Shared(?) Care

In the previous post, I highlighted the deliberate absence of performance measures for our mental health system and why that is.

I gave an example showing that when people in the system work in an information vacuum, it becomes impossible to prioritize or assess the impact of their efforts. In this post, you’ll see another example, more directly related to patients’ experiences of the health system: shared care.

But first, pop quiz! What is shared care in mental health?

  1. more than one treatment provider is involved with the patient
  2. a family physician refers the patient to a specialist for advice
  3. treatment providers talk to each other about a case
  4. different providers divide up the work so each has their own piece
  5. bouncing patients between treatment providers so they never see the same person twice
  6. a meaningless marketing label that means whatever you want
  7. a solid, meaningful treatment philosophy that is universally diluted and abused
  8. whatever receives funding from the shared care committee


“Shared care” is another of those aspirational motherhood terms like “patient-centered” that are hard to disagree with. In the psychiatric context, it means that family physicians, psychiatrists, and potentially other professionals work together to provide the best care for the patient. Each contributes as part of a unified, cohesive treatment plan.

Notice words like “together,” “unified,” and “cohesive.” Shared care is all about effective collaboration.

Collaboration requires many things to be shared: common goals, awareness of others’ needs, roles, actions, and responsibilities, the context in which people work. Lots of feedback and listening to each other.

As it happens, my previous work was all about facilitating effective collaboration and how technology can affect that, positively or negatively. It’s a highly multidisciplinary field, bridging technology, psychology, sociology, management, and other specialties. So yes, this world of Zoom we’re in now is right up my alley. For two decades, I did cutting-edge R&D, published extensively, and ran companies built around collaboration practices and technologies.

How it could work

There’s no one model of shared mental health care. But what would shared care, say between a family physician and a psychiatrist, look like? You’d expect to see several practices like these:

  • understand the skills and limitations each brings to the case
  • understand each others’ needs, work context, challenges, and resources
  • work together to create a treatment plan that meets everyone’s needs
  • psychiatrist and family physician at times jointly meet with patient
  • each professional learns from the other
  • shared understanding of patient’s goals and progress
  • assessment and appreciation of what individual contributions bring, how effective they are, and which parts can be improved
  • ongoing two-way communication over time regarding the case
  • back-and-forth discussions, questions and answers, etc.
  • awareness of what each participant contributes to the case, as well as gaps in the overall treatment

If done well, patients benefit from consistent and improved care. Practitioners develop increased skills by learning from each other and better appreciate how their contribution fits into the overall system. Scarce resources can be used more effectively.


If there’s virtually no feedback, interaction, or awareness between collaborators, is it really shared care?

Consider a traditional referral-consultation model:

  • family doc sends in referral
  • psychiatrist sees patient once for consultation
  • psychiatrist sends written report to family doc
  • family doc resumes care based on psychiatrist’s suggestions

Technically, both the psychiatrist and the family doc are involved in the treatment. There is some information going back and forth. But it’s pretty thin as far as collaboration goes.

It’s not one or the other, of course. Shared care is a continuum. The family doctor might call the psychiatrist later with questions or seek clarification. Other interventions may be discussed. The psychiatrist might see the patient again, send another report or make further suggestions. And so on.

Psychiatrists may be trained to do a full assessment in under an hour, but that doesn’t mean it will be complete and accurate. That may be because it’s a particularly complicated case, or the patient may not (for many reasons) be able to fully understand or give accurate answers to all questions.

Most psychiatrists who see a patient multiple times find their understanding of the patient evolves over time, as do their recommendations. Seeing someone for a one-off visit can result in significant simplifications, omissions, and errors.

Measuring success

For straightforward cases, a one-off traditional consultation may be all that is required. The report gives the family doc what they need to better manage the patient, and the patient gets better. Everyone is happy.

Notice that even here, success is judged from the perspective of the patient, as well as the family doc (in terms of having gotten what they needed from the psychiatrist). The psychiatrist is providing a service to the family doc.

But how does the psychiatrist know if the service they’ve provided is useful?

If there’s no further communication after sending the report, they don’t. They don’t know whether the patient got better or not. They don’t know if their recommendations were helpful, tried, or even made sense. Without feedback, they don’t know what value, if any, their participation added.

At most, they might get the hint when people stop referring to them. If there are other options.

Importantly, the psychiatrist learned nothing more about the needs of the family doc, the constraints they work under, or how they might provide better assistance in the future.


Unless that feedback is provided by some other means, they’re operating in an information vacuum. And as we know, the overall system is in no hurry to provide any concrete information about the quality of service.

What could possibly go wrong?

  • If a psychiatrist does a shitty assessment or makes poor recommendations, they’ll never know about it. They think they’re doing great and have no reason to change what they’re doing.
  • If their recommendations don’t work, aren’t useful, or can’t be followed by a family physician, they may never know. Again, future improvement isn’t likely.
  • The psychiatrist might assume that family docs have the time, skills, resources, and willingness to follow up with treatment recommendations. There’s little opportunity to learn about the constraints family docs work under and what they need.
  • Most psychiatric treatments involve trial and error, and without follow-up, may mean re-referral. Which can involve lengthy delays. And often, the patient starts from scratch with another psychiatrist.
  • Patients may receive inefficient, ineffective, disjointed, sub-par care. Especially if their illness is at all complex.

In other words, one psychiatrist may be doing the most horrific job in the world. Another might be doing the best job in the world. It’s possible that neither would ever know.

And nobody else in the system sees there is a problem or what needs to improve.

Hidden problems

These problems are hidden, and you need to go digging to find them.

Nobody measures or reports on these things, so how do we know these problems occur? We hear lots of stories from patients. We ask and then listen to family doctors to appreciate their needs and struggles.

Many people find ways to get feedback, engage in more collaborative activities, and learn from patients and colleagues. But it’s a deliberate effort. Not everyone bothers.

Some psychiatrists pretty much do only one-size-fits-all, one-time assessments. If you asked them, how many would say their advice isn’t helpful or sufficient for family doctors to manage cases? Some may be surprised at the question, not having considered how their assessments are used at all. Family doctors see it differently.

How widespread are these problems? They “seem” pretty common, but that’s largely anecdotal and based on our very narrow viewport on the system. Other people have vastly different perspectives.

There’s really no way to know the frequency and severity of these problems. Which is really the issue.


The busier things are, the worse it gets. Waitlists are longer. Time to see patients shrinks. Services are more tightly restricted. The distance between family docs and psychiatrists grows. Opportunities for feedback and collaboration wither.

For many, job satisfaction suffers as they find it more difficult to provide the type of care they want, especially for more complex patients. Burnout increases. More people leave. Others get more jaded. Some just keep their head down and continue on, oblivious.

In computing, there’s a phenomenon called “thrashing.” As a system gets busier, more and more time is spent on busy work (housekeeping, management, repetitive and redundant tasks which have little impact overall). This leads to less and less time for productive work to achieve goals. An apt metaphor here?

Everyone lives more and more in their own echo chamber. Viewpoints narrow further, and system thinking decreases. “The way we do things around here,” good or bad, becomes increasingly entrenched.


Isolation breeds misconceptions and contempt.

Psychiatrists see themselves more and more stretched. The scarcity of specialist time feels more pronounced, justifying ever-more abbreviated patient involvement. Ongoing treatment of patients and follow-up care is a luxury they can’t afford.

Resource-wise, it just makes sense to devolve follow-up care to family doctors who have so much more time to spend with patients. Except, of course, they really don’t. Family docs are stretched beyond belief and have far less time. But the family doctor crisis isn’t in the face of specialists each and every day.

Good mental health care takes time that doesn’t fit into increasingly abbreviated family medicine appointments. Family docs who devote that time do so at the expense of their other patients or their own health. Most do what they can, even if it’s not enough. Some do virtually no mental health care. And what about the growing numbers without access to any family doctor?

System access problems? Not a thing. Any family doctor can get a consultation by referring their patients through mental health intake. Crisis? USTAT is there. If only.

Yes, psychiatrists may be working flat out and focused on the task at hand. But if they’re too entrenched in their bubble, they may not be fully cognizant that the one hour they spend follows many months of rejections, waiting, and other delays.

Without evidence to the contrary, some people (who should know better) are deluded into thinking that the system on paper reflects reality.

Misconceptions flow in more than one direction. Frustrated family doctors may feel psychiatrists don’t care or are completely oblivious to the needs and realities of family practice. Private-practice psychiatrists who follow patients? Obviously, a ludicrous and inefficient drag on resources, who cherry-pick the “weepy well” patients who don’t need to be seen at all. The family doctors can see them. That’s why we do shared care here.


Without rich feedback and collaboration, shared care is an empty buzzword. A myopic fantasy.

It justifies silos, narrows thinking, reinforces the status quo, and abdicates responsibility. It stifles innovation and suffocates empathy.

It reassures us that we’re each playing the part we should be.

It’s not our fault.

Any system this large, this complex, and this important needs to deeply incorporate shared understanding, awareness, collaboration, feedback, and empathy. Only then can true shared care follow.

Individual efforts are important but only go so far. Systemic solutions are at odds with the perverse incentives at the core of the system.

There’s no easy path forward.

Related: see all Victoria posts here

We Have the Mental Health System We Designed

Minister of Mental Health and Addictions Sheila Malcolmson sounds very proud of our new mental health system:

We inherited a broken system that had been long neglected, and over the past four years we have made historic investments to patch the holes in this fragmented system. But now we are now moving beyond filling gaps, to make true system-level change.

Our government invested a historic $500 million in Budget 2021 to build a comprehensive system of mental health and addictions care that people in British Columbia deserve. (emphasis added)

Excerpt from an opinion piece that ran in Black Press Media’s community newspapers Nov 29th

What we deserve?

I don’t know about you, but I’d be offended to think we deserve what we have, given most people believe what we have now is pretty horrible.

People often want to know why the system works this poorly or why someone doesn’t fix it.

Actually, it’s working exactly as it’s supposed to.

People may be surprised (or a bit pissed off) to hear that, but it’s true. It’s working very well to achieve its goals. Unfortunately, those goals don’t have a lot to do with providing effective mental health care.

We may not have the system we deserve, but we have the one we designed.

It doesn’t work? Prove it!

For such a large, frighteningly complex, and enormously expensive operation, there’s very little data saying how well it actually works. You know, at providing people with mental health care.

I’ve talked about this before. Nobody publishes useful measurements or metrics about what seem to be obvious things like how long it takes to see a psychiatrist or counsellor.

What we have instead are periodic funding announcements. “We’ve invested XXX million for…. opened XXX new beds for…”

And you think there’s any kind of measure for any given person that says how they are when they first encounter the system, or at any time after that? Don’t be ridiculous!

Would you tell me, please, which way I ought to go from here?

So, if there’s no data about how the system operates, how do you know how well it works or where the problems are? Where should effort be focused?

Let me answer that by talking about navigation (in two senses).

First, there is navigation in terms of people finding the right services in the system. It’s not easy. So people want to fix that. A lot of people.

I’ve lost track of the number of databases, directories, websites, referral services, processes, and other overlapping efforts spawned by a wide range of individuals, organizations, and committees. An incredible amount of time, energy, and manpower has been devoted to this.

“Imagine, if only everyone could use the same referral system, we’d be able to effortlessly track all referrals and know about wait times everywhere in the system…!”

And how much better would things be if this problem was fully solved?

Think about the benefit of replacing smoke detectors in a building… as it’s burning to the ground. That much better.

It’s more likely planning stakeholder meetings about visioning for replacing smoke detectors…

The best navigation and referral system in the world doesn’t help if there aren’t enough resources to refer to in the first place.

But it’s hard to appreciate the scope of the resources problem without data. You can’t assess the full impact of a potential project. So we devote countless efforts to projects that can’t work or will have minimal impact.

Planning and prioritizing can’t be effective when we’re all in the dark about how the system functions.

To be fair, many people deeply involved in the system generally appreciate, albeit imperfectly, how it functions. That’s why they’re desperate to do what they can to try to improve things. While they may not be able to create accessible treatment resources, carving off a piece of the problem within their circle of influence is a natural and human response.

The unacceptable alternative is sitting there and doing nothing. They likely know the odds of their navigation system being meaningfully different from others. Or the odds that the largest organizations—with the worst wait times, with zero incentive to give up control or want to see their wait times published—would participate in their universal referral system.

Optimize for minimum negativity

If providing the best mental health care possible isn’t the system’s primary goal, what is it? This may sound cynical, but minimizing embarrassment for the government seems to be the overriding principle.

Health care (including mental health care) is ultimately the government’s responsibility. If things aren’t going well, the government is ultimately blamed.

Yes, other things being equal, better care is preferred to worse care. The people working in government, health authorities, and health care settings aren’t monsters, and they don’t enjoy seeing suffering.

But at what cost? People may bitch and moan, but the situation isn’t bad enough that it’s gained enough traction in the public eye to influence voting patterns. Other issues are more pressing. The downsides (higher taxes, etc.) could have more impact, e.g., providing leverage for the BC Liberals to attack the NDP. Plus, nobody is (credibly) seen as doing anything better; the Liberals aren’t about to invest more.

Conversely, an excellent mental health system isn’t seen as enough to swing voting patterns in the positive. It’s not just a matter of it being too expensive. We’ve repeatedly seen that when money is truly seen as needed, it’s available (COVID, bailouts, etc.). The political backlash that would have resulted from ignoring those situations justified the costs.

Drawing more attention to the problem would be a political liability.

In this view, transparency in the system is a negative. Concrete data on how poorly it functions is ammunition for opponents.

If there’s no data, you can claim anything you want.

If we don’t measure, we don’t look as bad.

As I said, the system is doing exactly what it’s designed to do.

Ministry of Mental Health and Addictions

There’s no clearer example than this recently created ministry responsible for mental health and addictions.

Does it manage the system? Does it actually provide treatment? Of course not.

I have yet to be convinced that spinning it off into its own ministry was about anything other than creating a glorified public relations factory.

Drip, drip, drip. Bits of funding here. Bits there. Announcements and announcements. Sprinklings of good news.

Nothing about how well the system works or what’s still needed.

The public doesn’t need to know that. There’d be no benefit.

You may have missed the Minister of Health rallying against a proposed federal mental health transfer. While the federal effort may well be as cynical a public relations effort as the provincial one, it would involve the province reporting actual data on access to mental health care in BC. That disclosure is not in the BC government’s best interests, no matter if the extra investment could improve care.

Instead, we see the usual political playbook trotted out, as reflected in the quote at the start of this piece. To paraphrase:

After discovering the (shocking!) horror left to us by the previous (evil) government, we’ve gone to heroic lengths to dig ourselves out from the disaster we inherited. We are now selflessly going above and beyond to build an even shinier future. And everyone gets a pony! This radiant future (and the pony) will immediately burst into flames if anyone else were elected.

Could we build a better system?

At finer-grained levels, we know that some things would help the system deliver better mental health care.

And that while there are definite costs, in the long run, it’s usually cheaper to fix problems early on when they’re small than wait until they’re bigger and cost more to fix. Which is how our crisis-driven system functions today. That doesn’t even factor in the indirect costs of not providing timely and effective care.

For the sake of argument, let’s say that our idealized system measures people’s needs and routes them to the right place for treatment with the appropriate professionals. It continually measures their progress, publishes and manages wait times and outcomes against some set of standards, ensuring sufficient resources to meet those standards. These types of systems are generally classified as stepped care.

Could we build this?

Given the broad scope of such a system, encompassing so many professions and organizations, it would require tremendous leadership at the highest levels.

For all the reasons already given, this would be a disaster politically.

In our short-term, next-election-focused system, no politician in their right mind would be okay with this. The price to pay is way too high.

Until the price of suffering is perceived as too high…

Until mental health affects the electoral calculus…

Until the perverse incentives at the root of the system change…

The system will keep doing exactly what it was designed to do.

No single raindrop believes it is to blame for the flood

Until then, we continue on, and we all continue to suffer. Without a clear picture or adequate data, everyone runs around doing what they think is right, with no feedback to the contrary. The blind leading the blind. Or, if you prefer, the inmates running the asylum.

Next time, I’ll provide another example of the consequences of this approach on patient care. I’ll explore the promises and pitfalls of shared care in a landscape devoid of shared information.

Related: see all Victoria posts here