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___Guides to specific issues_______________________________1
Why do we have eligibility criteria?
This issues guide is linked to the vignette ‘The problem of numbers’.
All New Zealanders are eligible to receive primary mental health care (PMHC) as part
of the provision of primary care. The high prevalence of and morbidity associated
with common mental health problems such as depression and anxiety, and their
responsiveness to treatment, provide a strong argument in favour of case finding
and management in primary care. However the relative lack of specific funding for
primary mental health and the time and resourcing involved make case definition
and the purpose for which cases are being identified two critical issues.
Case definition
Generally in health care, cases of a particular diagnosis are defined on the basis of
signs (externally observable changes or problems) and symptoms (changes or
problems the patient is aware of). Mental health problems in primary care often
present as combinations of signs and symptoms that do not easily fit one diagnosis.
This is one of the reasons GPs may not use strict diagnostic categories when
identifying people who might benefit from treatment. In PMHC a case (i.e. a
recognisable problem that can benefit from treatment) is more likely to be defined
on the basis of symptoms and functioning than on good fit with traditional
psychiatric diagnosis.
Purposes of case definition
Case definition is important because that determines how cases can be identified:
once there is a definition it is possible to devise means to include and exclude people
from case status. Case definition contributes to the decision about whether a person
might benefit from a particular treatment, and in some instances may determine
whether a patient is eligible for treatment. Access to services may be dependent on
a DSM diagnosis for example or the result of a score on a psychological symptom
severity rating scale.
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Why do we have eligibility criteria?
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Clinical eligibility criteria
Clinical eligibility criteria are the means to ensure that only ‘appropriate’ problems
are defined as cases. ‘Appropriate’ in this context means likely to benefit from
treatment. Clinical eligibility for pharmacological treatment in PMHC in New Zealand
is based on the GPs usual clinical assessment, as for many other treatments available
in primary care. When the primary mental health initiatives that included access to
talking therapies were set up, it was decided that in some instances eligibility was
determined on the basis of a combination of the usual GP clinical assessment and
the outcome of an additional assessment procedure, as the desire was to ensure
only people who really needed treatment were referred on. Because psychiatric
diagnostic procedures can be time consuming and are often not a good fit with the
combinations of signs and symptoms presenting in primary care, clinical eligibility
criteria for talking therapies in PMHC in New Zealand are commonly based on simple
sign and symptom checklists that have been calibrated against diagnostic
instruments, usually for the purpose of screening. The K10 is an example of such a
measure. It is a non-specific measure of psychological distress and does not indicate
whether the underlying problem is, say, depression or anxiety. The PHQ-9 is a similar
instrument developed for the detection of depression in primary care.
Policy-based eligibility criteria
The overall decisions about access to care are made at a policy level. The decision by
some DHBs to ensure that only people with K10 or PHQ-9 scores over a certain level
had access to the new primary mental health initiatives’ talking therapies is an
example of this. Other policy level criteria for access to the additional resources
made possible under the initiatives were ethnicity and socio-economic status.
Rationing as a purpose of eligibility criteria
Eligibility criteria provide a mechanism for controlling how many people in certain
groups (e.g. ‘cases’, ethnic or socio-economic groups) have access to services. The
demand on services is determined by the eligibility criteria. The need to manage
demand depends on where in the system the ability to allocate resources is located.
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Why do we have eligibility criteria?
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Some primary mental health services, such as access to antidepressants, are
allocated on the basis of clinical decision making. Because the budget for medication
is not held at PHO or practice level, there is no need perceived at that level to
manage demand for them. However, for the psychological interventions that are
part of the primary mental health initiatives, the budget is fixed at PHO or practice
level, which means the demand must be managed at that level.
A fixed budget in the face of demand that might exceed it means scarce resources
must be allocated across competing demands. In this situation, rationing or demand
management is inevitable. Health service rationing can be applied in either an active
or passive way.
Passive mechanisms of rationing are determined by structural elements in the health
service and the consequences of policies set at Ministry and DHB level. Those with
relevance to PMHC in New Zealand include financial barriers to care, workforce
availability, time, distance and geographical location. In PMHC, the various kinds of
service and treatment are distributed unevenly across the country, and on top of
this, limited funding tied to specific services/treatments within PMHC means that
some services/treatments will be rationed more than others. For example, drug
treatments are less subject to passive rationing effects than are psychological
treatments.
Active rationing requires decisions about how the resources are to be allocated and
how demand is to be managed. This is ‘priority setting’ and occurs at DHB, PHO,
practice and clinician level. Rationing or priority setting decisions are made explicitly
and implicitly every day in health care, all around the world, by politicians, funders,
service providers and clinicians.
Eligibility criteria for entry to a treatment programme serve three key objectives. The
first is policy-related, that is, ensuring the programme is delivered to those who are
identified in the policy as the target for intervention. This might be based on socioeconomic status, ethnicity, age or problem type. The second is a clinical objective
related to ensuring that identified cases are directed to appropriate evidence-based
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Why do we have eligibility criteria?
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treatments. Examples of this are diagnostic assessments. The third is an economic
objective. This often relates to ensuring the service is delivered in a way that is
within budget and is sustainable for the future. Depending on the economic criteria
that are being prioritised, examples include ensuring the treatment is offered to
those who will benefit most, to those with the greatest need, or that the treatment
is the cheapest of effective available treatments. Determination of some of these
depends on the nature of the outcome being measured, such as how benefits from
treatment are defined. For example, outcome could be defined as a reduction in
symptoms or an improvement in functioning, and then criteria would need to be set
to determine what degree of change in these would be acceptable.
At PHO level, eligibility criteria are one of the few mechanisms available to manage
demand for services. For example, symptom-based thresholds for entry to treatment
programmes are easy to alter. At clinician level, symptom-based thresholds may
mean that a person who the clinician considers would benefit or is badly in need of
the service, would be ineligible. As it is clinicians who are providing the assessment
i.e. screening for the eligibility criteria, they are in a position to reinterpret the
criteria for the benefit of an individual patient.
Roles of DHBs, PHOs and clinicians in relation to eligibility criteria
The role of DHBs and PHOs is to be explicit about the implications of both national
and local eligibility criteria and to communicate those clearly to clinicians. The role of
clinicians is to understand the local implications of eligibility criteria and attempt to
operate criteria in a way that professionally balances individual and population
health needs.
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Why do we have eligibility criteria?
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‘The problem of numbers’
(click here to go back to guide)
Coastal Care is a collective of PHOs serving a mixed urban/rural population. The
PMHC programme Futurefocus uses several private clinical psychology practices as a
supplier of CBT-based brief interventions for depression. This is a longstanding
successful programme dating from before the Ministry of Health-led primary mental
health initiatives, for which Coastal Care received DHB funding as part of earlier DHB
moves to ‘outsource’ a number of clinical and support services.
Coastal Care won this DHB tender on the argument that this would reduce the
burden on secondary care community mental health teams, who had difficulty
recruiting and retaining clinical psychologists, and would also improve access to
appropriate treatments for depression. The Futurefocus programme has some
similarities to a ‘managed care’ approach. There are clearly articulated programme
entry criteria which are adhered to as the programme manager, Bob, pays careful
attention. The key criteria are that the programme is for those aged 18-65 years with
a PHQ-9 score over 20 (severe). Patients are allocated up to 8 CBT sessions and the
mean session uptake is 6.
The advent of the Primary Mental Health Initiatives brought an expectation of
treatment of a broader range of common mental health problems. Furthermore, the
initiatives were to focus on problems of mild-moderate severity, whereas the
Futurefocus programme has focussed on moderate-severe cases. The initiatives
would only offer a maximum of 6 sessions with the expectation of a mean of 4.
Bob is fielding a request from the DHB to ensure the programme is funded from the
new Primary Mental Health Initiative allocation. However, the existing programme
does not meet the criteria due to the high threshold for entry and the local
psychologists are reluctant to reduce their possible number of sessions.
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Questions to consider
1. What are the key steps Bob needs to take in terms of information and
relationships?
2. Would you advise him to negotiate with the psychiatrist about numbers of
services? If so what would the main argument be?
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Why do we have eligibility criteria?