Still in various countries , the psychiatrist : Population ratio is very low, clinical psychologist number is even less than psychiatrist, and their role is not recognised except in child guidance clinic. Solution of this can be training to the primary level health care workers. But best solution is to create new primary level staff & trained them, so that they can help the patient even in primary level. Because qualified professional are mostly available at the tertiary level institution.

One of the important aspect of the quality in health services is the functional quality or services delivery such as access, appointment, admission process, cost, waiting time, service environment and etc.

Hi Jose.

It is fundamental to consider the influence of an organisations service structures, philosophy, aims and objectives and cultural factors. It is important to be cognisant of the importance of interdisciplinary and Multidisciplinary cooperation, collaboration, mutual respect, experience knowledge and relationships between professional groups and individual practitioners within each specialty area (e.g. psychologists, psychiatrists, nurses, social workers, etc) and how these factors are promoted and driven within public health organisations. In addition, how management and organisational structures and policies within the public health system and professional codes of practice and increased accountability influence the roles of psychologists.

The public health system is under increased stress to provide high quality care often within significant resource constraints. Psychologists and other health care professions are trying to balance increased workloads, professional stress and potential burnout due to increased patient numbers/expectations and changing government policy and changes in practice, professional standards and potential legal accountability.

Resources:

Komer et al (2015). Relationship of organizational culture, teamwork and job satisfaction in interprofessional Teams. BMC Health Serv Res. 15: 243. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4477418/

Jan Hoogervorst, Henk van der Flier, Paul Koopman, (2004) "Implicit communication in organisations: The impact of culture, structure and management practices on employee behaviour", Journal of Managerial Psychology, Vol. 19 Issue: 3, pp.288-311, https://doi.org/10.1108/02683940410527766

Wahass, S.H. (2005). THE ROLE OF PSYCHOLOGISTS IN HEALTH CARE DELIVERY. J Family Community Med. 2005 May-Aug; 12(2): 63–70. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3410123/

Dingfelder, S.F. The intersection of psychology and public health. American Psychological Society. http://www.apa.org/monitor/2011/04/intersection.aspx

Thank you, Dr. Lal, for your answer. The situation that you describes about the difficulties which patients experience to get acces to clinical psychologists in public health system fits pretty well to the situation here in Spain. People suffering because of anxiety, affective, behavior, personality... disorders are referred to clinical psychologists only after several months, or even years, on drug therapy by GP in primary care level or by the psychiatrist in second level. Even when so many guidelines prescribe psychotherapy (or psychotherapy+drug therapy) as the first therapeutic option, it seems like public health system is sure that keeping psychotherapy as a second option is the most efficent strategy.

I appreciate your response, Dr. Zarei. Do you think the three first factors you mentioned (access, appoinment, and admission process) could be considered as three differents steps or labels of a common factor: admission process?

These three (admission , waiting time, and appointment) can be considered as admission process. Access is different, however, and has different aspects, such as geographical access (Geographical distribution of providers or professional/population ratio ), Having the right to choose a provider from among providers, and financial access (Cost of services).

Thanks a lot, Professor Shanahan. Your references suggestion is being very useful to me.

I would add the understanding of those in leadership positions of what is behavioral health, what is psychotherapy, and what is needed to provide effective services. If those administrators do not know (or do not care), the provision of services is very deficient. They would burden clinicians with 13 patients in one day and no cap in the number of patients. In the USA, there are several disciplines that can engage in these services. In addition to psychiatrists (who do mainly medication control) and clinical psychologists (at the PhD level who do therapy and testing), there are other master level practitioners who can obtain a clinical license after 3 or 4 thousand hours of post master work under supervision and after passing a national test. They come form fields such as social work, educational psychology, counseling psychology, and other degrees. In my experience, the provision of services to the poor and those without health insurance is done mainly in public settings and the quality varies greatly from state to state.

Thank you very much, Dr. Alzate, for describing your experience in the public health system so thoroughly. It helps me to realize that our situation in Andalusia does not differ much from others.

I totally agree with you that the (poor) understanding of psychological treatments by the administrators of the public health system could be a key institutional factor. Many other institutional factors depend on that. Even when the hierarchy of values and philosophy of the health system could be explicitly oriented to take care of people's mental health, their specific strategies to develop this objective depend on how mental health is conceived by their leaders or managers.

By the way, you mentioned that this issue, in the USA, varies a lot from one state to another. Could you clarify, from your own point of view, what factors explain these differences, please?

You are welcome. Several Factors: 1. There is no universal health care in the US. 2. Because of #1, millions of people do not have health insurance-those whose jobs do not provide health insurance (i.e. Walmart employees), or are unemployed, or disabled and do not qualify for public health insurance, or students who can't afford private health insurance and their parents do not have it either, plus most undocumented (some undocumented may have health insurance through their jobs). 3. The provision of and access to health services depends on where people live. Some states provide health insurance to its residents (i.e. Massachusetts); some states have counties (subdivisions within states) that have their own system to provide for the poor/uninsured/underinsured (i.e. Harris County where Houston, Texas is and where I live); some cities provide most of health care to the poor/uninsured through community health centers that are private, not for profit, and may or may not receive help from the local government. Some get money from foundations, others do fund raising. In many places, the only health care for those without insurance is provided in emergency rooms - including mental health (i.e. when people have panic attacks). This has created millions of people who are sick, can't get the treatment they need, and end up increasing costs by going to the emergency room. As you can see, the health care system here is a mess But, for those with a good health insurance and who live near services, health care is excellent, with state of the art facilities and five star hotel attention. However, some have very high co-payments and co-insurances (some fees that don't exist in Europe or Latin America as far as I know), so they end up with huge medical bills, despite having insurance.