14 September 2018
Mental Health Plans – why GPs can’t be sidelined
Frankly, I am surprised it has taken the Australian Psychological Society this long to demand greater access to Medicare funding.
In their recent submission to the MBS review, 1 the psychologists have asked to be reimbursed for writing their own Mental Health Plans, have more Medicare-subsidised sessions at their discretion without review, and be able to receive referrals from a wider range of referees, including obstetricians, teachers and family health nurses.
From my perspective, after spending 30-odd years in general practice with a heavy bias towards mental health, I have seen enormous changes in psychiatry and psychotherapy, some good, some not so good.
I believe we, as GPs, need to take this latest push from psychologists very seriously. We need to reaffirm our role in the treatment of mental illness and the promotion of mental health among Australians, before we find ourselves sidelined and our role becomes irrelevant.
Billions of dollars and an equal magnitude of effort has been poured into mental health over couple of decades. This country is now much more aware, understanding, accepting and proactive with regard mental illness and its impact on society.
Psychologists have played an important role in this transition. The number of practising psychologists has ballooned in the last few years. Mind you, I do question how much accessibility to good quality psychotherapy has improved, especially in some of the most disadvantaged areas.
The cost in western Sydney for an hour session with a registered psychologist ranges from $160 to $180, and upwards of $200 for a clinical psychologist. Very few bulk-bill.
The ATAPS program provides funding for the disadvantaged such as those on a Health Care Card or indigenous patients or for those who need more intensive therapy, such as those considered at risk of suicide. But there remains a large, needy group who don’t qualify.
And Headspace centres already provide an option for some people to access subsidised mental health services without the pre-requisite involvement of the patient’s GP. But their main problem lies in the lack of continuity of treatment, both in therapists and duration.
The qualification and quality of their staff also varies widely. I recall a teenage girl with psychotic symptoms was asked to stop her medications (prescribed by myself and confirmed by a local mental health team psychiatrist) by a “counsellor” from Headspace. When I rang to ask why, this counsellor had no idea what those medications were or what they did.
GPs have traditionally been the gate-keepers in the Australian health system, but of course that does not necessarily mean we should keep that position forever. We have to earn it, and continue to earn it if we want to maintain our central role in our healthcare system.
Unfortunately, a 10-minute consult, a few boxes filled in on a standard form and a K-10, often constitutes a “mental health plan” in today’s general practice.
However, we are supposed to be the health professional who knows practically everything about the patient. Not only their psychological symptoms, but their entire health, their lives, their stressors, their fears and their expectations. And so often we do, don’t we?
We are the ones who need to assess if there are other comorbidities, such as thyroid dysfunction, or brain pathology to explain their symptoms before they embark on psychotherapy.
Mental Health Plans as they should be written – by a GP – ensures diagnosis and treatment goals have context. The mental illness is one part of the patient’s overall health.
A Mental Health Plan written by a psychologist as proposed by the submission to the MBS review, cannot, by definition, be that holistic. I don’t doubt that psychologists write their own plan of management for patients they see, but the Mental Health Plan should be done by GPs detailing the diagnosis and psychotherapy treatment direction.
Also, in their submission, psychologists want to be allowed to conduct 10, 20, 40 subsidised sessions at their discretion, with no review. This would give them free rein to access Medicare money (and a substantial quantity of Medicare money) without any checks or balances being in place.
In addition, the quality and ability of community psychologists varies widely, which is why each treatment program should be individualised and monitored regularly.
I do agree that the current pre-requisite that an update report be written after six sessions could be more flexible, and that could certainly be determined by joint discussion between the GP and psychologist involved. But regular review by the referring GP ensures a degree of accountability that is in line with every aspect of best practice.
The other change the psychologists seek is to have a wider referral base. Maybe it’s changing, but in 30 years of practice, I have yet to come across an obstetrician making a detailed mental health assessment. And while community nurses, midwives and school counsellors are in a good position to screen for and detect signs and symptoms of mental illness, these are screening processes and the mental health examination should be conducted by properly trained doctors who can make the diagnosis and write the Mental Health Plan before treatment is instituted.
Mental health care and treatment of mental illness really has come a long way. GPs are now very much part of the team approach, with all of the available services, including psychiatric and psychological, having an acknowledged valuable role.
Recently a patient of mine had an extended hospital admission for psychotic depression. Over this time, the hospital mental health team contacted me regularly, updating me on my patient’s progress and provided me with a very detailed discharge letter – a far cry from the cone of silence that existed in my dealings with mental health services in the early years of practice.
Vital to this progress is communication and coordination, and vital to this communication and coordination is the current role of the GP.
Should the Australian Psychological Society be successful in its submission, we risk fragmenting a system that, while not perfect, represents a great improvement from where we’ve been.
Sidelining GPs in the delivery of mental health services would be a major backwards step and should not be allowed.
Dr Stephen Chow is a General Practitioner working in Minchinbury, New South Wales