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The Primary, Secondary and Tertiary Health sectors with specific reference to the provision of mental health services.

The delivery of modern health care depends on groups of trained professionals who come together as interdisciplinary teams. All the professions work together for the good of the client, with the professions supplementing each other’s input towards more effective and comprehensive service delivery.

These professionals function at three levelsor tiersof health care, or in three ‘sectors’ i.e. Primary, Secondary and Tertiary. The choice of the words ‘levels’, ‘tiers’ and ‘sectors’ is misleading as it suggests that the primary, secondary and tertiary health services are discreet categories. In fact the distinctions between the levels have become increasingly blurred. Increasing numbers of clinical staff are working across the boundaries particularly between primary and secondary care.

The three ‘levels’, ‘tiers’ or ‘sectors’ are more accurately described as a continuum with primary at the bottom, secondary in the middle and tertiary at the top. Consider the graph below, which attempts to show that the three ‘levels’ flow into each other, just as the colours do:

Tertiary Secondary Primary
Tertiary
Secondary
Primary

Even though the boundaries are uncertain, we can still describe and define the essence of each of the three levels of service.

Primary care is the term for the health care services usually offered in the local community, i.e. not in a hospital setting. It refers to the work of health care professionals who act as a first point of consultation for all patients/clients within the health care system.

Primary care is usually provided by general practitioners and their attached and associated staff such as nurses, along with other professionals such as physiotherapists and dieticians. It also includes local pharmacists. It is important to note that the patient’s general practitioner remains the central hub around which all treatment, assistance or therapy is implemented. If for example a patient seeks advice or help from a dietician or psychotherapist as a first point of call, these professionals are obligated to (a) inform the general practitioner that his/her patient has solicited their help and (b) to keep the general practitioner informed of progress and outcome.

Primary care is also strongly oriented towards prevention, along with cure. This is where support workers come into the picture. Part of their duty is to actively promote social well-being and a fulfilling and productive life style for their clients, as this is the strongest defence against the onset of mental illness and relapse.

Secondary care is the health care services provided by medical specialists and other health professionals who generally do not have first contact with patients, for example, cardiologists, urologists, psychiatrists and dermatologists.

Note that although ‘secondary care’ typically occurs in a hospital environment, it is not synonymous with ‘hospital care’. Many secondary care providers do not necessarily work in hospitals, such as psychiatrists or physiotherapists.

Secondary care services are usually provided by specialist teams made up of a variety of health professionals lead by consultants. A consultant is a specialist who is consulted by primary health care professionals when they are of the opinion that their client needs more specialized service than that offered at the primary care level. As such secondary care professionals usually receive clients through referral.

Tertiary care is highly specialized consultative health care, usually for inpatients and on referral from a primary or secondary health professional, in a facility that has personnel and facilities for advanced medical investigation and treatment. Examples of tertiary care services are neurosurgery, cardiac surgery, plastic surgery, treatment for severe burns, advanced neonatology services, palliative care, and other complex medical and surgical interventions.

So, what’s the situation in New Zealand?

Each week hundreds of thousands of New Zealanders seek advice or treatment from the health service. Over 90% of these contacts occur in the ‘primary’ sector – the doctors, nurses, pharmacists, physiotherapists and other health professionals working in your community.

Health professionals working in the community (typically primary care) have generally been quite isolated from their counterparts working in hospitals (typically secondary care). Communication between the two has typically been distant and formal (mainly through letters and emails) and the systems for sharing health information about patients are limited.

A new approach was adopted in NZ in 2009. The approach took the name of its focus: Better,

Sooner, More Convenient.

It aims to create Better services for patients, through increased collaboration and information

sharing of particularly primary (community-based) and secondary (mostly hospital-based) health

professionals, creating a more continuous health service.

The Sooner aspect of the policy is self-explanatory; it involves less waiting for patients. By providing more services in the community and creating a smoother flow between different parts of the health service, patients can get treatment more quickly.

The More Convenient aspect of the policy focuses on increasing service delivery as close to the patient as possible, i.e. at the primary care level. It’s almost always easier to arrange a time and day for a treatment procedure that best suits you at your local GP than it would be at a hospital.

Additionally, assistance in the home or another convenient setting (by for example a mental health worker, or district health nurse) can help to ensure that they remain well in the community, avoiding unnecessary stays in hospital.

By pursuing its focus, the Better, Sooner, More Convenient health policy seeks to:

Keep people healthier in the community for longer.

Be prevention oriented, i.e. identify problems earlier, when they can most effectively be addressed.

Reduce unplanned, urgent hospitalisations.

Utilize the full range of skills of clinicians and support workers, following a team approach.

Extend training, so that people with no formal health qualifications can perform work which helps protect the health of the community.

Two key organizational players in the primary health care sector are Public Health Organizations (PHOs) and Non-Governmental Organizations (NGOs). While PHOs are allocated funding for health promotion in line with their population base, most NGOs are dependent upon government contracts to provide specific services.

Examples of NGOs and PHOs involved in Mental Health in Gisborne, New Zealand are:

Te Kupenga Net Trust

Supporting Families

Challenge Trust

Ngati Porou Hauora

Examples of professions and roles typically found in one or more of the sectors:

Psychotherapist

Psychotherapists are trained to do psychotherapy. They help individuals, couples and groups to see, think, feel or act differently and overcome general life problems they are experiencing with various types of psychotherapy. Psychotherapists are typically found in the primary sector and often act as a first point of call.

Clinical Psychologist

Like Psychotherapists, Clinical Psychologists do psychotherapy, but are additionally extensively trained in mental illness and psychological tests, which given them an added diagnostic function. They are trained to assess various psychological constructs such as personality, emotion and intelligence. The information that the psychologist provides is usually used to generate a more accurate and comprehensive picture of a client’s current state, for use in treatment planning and referral. They are equally at home in the primary and secondary sectors.

Occupational Therapist

This is the professional group that uses activities and occupations to enable people to recover from mental illness. They work with people to regain lost abilities, or to develop new skills and interests. Occupational therapists are found in both the primary and secondary sectors.

District Inspector

They are the watchdogs of patient’s rights, ensuring the Mental Health act is correctly applied and the rights of individuals are respected and upheld. They are appointed by the Minister of Health under the 1992 Act. They are always Barristers or Solicitors and this role is conducted in addition to their usual legal practice. Their role does not include being the patients advocate or legal advisors for mental health services. They visit every individual subject to the act and provide them with information on the process, explain their role, the patient’s rights and discuss options for review. As their role is to oversee patient rights, more particularly where patients are treated or assessed involuntarily, they are therefore chiefly active in the secondary and tertiary sectors.

Duly Authorised Officers

They are the front line operators of the Act. They are appointed by DAMHS (Directors of Area Mental Health Services) and are trained mental health professionals. They should have identifying cards provided by the Hospital or Health Service. They usually staff a 24/7 service and are there to assist anyone who applies for an assessment of a person for whom there are mental health concerns. They can also help an individual make an application for assistance themselves. Their job often entails responding to crisis situations. They consider clients diagnostically and then make their decisions as to whether further diagnostic examination and/or treatment is necessary, and also whether such examination or treatment should be compulsory. District Health Boards keep a list of their telephone numbers so that you or your family or whanau can ring if you need help or advice. DAOs work in the secondary sector.

Psychiatrist

This is a qualified medical doctor who has obtained additional qualifications to become a specialist in the diagnosis, treatment and prevention of mental illness and emotional problems. Given the psychiatrists level of specialization, they work in the secondary and tertiary sectors.

Responsible clinician

Every person undergoing compulsory examination or treatment, must have a ‘responsible clinician’. This is usually a psychiatrist and is the person responsible for a person’s treatment while they are under the Mental Health Act. They are found in the secondary sector.

Mental Health Nurse/Psychiatric Nurse

These people provide treatment, care and support for people with emotional, mental and behavioural problems. They increasingly work in community settings, but the majority work in hospital outpatient or outpatient settings. They are skilled in the specialised use of communication, counselling, psychopharmacology, applying speciality knowledge in the provision of clinical assessment, monitoring, therapeutic interventions, treatment, and referral to other health professionals. Some have special responsibilities under the Mental Health Act 1992 as duly authorised officers. They are found in all three sectors.

Mental Health Support Workers

They are mainly employed in the non-government community support services sector. They provide support and practical assistance and deliver rehabilitation services or programmes that facilitate the recovery process for people experiencing serious mental illness or emotional distress. They are closely aligned with the primary sector.

Social Workers

These people look after social and practical needs such as family assistance, welfare benefits, housing, jobs and so on. They are typically found in the primary and secondary sectors.

Clinical Specialists, previously known as Keyworkers

Clinical specialists are usually psychiatric nurses or social workers, and work for DHBs mental health services. They form the link between the DHB’s Mental Health Service and the client and are responsible for implementing the client’s management/treatment plan as developed by the various mental health professionals involved with the client. They often work closely aligned with mental support workers and will visit clients in their homes if it’s part of the management/treatment plan. Of all the roles typically found in the DHB’s mental health system, they are often ‘closest’ to clients and take responsibility to coordinate treatment options for them. At the moment they are more likely to be found in the secondary sector, but given their role of active and ongoing contact with clients/patients and their support workers, often find themselves defined as part of the primary sector.

often find themselves defined as part of the primary sector. This document compiled and integrated from

This document compiled and integrated from various sources on the www. Intended use: National Certificate in Mental Health and Addictions Support CMHA 401. Context and Safety Tairawhiti Campus, 2012