The Impact of Organisational Culture on GP – Mental Health Service Shared Care

AbstractOBJECTIVE: Literature on mental health shared care often refers to positive organisational culture as being necessary for the successful development and sustainability of shared care between general practitioners (GPs) and mental health services. What is not specified is what is meant by ‘positive organisational culture’ in this context, nor why it makes a difference. This study investigates how organisational culture in both general practice and mental health services impacts upon mental health shared care both positively and negatively. DESIGN: A brief review of literature is followed by qualitative interviews with GPs, mental health service clinicians, mental health service managers and shared care coordinators, conducted using a convenience sample with a snowballing technique. SETTING: Mental health shared care between GPs and mental health services in the Australian States of South Australia (SA) and Western Australia (WA). MAIN OUTCOME MEASURES: Participants identified a number of organisational culture factors as impacting on GP mental health shared care in GP culture, mental health service culture, and the intersection of the two cultures. DISCUSSION: Organisational culture and differences in organisational culture impact on any long-term shared care model. A number of themes relating to the professional training and background of participants and of the organisations in which they work impact on the effectiveness and sustainability of the way they work together. Two models of shared care are identified that address these themes in different ways. CONCLUSIONS: Organisational culture is largely unrecognised and misunderstood, particularly in terms of GP culture, but is a major factor that needs to be addressed in mental health shared care. The way a shared care model addresses (or does not address) these factors can affect its sustainability and ‘upscale-ability’ (the ability to take a small model and apply it across a broader geographic region or larger number of participants) and hence its effectiveness in delivering the desired outcome for professionals, consumers and carers.

Abbreviations: CMH - Community Mental Health, GP - general practitionersMBS – Medical Benefits Scheme MHW - Mental Health Worker)

Abstract word count = 313 including headingsArticle Word Count = 3430

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IntroductionMental Health Shared Care addresses the Federal-State funding divide in Australian mental health care. Mental health shared care literature usually states that a ‘positive organisational culture’ is necessary for effective sustainable shared care, without defining the term. [1, 2]

This study thus sets out to discover: 1. What are the cultural barriers between mental health services and GPs

that prevent spontaneous shared care? 2. What are the cultural and other factors that affect whether a shared care

model works?

MethodQualitative interviews were held with current and past participants in mental health shared care, using a convenience sample and a snowballing technique. Participants included GPs (N= 6), mental health service shared care participants or coordinators (N=5), senior mental health service managers (N=2), Divisions of General Practice shared care coordinators (N=4). Interviews were conducted in SA and WA, usually in person but some via email because of distance and time barriers, in late 2006 and early 2007.

Questions were used as discussion starters and participants were encouraged in free range exploration of their ideas. Questions related to shared care barriers, organisational culture in general practices and mental health services, and factors promoting shared care.

Handwritten notes were taken concurrently during the interviews, and later examined for themes. These were categorised according to commonalities and differences. Identified themes are listed in Table 1 and expanded in the following text.

Rationale for Shared CareGPs are often the first point of contact with the health system, gatekeepers to the system, coordinators of care, and the service with the most enduring relationship with consumers. [3, 4] Despite this ‘front end’ role, in part because of their Medical Benefits Schedule (MBS) funding and small business model, general practice stands somewhat apart from the public health system. [5, 6]

Coordinated mental health shared care can offer the benefits of reduced duplications, improved quality and timeliness of communication between providers, [7] elimination of gaps in a service pathway [8] and better continuity of care because of the GP’s longitudinal and holistic view. [9] Other perceived benefits mirror the benefits of effective primary care - improved health through prevention and early intervention, reduced demand on emergency departments, crisis services and hospital inpatient units. [10] Consumers expect that their

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health professionals communicate and collaborate on decisions regarding care, providing co-ordinated holistic health care. [11]

Shared care arrangements enable mental health services and GPs to negotiate the division of labour. Often this means GPs dealing with high prevalence disorders (eg depression and anxiety); however increasingly GPs have been managing more complex disorders, positioning public mental health services towards more acute disorders. [12]

Definition of Shared CareIn early 2006, 18 mental health shared care projects were operating in Adelaide, usually small scale and based on a service provider to whom this way of working is a passion. [1] The models vary considerably in how the GPs and publicly employed mental health clinicians work together.

Table 1 categorises some of the models self-described as ‘shared care’. For the purposes of this study, shared care is defined as where the ongoing care provided to the consumer is shared, [13] (the fifth option). This model requires a significant level of coordination and information sharing.

Table 1: Models of Care (aqua circles indicate a ‘unit of care’, CMH = Community Mental Health, MHW = Mental Health Worker)

Type of model Description Split care Care is divided between two or more providers working in

isolation (traditional referral system).[1, 14]Consultation-liaison

Care is provided by one provider with another provider occasionally providing advice but not providing ongoing care for the consumer. [1]

Shifted outpatients / liaison attachment

Psychiatrists, allied health workers or multi-disciplinary teams provide clinics and work from the GP surgery, but care is not coordinated with the GP.[14, 15]

Primary Care Teams

Multidisciplinary workers are employed by the GP practice or Division of GPs to work with GPs upon GP request. (Interaction controlled by the GP.)

Shared or collaborative care

General practitioners and mental health service providers formulate an agreed management plan which specifies ongoing roles and responsibilities of the various providers. [14]

(Table adapted from Keks NA. Altson BM. Sacks TL. Hustig HH. Tanaghow A. Collaboration between general practice and community psychiatric services for people with chronic mental illness. Medical Journal of Australia. 1998. pp 8-13.)

Organisational Culture

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Organisational culture is a metaphor for examining less tangible organisational issues, symbolic aspects of organisational life such as shared meanings, values, norms and belief systems, relationships within the organisation and with external entities. [16] Organisational culture is the shared reality of participants, [17] based on each participant’s relationship with other participants, their work tasks and environment as well as their pre-existing experiences such as training and other work experiences.

A strong culture can be used to legitimate activity and resist external pressures to change, hence forming a significant barrier to the development of new ways of working.[18] Culture can change, but often requires extreme circumstances.[19]

Medical Organisation Cultures

The majority of literature on health organisational cultures relates to hospitals. Little directly examines public community mental health services or general practices as they exist in Australia, or their interaction.

A profession’s body of knowledge, taught at university and reinforced through experience is key to defining professional identity. [11] It is these different skills that professionals bring to the shared care team. However professional identification also poses problems: different ideologies and goals, unequal power, perceptions of occupational prestige, role overlap and distrust of other perspectives, historical, political, social and moral factors. [11]

General practice and mental health services are staffed by clinicians trained under different clinical paradigms and funded through different structures. [1] Doctors are characterised as perfectionist, work driven [20], and preferring autonomous decision making styles. [21] Doctors are at the top of the health hierarchy in hospital, community health, and particularly in the general practice setting, small businesses usually owned by GP partners. General practice is funded through the Australian Government MBS to be independent small businesses.[5] GPs are increasingly working in larger practices with practice managers, and other clinical staff such as a practice nurse and allied health specialists. More GPs are working part-time, and the proportion of female GPs has increased.

Community mental health works in a multi-disciplinary model, [5] with allied health professionals (psychologists, mental health nurses, occupational therapists (OTs), social workers, Aboriginal health workers) working alongside specialists and other doctors. Power and control is divided between the doctors and specialists who work as visiting clinicians directing care, and allied health workers who are present all the time and hence have ‘ownership’ of office space.

Issues between GPs and community mental health services identified from the literature fall broadly into a few categories described in Table 2.

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Table 2: Explanation of Mental Health Shared Care Barrier categories

Barrier Description Organisational barriers, funding structures

Organisational barriers such as personal issues, employment terms and conditions, [22] funding structures and work pressures and a lack of understanding of each other’s systems and constraints [23] complicate relationships between the organisations. This aspect tends to be most easily explored in the literature. Other structural issues relate to the ‘categories’ of mental illness diagnosis for which specialist mental health services will provide care (inclusion / exclusion criteria). [23, 24]

Trust / respect Generally GPs tend to refer to specialists and practitioners whom they know, providing a level of confidence in ability and mutual understanding between referee and receiver. In Shared Care GPs are often referring to an organisation rather than a clinician. The relationships between GPs and community mental health services described as one of apprehension, the ‘high degree of suspicion and animosity’[1] and the perception that GPs do not understand the skills an OT or a social worker might bring to client care. [9] Conversely allied health practitioners reported disbelief that their voices would be heard in the Shared Care partnership. [11]

Paradigm / perspective

The different service providers, while providing a broader mix of skills, also poses problems: different ideologies and goals, unequal power, perceptions of occupational prestige, role overlap and distrust of other groups’ perspectives, historical, political, social and moral factors, [11]

many different ‘maps of the world’ (understandings). [22] Different professions are trained under different clinical paradigms [1] - doctors are educated in a medical model whereas allied health are often educated and trained in a broad psycho-social and public health models. Alternately, GPs as ‘generalists’ often have an holistic and longitudinal view of a consumer’s life [9], while community mental health workers have an area of specialisation or expertise and may have a sporadic, time-limited or crisis-intervention view.

Roles Shared care may involve intersection in the roles that each participant expects to fulfil, which may be compounded by a lack of understanding of how the participants will work together to ensure that the required range of services is provided between the providers. The literature suggests the role of case manager in particular is contentious, with both GPs and community mental health services expecting to fulfil this function. [12, 23, 24, 25] (Shared Care however puts the GP as pivotal to the patient’s care, often as the de facto case manager. [12]) There may be anxiety and disputes about professional territory, [21, 26] with participants resisting changes that impinge upon their current or traditional role in health care. [21, 26] Participants may have little understanding of the services other partners can provide clients, or what functions they are accustomed to encompassing in their work. [9]

The clash of roles also intersects with power.Knowledge A profession’s body of knowledge, as taught at university and

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reinforced through practical experience is key to defining professional identity, [11] defining difference from other professions. Shared care models value the different skills and perspectives that different professionals bring to care provision. However close understanding of one’s own knowledge base and lack of understanding of other professional knowledge bases leads to a lack of trust in professional ability and concerns about the ability of other partners to manage particular clients or conditions. [9]

Power Closely related to roles is power. Relationships between providers are described as uneasy power relationships, [1] as ‘fear of losing the overall management of consumers’, and as removal of power and responsibility from public mental health service. Conversely, GPs often report referring into public services as referring into a ‘black hole’ – they don’t know who will see their patient, what discipline, or when it will occur, what level of service they might get, and often receive little feedback. Some mental health professionals reported feeling threatened by GPs assuming more prominent roles including some case management aspects [13, 23] and felt a level of disbelief that their voices would be heard. [11] Alternately, some less powerful professions may see the shared care model as a way to redress the power imbalance through asserting dominance on the process. [11] Nurses tend to be highly aware of power imbalances and where they sit in the hierarchy, doctors are reported as being largely unaware of the power imbalance (which is favourable to them). [21] A feeling of powerlessness amongst participants is a barrier to change.[22]

Perceptions of each other

Further complicating shared care is perceptions of each other, and how they are perceived by other participants. Participants report the perception that GPs did not want to talk to the mental health nurses (which they felt was because they ‘aren’t good enough’), that GPs did not have the time, interest or skills and do not ask for help from nurses (ie: do not recognise their skill level),[9] and negative perceptions by the mental health specialist system of the abilities of generalists.[9] There is a general lack of understanding of each other’s systems and constraints.[1]

Shared Care Model SustainabilityIn organised shared care, organisations come to an agreement about how they will work together. Roles, referral criteria and methods, and communications are negotiated in advance.

The majority of models in the literature involve a coordinator to facilitate referrals and communication between providers, [10] service design and recording, monitoring, review and discharge [27] and in some models providing triage and assessment. The coordinator may be based at community mental health, GP surgeries, [27] or a Division of General Practice. Coordinators may be of any profession [10] including non-clinical.

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The coordinator is a ‘face’ for the service, a point of contact whose skills are trusted and whose role is understood by the GPs and mental health clinicians. [12] Whether the coordinator is clinical or non-clinical, the coordinator is the interface between the cultures of the GP surgery and the public mental health system. They provide a buffer function, dealing with both cultures but keeping them slightly separate.

The involvement of a coordinator is a key point in determining sustainability. Shared Care models are often funded in a short-term project manner. The coordinator facilitates rapid results as is required in short-term funding, but means sustainability is dependent on ongoing funding for their position.

Interview Results

Based on this understanding of Mental Health Shared Care and Organisational Culture, a series of interviews was conducted with GPs, community health clinicians, senior mental health managers and shared care coordinators in SA and WA. Table 3 catalogues the common themes drawn from the interviews.

Table 3: Themes identified from Interview Notes

Theme ExamplesPrimary care focus Focus on primary care (as opposed to acute care)

to enable shared care to be seen as important for mental health service participation, and adequately resourced.

Interprofessional barriers Relating to training, language, professional paradigm, focus of therapy and mutual understanding of roles. Hierarchical issues between various professions.

Logistical barriers Such as small business being funded on an activity basis whereas public sector employees are salaried, affecting time availability for non-financially supported activities such as meetings and telephone calls.

Bureaucratic barriers Issues regarding geographical boundaries which are fluid for GPs according to patient demand and often cross mental health service boundaries. Differences of focus and methods of working between individuals, teams and services.

Role definition and intersection

Most notably, that both GPs and mental health service clinicians are used to having a case management role. Most professions involved are trained as autonomous decision makers and accustomed to professional independence.

Primary Care Focus

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The most consistent theme identified by study participants to support mental health shared care was the need for a primary care focus. However many participants commented that mental health services focus on the acute sector – ‘the overarching focus is on beds’ - with community mental health being a less prestigious and less-funded area of work, often more ‘acute in the community’, than primary care.

Management will to focus on primary care was seen as necessary but difficult to muster and maintain - participants commented on changing priorities and political imperatives. The perception of ‘constant reform’ developed cynicism in participants. Short-term project funding for shared care was frequently mentioned as a barrier to sustainable change.

Despite the need for primary focus, several participants commented that working in an acute setting was necessary for credibility in the mental health system, with the dominant professions (psychiatrists and mental health nurses) trained in acute settings.

Interprofessional Barriers : Mental Health Service Culture

Professional barriers between mental health service allied health and GPs were mentioned by all participants. Barriers between GPs and psychiatrists were considered minimal because of their shared medical training and MBS-defined relationship.

GP participants commented on the lack of consistency across teams and regional boundaries, affecting referral pathways, criteria, services provided, and communications. This caused confusion, particularly for GPs who practiced near the region boundaries.

Issues between allied health and GPs were seen to be reflective of the hierarchical acute care setting. Several participants related stories of clinicians reluctant to telephone GPs because ‘he won’t want to talk to me’ and one GP participant said he found some allied health did not want to talk to doctors. Study participants understood this perception in the context of the acute sector hierarchy.

The community health hierarchy was seen as less overt than in acute, but still in evidence. One psychologist participant stated ‘doctors have the power, nurses have the numbers, and allied health have a weak voice’.

Mental health service participants felt consistent broad-scale change was difficult to implement due to the lack of an agreed central policy, tensions between numerous policy drivers (state governments, Australian government, Australian Department of Health and Ageing, state Departments of Health, health regions, local management) and changing political imperatives.

High stress levels, burn-out and high staff turn-over in mental health services were mentioned by all participants. Constant demand and a perception of being under-resourced meant staff had reduced capacity for change - ‘one

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extra thing we have to do.’ One coordinator stated that her program was established by first transferring chronic stable consumers to GP-only care (with rapid re-entry options) in order to free up mental health service clinicians to participate in shared care.

Several participants mentioned mental health service culture as averse to ‘outsiders’. One coordinator participant said they needed people with systems understanding and change management skills, but those people were rejected for lack of acute clinical mental health experience (or having ‘gone to management’). The same participant commented that her credibility was based on time worked in acute, and that while there was rapid staff turnover, it was from a closed pool - vacancies were advertised internally.

GP skills in mental health were commented on very positively by participants although this was not felt to be widely recognised, with a common misperception of ‘specialist’ mental health services, versus ‘generalist’ GPs. One commented that mental health was seen as a ‘difficult field’ which conveyed a sense of importance on the workers - ‘it is harder in mental health’. She noted that this not only ‘talked up their own game’ but also increased the stigma about mental illness. This sense of ‘specialness’ is compounded by professional identities that are invested in certain roles and ways of working. Sharing care is in some sense giving away power, importance and identity – letting go of the idea that ‘only I can help you’.

Participants felt that GPs sometimes do not understand what various clinicians do in mental health, particularly social workers and occupational therapists, affecting communication and willingness to accept decisions from these clinicians. Several clinicians felt that GPs were reluctant to attend education sessions run by non-doctors, perceived as GPs believing only specialists were experts.

Several shared care coordinators mentioned language barriers: different terminology used to characterise risk levels or specific inclusion/exclusion criteria. Mental health services were not aware of GP information requirements and the level of detail that would be useful. One participant’s service had recently changed their discharge letters to GPs from ‘please monitor’ to much more individualised details about warning symptoms.

A lack of understanding of the pressures on GPs also hindered communication. One coordinator explained that mental health services are based on communication – counselling, verbal exploration. Conversely time-poor GPs need succinct messages – ‘who, what, when, why’. The same coordinator felt poor messages left by clinicians impacted call-return rates. Participants frequently mentioned that mental health service clinicians did not understand general practices as small businesses. This affected their understanding of the GPs’ need for billable time to cover overheads. Criticisms of ‘GPs always want to be paid’ reflect this.

GP participants said they ‘knew nobody’ in mental health due to staff turnover, whereas in other areas they had a personal relationships with clinicians. This

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gave GPs the perception that referrals to mental health were ‘referring into a black hole’.

The (stereotypically) medical paradigm of doctors versus the bio-psycho-social paradigm of allied health was mentioned by participants as a barrier to understanding, although as one GP participant pointed out, the different viewpoints should mean better clinical understanding.

Interprofessional Barriers: General Practice CultureThe concept of general practice culture proved difficult. Participants talked of the small business mindset (the need to cover overheads and make a profit), ten-minute paradigm (the need to fit each patient into short pre-determined time periods), medical / bio-medical paradigm, autonomous decision making, and the need for GPs to be decisive. These factors impact on joint decision-making and shared care. GP practices are independent, yet mental health services want to relate to all practices in the same way. Working through Divisions of General Practice was one answer, but Divisions can only influence, not enforce positions.

Several participants mentioned that GPs have chosen to be generalists and some fear becoming the ‘mental health GP’, seeing only mental health patients. The concept of GPs as generalists was considered positive and negative – they have a broader view of the patient’s physical and mental health, and life-journey, but the label also engendered a lack of understanding about the role and skills of GPs in mental health.

One change to general practice culture mentioned was the impact of corporatisation. The corporate ‘walk-in’ model and bulk-billing was positive, but meant clients were unlikely to have a regular GP for ongoing shared care.

Logistical BarriersShared care literature recognises logistical barriers between mental health services and GPs, and all participants concurred. Barriers identified include salaried staff having time for meetings versus GPs being paid only when they see a patient, salaried workers wanting to meet within office hours, and GPs not wanting to cut into consulting time with non-billable work. Care planning and case conferencing MBS item numbers partially address this, but restrictions make them unworkable for frequent communication about complex high needs consumers.

Participants mentioned GP receptionists or practice managers as gatekeepers. Having calls to GPs blocked by the receptionist was seen as professionally offensive. Getting to know practice staff could however facilitate good relationships with GPs.

Some barriers mentioned related to factors discouraging GPs from doing mental health – the need to bulk-bill patients on low incomes, time requirements for mental health consultations and a high “DNA” (did not attend) rate, representing lost income against overheads.

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Bureaucratic BarriersBureaucratic barriers such as non-alignment of geographic service boundaries is largely self-explanatory and relates to arbitrary divisions of labour amongst community mental health teams, whereas the catchment for a GP is determined by the client’s willingness to travel. For GPs with practices near the service boundaries, this leads to confusion about which service to contact and which model of care might be offered, particularly as it is usually determined by client home address rather than clinic address.

Role definition and Intersection Both mental health clinicians and GPs were described as having autonomous decision-making styles as part of their professional service-provider roles. Conversely, shared care requires that decision-making is done in consultation. One participant, a retired GP, characterised GP style as ‘shoulds’ – the GP sees a patient every ten or fifteen minutes and instructs them: ‘you should do this, you should do that’. Another participant described the change for shared care partners from ‘telling everyone what they need to do’ to working in partnership.

Sharing care affects power and control over patient care. Mental health service clinicians are accustomed to a case management role, as are GPs. Shared care means that one will give up this role, determined by the model or on a case-by-case basis. Two participants noted that historically mental health services did everything for the patient – patients were ‘there for life’ and all their care needs were controlled in a patriarchal manner.

All clinicians were concerned about their duty of care under a shared care model. Practicing in isolation, they knew what services the patient was getting. Trusting an external partner to perform certain services requires belief in their skill set, that they will act as agreed, and will make contact if something changes.

Participants’ perceptions of what works

A considerable degree of pride and ownership was invested in functioning shared care programs, particularly by coordinators, reflecting how models have developed around strongly committed individuals. Coordinators tended to see their model as ‘best’ and consequently had difficulty identifying barriers. This parochialism is a barrier to developing a single approach across a broad geographical area.

‘Culture carriers’ straddling both systems, were seen as effective. Two participants described a coordinator employed between mental health services and the Division of General Practice, attending mental health service intake meetings and fielding GP calls. Methods of building understanding between mental health services and GPs described included joint education, ‘A day in the life of…’ education sessions, and GPs doing clinical attachments in mental health services.

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Working through Divisions was seen as a way for mental health services to build relationships with GPs en masse. Divisions were considered to have better access to GPs, capacity to conduct practice visits and expertise in communicating with GPs and practices.

Discussion

Despite the variability of programs, participants identified a number of consistent themes that need to be addressed for shared care to succeed, some of which were not mentioned in the literature.

The focus on primary care and conversely, the influence of the acute sector and interactions of acute-trained professionals was a strong focus for many participants in this study. Broad detail regarding interprofessional interactions, roles and communication is touched on in other contexts in the literature, but interviews provided information on the impact and relevance to mental health shared care.

Participants advised that mental health services need space to move to a shared care model, to make this way of working ‘instead of’ not ‘as well as’. The pay-off is that shared care increases service capacity, quality and safety.

Interviews with GPs tended to focus on differences rather than commonalities of general practice. GP participants found the concept of ‘general practice culture’ difficult, reflecting the difference of an internal versus external viewpoint. Interviews with other participants identified the notion of ‘GP-land’ describing the environment and mindset of general practice. It is unsurprising that general practices with similar structures, goals, practices and restrictions, and consisting of a similar mix of professionals, would have a common culture.

Almost all participants mentioned the importance of having defined communication points and methods, and defined roles for case management and decision making, agreed in advance. Written care plans were mentioned as a tool for defining roles and responsibilities. Methods of developing relationships and awareness between the two sectors were mentioned as promoting understanding of each other’s constraints, skills and services rather than directly promoting shared care.

Two broad modelsFor this section the terminology “projects” will be taken to mean specifically organised arrangements and “models” to mean the type of structural arrangement that a project may implement. The “model” may be shared by a number of projects. From the interviews, shared care projects tended to two models, (Table 4) based on the interface between GPs and mental health clinicians.

Type 1: A coordinator is employed to manage the interface between mental health services and GPs. This addresses the issue GPs have with not knowing whom to contact in mental health services and not being able to form

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a professional relationship. This does require a certain type of person to fill the coordinator role. Coordinators typically need to speak the languages of both “sides” in the arrangement and facilitate effective communication, organisation and decision making. Two participants told of an instance where the coordinator was not good at working ‘both sides’ and the model did not work. The model is also limited by the capacity of this one person, and is vulnerable to staff changes in this key role. There is no systemic change or increased understanding of GPs in team members except for the coordinator. (Dependence on individuals was named as one reason that shared care models could not be ‘upscaled’ and made consistent.) At a certain size, this model functions well and is relatively easily implemented. This model is widely supported in the available literature.

Type 2: One example of this model was found through interviews - it was not found in the literature. The entire team is re-oriented towards shared care with GPs (systemic change), and the coordinating role is shared amongst team members on a daily roster, requiring all team members to make changes and participate.. Capacity is limited by the capacity of the entire team. The negatives of this model are that GPs will not necessarily get to build relationships with individuals on the team, and GPs may find team members that they prefer to work with or prefer not to work with, leading to imbalances in workload amongst team members. However given the turn-over of staff in many mental health teams, this ‘role’ focus rather than ‘individual relationship’ focus may have an advantage. Being systemic, this model may take longer to implement but in the instance examined in this study, worked well.

Table 4: models of shared care (red indicates areas of change)

“Before” Each community health service clinician may deal with a number of GPs, and each GP may deal with a number of clinicians.

Type 1 model (red indicates the area of change, the coordinator) GP and clinicians numbers remain unchanged but there is a single point of entry, the coordinator. Requires less change by

Type 2 model. (red indicates the area of change, the CMHS team) Each clinician takes a turn as the duty worker on a daily roster system so each clinician builds relationships with a number of GPs, but in a

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participants than Type 2 model.

manageable way and with the single point of entry that GPs require. Less dependent on an individual.

ConclusionService integration is a strong movement internationally and is demanded by consumers, requiring service providers to work in different ways. The benefits to consumer outcomes are well-documented in the literature and understood by participants.

There are a number of barriers to shared care relating to those professionals involved, their service provider roles, interprofessional barriers, and organisation cultural mismatches. Neither organisation was set up to work with external agencies in a shared care manner and none of the professions involved are trained in interdisciplinary, inter-agency shared care.

General practice culture remains largely unexplored in literature despite its impact on coordination of services in the primary care sector. Comprehension of cultural factors and understanding of the realities of various participants facilitates effective integration of services between general practice and state-funded services. The fact that so many small shared care arrangements exist demonstrates that there is considerable will and desire to work together and that it is possible to overcome the barriers.

The two models into which these shared care projects tend offer different methods of addressing these barriers, both with benefits and disadvantages. Decisions regarding which should be implemented depend on capacity of the organisation and the overall systemic goal. Both are capable of delivering coordinated care that benefits consumers and clinicians; it is the effects on the system that differ most markedly.

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