH) • History of conflicts between some partners • Staff shortage, lack of support or solutions • High human resources turn-over • Uneasy negotiation with psychiatric leaders or hospital managers • Various access problems for regular or specific MH clienteles

12. Essential Conditions to Successful Implementation • Realistic timeline to build a positive background to their implementation including development and consolidation of various collaborative processes • Favourable human factors characterized by stability, dynamism and constructive leadership as well as management skills for continuous adjustment • Space for innovation to cope with special needs • And, sometimes, required investments to address complexity or resource shortage

13. Main Components for Collaboration Setting the problem Devising a common direction Structuring the local services network

14. Main Components for Collaboration • Setting the problem: • Continuous process involving all partners • Interdependence • Quality and frequency of contacts, or connectivity • Credible and competent leaders • Positive expectations • Devising a common direction • Development of a common perspective • Sharing of relevant information • Structuring the local services network: • Power redistribution • Implementation of mechanisms or strategies to support collaboration and integration at clinical and functional levels • A large sense of affiliation

15. Quebec MHAP Usefulness • Strong population-based analysis, with PRIMARY CARE as services anchorage • Cohesiveness recognized by all main health system actors: • Same orientations for all • Same structural measures for all • Legitimacy, a strong control lever for managers to introduce changes

16. Comments ?Thank you

17. Conclusion • Changes: dynamic and slow to implement • No recipe: historical background, uniqueness, critical human factors, physician investment • Sustained dialog: imperative, time-consuming and sometimes challenging = need forformal and informal meetings, need to enhance personalized relationships and foster linkage • Collaboration as a baseline: interdependence, connectivity, information sharing, power redistribution etc. • Extensive resources are not a key success and scarce resources are not a deterrent • Public policies: a must for overall vision, cohesiveness, legitimacy