18 November 2020

Loss of mental health plans would be a ‘massive blow’

AMA General Practice Mental Health Psychiatry Psychology

The Productivity Commission’s recommendation to replace GP mental health treatment plans with a national digital platform runs contrary to the findings of its own report, says AMA Vice President Dr Chris Moy.

The commission’s Mental Health Inquiry released this week said mental health treatment plans should be scrapped, and a national platform for referral and treatment built “as soon as possible”. This was one of 22 recommendations in the report, which found mental ill-health cost the Australian economy at least $220 billion per year.

It found GPs were not incentivised to spend enough time on mental health consults, that they were not all sufficiently culturally competent, and that some lacked mental health skills and were too dependent on medication as a treatment option.

Creating a “a person-centred mental health system” was a key reform priority, but current mental health treatment plans showed “no evidence of having improved either GP referral practices or mental health outcomes for people”, the commissioners said.

They included lawyer Ms Julie Abramson; Royal Australian and New Zealand College of Psychiatrists Fellow Professor Harvey Whiteford; and Stephen King, an adjunct professor at Monash University whose disclosure of interest says he is married to a private practice psychologist.

While community health services such as GP clinics and PHN-commissioned services were identified in the inquiry as the most common face-to-face gateways to mental healthcare, some patients faced significant barries such as wait times for appointments in regional areas, the cost and time of attending, and cultural differences between patient and practitioner.

The platform would become the new requirement for accessing MBS-rebated psychological therapy.

A key part of the platform would be a tool for standardised assessment and referral, freely accessible to patients and clinicians, which would allow culturally relevant online or in-person support regardless of where the patient lived, they said.

“The way most GPs are subsidised creates a financial incentive for them to limit their discussion time with each person, and not all GPs are competent in relating to the variety of cultural backgrounds of people who may need their help. Furthermore, while many GPs do an excellent job, some lack knowledge and skills in mental health, and rely too readily on medication as a treatment option,” the authors wrote.

“GPs would remain a primary gateway to mental healthcare for people who have ready access to them locally and/or have physical as well as mental health concerns … With mainstream community health services (including GPs) linked to the new national digital mental health platform, people would be assured they are receiving an assessment that is rigorous and treatment recommendations that are evidence-based and match their needs.”

Dr Moy, an Adelaide-based GP, told The Medical Republic the recommendation to replace the plans with a platform was contradictory to what the report showed.

“The bit that is really silly is that the report recognised the central importance of general practice – how we see more than all the psychologists and psychiatrists combined in terms of consultations, and there’s really good patient satisfaction – but then it talks about reducing funding by removing mental health items.

“I think [losing mental health plans] would be a massive blow.

“Obviously, an objective test is important and is part of it, but it’s already done – and we also need to put it in the context of the rest of the patient, which can’t be done in a machine.

“This takes the assessment outside the GP to a great degree, and where does that continuity of care and coordination of the patient come from later? It also disregards the fact individuals who have mental health problems often have significant physical problems as well.”

Good elements of the report included recognition of the under-funding of mental healthcare, and a focus on early prevention and diagnosis, Dr Moy said.

“They also highlight there’s a need to look at things like housing and employment – that if people have serious illnesses and are discharged from hospital, with no community back-up, they can have major problems. They’ve also recognised that there’s a massive dearth of psychiatrists and we really need to get that funding right and look at funding other members of a multi-disciplinary team.”

He would have liked to see more discussion of “patient-centred medical homes” with GPs, psychologists, social workers, and mental health nurses work as an in-house team to support patients long-term.

“Say if I had a patient who had some developing anxiety symptoms that had caused a number of problems, loss of job and finances – I could either get the mental health nurse or the psychologist involved, I could manage the medication, and then get the social worker involved to look at their home situation and get them on the path to sorting out the practical parts of life, which are going to be one of the greatest determinants of how they go.”

Dr Moy said he was pleased an inquiry has been conducted into mental health, but hoped the report is not “hijacked”.

“It’s important that the government does not merely get hypnotised by glossy, narrow and expensive models of care which has been their tendency, and to focus on supporting what the productivity commission has identified as ‘bleedin’ obvious’: that a GP does the heavy bulk of the work at the coal face – and we need to just build on this grass roots foundation by supporting funding for a multi-disciplinary patient medical home model of care.

“It’s been right there in front of them, but they’ve been missing the wood for the trees. This would leverage off the GPs’ knowledge of the patient to add comprehensiveness in psychiatric care of patients.”