Several diseases currently treated in specialized care could partially be treated in primary care [1,2,3,4]. This is also the case in the mental healthcare sector. Policy makers expect that substituting specialized mental health services with primary care is more cost-effective and better for patients in terms of continuity of care as well as travel costs and waiting times [5]. According to the WHO, integration of mental health care in primary care services is important to ensure accessible, affordable and acceptable services to people with mental health problems and their families [6]. They also state that it is an important part of integrated services for mental health to shift care from institutions to ambulatory primary care settings [6]. Substitution of care is defined as “the replacement of (a part of) an existing facility for (a part of) a different facility for the same patient population, while the original function of the facility is maintained” [7]. To be able to substitute specialized care with primary care, capacity and expertise in primary care must be sufficient. However, in many countries, the supply of general practitioners lags behind the growth in demand [8,9,10,11,12]. Increasing the medical workforce in primary care is therefore an important factor for substitution of care to succeed.
In the Netherlands, mental health nurses were introduced in general practice in 2008 to expand the mental health workforce in primary care [5]. Initially limited in number, their deployment rose following an expansion of the capitation fee allowance for general practitioners to hire them in 2014 The policy theory behind this was that an increased mental health workforce in primary care would facilitate substitution, shifting care from basic mental healthcare (BMH) to primary care [5]. Also, national guidelines were formulated stating that individuals in need of mental healthcare could be referred to basic and specialized mental healthcare only with a suspected psychiatric disorder [13]. Individuals without a suspected psychiatric disorder were to be treated in primary careFootnote 1. Mental health nurses are since then tasked with clarifying the symptoms of individuals in need of mental healthcare and deciding whether treatment in general practice or elsewhere in mental healthcare is more appropriate [5]. In Table 1, the role of mental health nurses within the mental healthcare system is depicted.
It is important to note that mental health nurses have a wide range of educational backgrounds, which partially overlaps with existing healthcare providers in basic mental healthcare (e.g., sociopsychiatric nurses, psychologists, social workers, nurse specialists) [14]. Therefore, substitution of care is mainly anticipated between healthcare settings (i.e., facilities), not between providers. As treatments by GPs and mental health nurses are exempted from deductible payments (385 euro, annually) in the Netherlands, individuals are incentivized to receive treatment in primary care as opposed to basic or specialized mental healthcare (to which deductibles do apply). The treatments given by mental health nurses encompass for example psychoeducation, lifestyle advice, self-management advice, activity planning. Magnée et al. (2017) argued that mental health nurses have the potential to facilitate substitution of mental healthcare in the Netherlands [15]. They found that a significant number of individuals were treated in the basic or specialized mental healthcare sector without being diagnosed with a psychiatric disorder. In accordance with Table 1, they concluded that this signals a potential to shift these individuals to primary care.
In earlier studies regarding substitution, researcher found that an increase in supply often led to an increase in demand [16]. This is also referred to as Roemers’ Law – an hospital bed built is an hospital bed filled [17, 18]. In other words, initiatives to substitute healthcare services often actually led to complementary healthcare services on top of existing healthcare services. Other studies did find substitution effects between primary care and more specialist care, however [19,20,21]. The extent to which mental health nurses have actually facilitated substitution of care within mental healthcare has been studied to a limited extent. Previous studies have mainly investigated potential shifts in mental healthcare for the total Dutch population. One study found a 19% decrease in new individuals in specialized mental healthcare between 2012 and 2016 in the Netherlands [22, 23]. At the same time, the number of new individuals in basic mental healthcare remained relatively stable. Between 2015 and 2020, varying numbers were published regarding healthcare use in basic and specialized mental healthcare. One study reported only a slight increase of 2%[24], while another study reported an increase of 10%[25]. After a relatively slow start between 2008 and 2012, the number of new individuals visiting a mental health nurse almost quadrupled between 2012 and 2016[22]. The number of individuals visiting a mental health nurse continued to increase between 2015 and 2020, although less explosively (+ 31%)[24]. Within these studies, the decrease in individuals treated in specialized care is partly attributed to substitution of care. The extent to which these findings are actually related remains uncertain.
In order to gain an in-depth perception of substitution within the mental healthcare sector, specific patient groups need to be examined as opposed to the entire mental healthcare sector. Also, the studies above did not include general practice care (i.e., diagnostic codes, consultations, etc.). In the Netherlands, every citizen is registered at a general practitioner who functions as a gatekeeper. Access to more specialized care is only granted after referral by a general practitioner. This means that GPs are usually the first point of contact within the healthcare system for any given health problem. Individuals can therefore be followed from the start of their treatment journey at their GP through the rest of the healthcare system. Previous studies were limited to series of cross-sectional, monodisciplinary ‘slices’ of these episodes of care. Thus, it remains unclear whether higher mental health nurse deployment was actually associated with a decrease in treatment elsewhere. To evaluate the substitution of care and the role of mental health nurses within this process, healthcare utilization patterns of individuals need to be investigated. Information from the start of the episode of care at the general practitioner, together with diagnostic information, is crucial for the completeness of such analyses.
Therefore, our aim is to study the association between the degree of mental health nurse deployment in general practices and the healthcare utilization patterns of individuals with mental health problems. Our first hypothesis is that individuals in general practices with a high degree of mental health nurse deployment would be treated less often by general practitioners compared to practices with a low degree of mental health nurse deployment. Our second hypothesis is that individuals in general practice with a high degree of mental health nurse deployment would consult basic mental healthcare less often compared to individuals in practices with a low degree of mental health nurse deployment. Opposed to earlier research we were able to include individual patient characteristics instead of analysing results on an aggregated level. Our study will focus on individuals with depression, since depression is among the most common mental health problems, and this is a large patient group that is expected to have a high potential for substitution [26]. As Meeuwissen showed [27], individuals with depression are treated throughout the entire mental health sector through the stepped care principle. This makes this patient group well-suited for care to be shifted between settings within the mental healthcare sector.
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