158 Chapter 5 psychologists work in hospitals, with only approximately 300 being part of primary care [27]. These reduced numbers persist despite the high number of qualified clinical psychologists in the country, around 5,000, that work mostly in the private sector [44]. Portuguese primary care and mental health support The Portuguese NHS is funded through taxes and follows the Beveridge model, in which GPs act as a gatekeeper to other primary and secondary care treatment options. Patients can only register with a GP practice in their residence area, and choice is limited due to the GP shortages in some areas. In 2018, 7.5% of patients enrolled in GP practices were not yet registered with a GP. Primary care practices are typically organised into teams consisting of GPs, nurses, and administrative staff, and are owned by the state. The staff, which almost exclusively includes salaried civil servants, is recruited through public hiring processes. Since 2008, GPs practices were administratively grouped into local groups, known as ACeS (Agrupamentos de Centros de Caúde). Local groups’ aim was to manage primary care resources, services planning and articulating the various GP practices within the coverage area and to develop health promotion and disease prevention actions. Local groups are typically responsible for overseeing the population of one municipality (except in more sparsely populated areas, where local groups cover more than one municipality, and densely populated areas, such as metropolitan areas, where there may be multiple local groups). Each local group encompasses a unit of shared resources (URAP, Unidade de Recursos Assistenciais Partilhados) which provides access to various professions such as nutritionists, physiotherapists, occupational therapists, psychologists, and social workers, pending GP referral. Psychologists integrated into primary care units offer various mental health services such as psychological assessment, psychotherapy, and behavioural counselling. While they cannot prescribe medicines, they should work with GPs to ensure that patients receive appropriate medication as needed, and collaborate with other health care professionals to develop comprehensive care plans that address patients’ physical and psychological needs [45]. Besides the national guideline for major depression from the Directorate-General for Health [46], most local groups have their recommendations indicating which patient groups should be referred to psychologists by GPs1. These local protocols were often developed in a context of short supply of psychologists, to aid prioritization of certain groups. GPs’ global prescription pattern is monitored periodically in a national reporting system published online. Despite that, there are no incentives (monetary or reputational) that shape GPs’ prescription of antidepressants and psychologist referral decisions. 1 Informal queries to GPs in various locations suggest that referral protocols used by local groups can vary according to the population needs and resources available. Referral recommendations range from referring all patients with mild depressive symptoms, to prioritizing long-term care, patients in smoking cessation, pregnant women, etc. or excluding some patients, such as excluding some psychopathologies in children and adults that should resort to psychiatric and pedo-psychiatric services.
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