GPs are still unpacking a budget surprise on mental health in residential aged care, and clearly the plan is not what they wished for.
Under a four-year, $82.5 million program, revealed in the May 8 budget, GPs will have a role in referring patients with a “diagnosed mental disorder” in residential aged-care facilities.
But the new services will be commissioned by primary health networks, in consultation with residential aged care facilities in their regions.
This indicates the design will not be uniform and won’t necessarily follow the team-based model advocated by doctors.
“Models of service delivery will be developed taking into consideration regional need and workforce availability and informed by stakeholder consultation,” a health department spokesperson told The Medical Republic.
“Subject to the service models developed by PHNs, services could be delivered by a range of mental health professionals including psychologists, social workers, occupational therapists, mental health nurses and counsellors.”
Dr Richard Bills, a Victorian GP with a long interest in aged-care patients, welcomed the investment but questioned how it was targeted.
“I think the challenge for PHNs in administering this is that they are somewhat remote from the coalface,” Dr Bills said.
“You need the capacity for flexible delivery – proactively and reactively – in dealing with distress in that environment,” he said.
“I think, the people who have the best handle on that are the ones who work in the facility, not just the staff and managers, but the GPs, in particular.”
In 2014, Dr Bills set up an offshoot company, New Aged Care, to bring regular nurse-led GP services to residential aged care patients. It now has a patient list of 400 and is under pressure to double in size.
One of the group’s services was educating aged care facility staff to identify and reduce stressors affecting patients.
Huge numbers of residents were being medicated for mental health-related conditions but would possibly be better managed through other means, Dr Bills said.
Dr Dimity Pond, professor of general practice at the University of Newcastle, said clinicians needed to push for a multi-disciplinary approach built on good communications between nurses and doctors.
“The other thing is that there are not too many registered nurses left in residential aged care these days,” she said.
“So are we looking at assistants-in-nursing referring people to a psychologist?”
Dr Pond cited the case of a patient mourning the loss of her house, who had stopped going down for meals. Nursing staff recommended she be moved into a high-care unit and asked the GP to prescribe a pill.
“I said, no, what you need to do is to get her to do some activities. Wheel her out, if necessary, at least for the first few times. She did pick up when they put in some time and effort. That was a social disorder.
“On the other hand, I have a patient in residential aged care with bipolar disorder who needs a psychologist.”
Dr Louise Roufeil, executive manager of professional practice at the Australian Psychology Society, said the government’s policy turnabout was “wonderful, long overdue”.
But no money had been earmarked to investigate or prevent high rates of mental illness in aged-care residents, although funding had been improved for community mental health nurses, she said.
“It seems rather silly. This isn’t prevention, this is fixing people up,” she said.
“Hopefully, we will get a chance to work with the department on how best to implement the program so it is accessible and GPs, who do the bulk of healthcare in aged-care facilities, are kept in the loop.”
Issues such as confidentiality, informed consent and privacy in aged-care settings would need to be overcome.
“Aged care facilities are not going to be used to us being there. Other than a few places where there have been one-off funding programs, there has been very limited potential for psychologists to work in aged care.”
Dr Roufeil said it would be a big ask for the sector to meet the government’s intended launch date for services in early 2019.
“As everybody knows, the inequity in the sector about Medicare-funded psychologists for aged-care residents has been an issue for a long, long time,” she said.
“But somehow this year there was a confluence of interest, with a number of people wanting the same thing. And it seems to have happened.”
The RACGP is opposing the planned reform, demanding instead a new Medicare item number for aged-care residents to access GP mental health plans.
“Funding channelled through primary health networks would be diminished by the administrative costs and the risk that initiatives are only temporary,” chair of RACGP Tasmania Dr Jennifer Presser said.
Leading Age Services Australia, the national peak body for aged-care providers, said it was not consulted on the plan.
More work was needed to understand the full extent of demand for mental health services in residential aged care and the best evidence-based interventions, LASA CEO Sean Rooney said.
“Ease of access to GPs is also an important part of the equation for mental health in residential aged care,” he said.
“LASA was not consulted on this measure, but our pre-budget submission clearly argued for sustainable funding solutions for residential aged care supporting the principles of access and quality, and much further funding support is required for this.”
Newly installed AMA President Dr Tony Bartone said he would stress the importance of GP-led, patient-centred care.
“Anything that fragments the role of the GP in the delivery of health care to their patients has to be looked at in its totality and ensure … that it doesn’t interfere with the direction,” the Melbourne GP said.
“We can have many, many members of a GP-led team working in unison. And, in that team environment, we can do so much more.”