The following article was published in MJA InSight in response to an early article by Rosenberg and Hickie in the same publication. (Link)
Stone L, Spielman K, Tam M, Lynch J, Su M, Senior T, Price K, Chalmers S, Burton G. Myth-busting: role of the GP in primary mental health care. MJA InSight. 2022 Aug 8. Available from: https://insightplus.mja.com.au/2022/30/myth-busting-role-of-the-gp-in-primary-mental-health-care/
Article
We are the best value mental health care in the country using less than 3% of the total mental health budget to see the majority of the patients needing community care. Current underfunding added to rhetoric that alienates and misrepresents GPs seems a counterproductive strategy if we are to provide better mental health outcomes for all Australians.
IN recent years, we GPs have seen a steep increase in mental distress, and the cracks in the system that fail the most vulnerable are familiar to us all. We are well aware of the enormous unmet need for mental health care at this time and we agree with Rosenberg and Hickie, who wrote in InSight+ recently that primary mental health care reform is long overdue.
Where we disagree with Rosenberg and Hickie is in our understanding of the problem and in particular, the role of GPs in contributing to the current mental health crisis and its various solutions. While they are entitled to question the efficacy and efficiency of all players in the system, we feel that Rosenberg and Hickie have misinterpreted the GP data.
As a group of diverse GPs with significant shared expertise in mental health care, we would like to take the opportunity to correct these misconceptions. Without an accurate understanding of the data we use to inform policy, solutions are likely to be ineffective.
MYTH: GPs do not review their patients and are therefore providing poor care
Rosenberg and Hickie state that “GPs wrote more than 1.2 million mental health plans for Australians in 2020–21 but of these, only just over one-third (36.8%) were reviewed, meaning patients’ ‘ progress was largely unmonitored by their GPs”. This argument has been used before by Rosenberg and Hickie (here and here). It was wrong then, and it is wrong now.
Counting mental health item numbers has always been a poor proxy for quantifying the mental health care that GPs do. GPs must use mental health plan item numbers, such as MBS item numbers 2700, 2701, 2715 or 2717, if patients need to access psychologists, social workers or occupational therapists under the Better Access program. However, the other mental health item numbers (the 2712 mental health review, the 2713 mental health consultation and the focussed psychological strategies numbers) are optional.
A review item number has a lower rebate than a consultation item number. A mental health review number offers a rebate of $75.80 while a consultation item number for an equivalent length of time is $76.95. If patients and GPs are financially penalised when mental health item numbers are used, why would we choose to utilise them?
Patients are rightly concerned that evidence of mental illness in the medical record may impact access to insurance, particularly if their mental health concern is self-limiting and short term Anecdotally, the authors are aware of patients who prefer not to use mental health item numbers because of privacy concerns. This is particularly problematic in children because the mental health treatment plan must include a diagnosis. Parents may be reluctant to “label” their children with a “mental health disorder” due to reasonable concerns around stigma and the pathologizing of normal stressors in childhood.
GPs are actively discouraged from using mental health specific item numbers by the Department of Health. The recent nudge letters from the Behavioural Economics Team of the Australian Government (BETA) threatened “compliance action” if the mental health item numbers were billed alongside consultation item numbers “inappropriately”. The Department actively targeted GPs who were statistical outliers, without any evidence of inappropriate practice. The fear of the “nudge” and the weight of the Professional Services Review is likely to have changed the billing practice of all GPs. Many GPs feel it is safer to avoid using these numbers at all.
GPs see 82% of the Australian community every year, with over 65% of GP consultations involving a psychological issue. Only 8.8% of patients receive a mental health item number. MBS mental health item numbers suggest that only 36% of mental health consults are billed as such. In other words, for every consult involving mental health billed using a mental health item number, there are another 1.8 consults addressing a mental health concern that are billed using another item number. Using mental health item numbers as a proxy for clinical activity is deeply misleading.
MYTH: GPs operate as solo clinicians, and would get better outcomes using multidisciplinary teams
General practice would not manage without the diverse skills of our health professional colleagues. However, mental health specific multidisciplinary teams are not the answer for many of our patients. There is also evidence that they may not be as effective as we expect in GP settings. In the UK, the introduction of multidisciplinary teams into primary care increased cost, reduced patient satisfaction and reduced quality of care.
Complex systems can harm patients with complex needs. Our patients do not always experience the collaborative, patient-centred care these teams espouse. In fact, there are some suggestions that patient centred care can increase inequity. As Dr Tim Senior writes:
“When we claim that the patient is an essential member of the team, it must sometimes feel like their role is akin to the role of the ball on a football team, kicked back and forward between the team members in search of that elusive goal.”
We also know that a long-standing therapeutic alliance improves outcomes in therapy. This is particularly important in vulnerable patients with a history of trauma. We also know that long term therapeutic relationships reduce healthcare cost. Outsourcing and modularising this relationship may have unintended consequences that should be carefully considered to ensure the benefit of such an approach exceeds potential harm.
There are plenty of multidisciplinary teams that already exist in this sector. Unfortunately, most of our patients face a series of closed doors when they try to access care — not unwell enough for public care and too unwell for private services; rural patients who cannot access or do not relate to metrocentric services; patients who have co-morbidities that restrict them from utilising siloed services; patients living with mixed emotional and physical symptoms who have experienced so much invalidation in the healthcare system they quietly disengage; patients with physical health needs who already have so much multidisciplinary team input they and their carers face a full-time job just managing appointments, and the associated bureaucratic requirements; patients who are too poor, too geographically isolated, too unsupported, too culturally and linguistically diverse or simply too tired to face the navigational complexity of care.
It seems inequity in mental health care is rising. However, patients who live with systemic disadvantage access general practice more commonly than other health services.
GPs treat populations who present with a broad scope of clinical presentations. Individual disorders like depression and anxiety are only a small part of the scope of our practice which is why our curriculum is so broad. Our work includes crisis to chronicity, cradle to grave, primary to tertiary prevention, single disorder to multimorbidity, community to tertiary care and remote to urban populations. Given the diversity of care we provide, we expect that we will collaborate with a variety of individuals, institutions and teams to provide care. These are bespoke teams, involving informal support networks, peer workers, individual health professionals, non-government organisations, public and private outpatient and inpatient services and social services.
Good GPs integrate their understanding of context, relationships, meaning, life story, and bodily health alongside what the psychiatric model separates out as “mental health”. This fundamental difference in how we see people means that strategies developed for psychiatry and psychology led segments cannot be generalised into our context. Using evidence justified in one context to drive policy in another is poor science and poor practice.
MYTH: Technology is fundamentally “good”
Technological solutions, particularly when used to analyse patient-centred outcomes of care, are a growing resource, but are currently best suited to single disease modelling. There are ethical concerns about the use of artificial intelligence in mental health care that bear examining, particularly around privacy and transparency. AI algorithms incorporate hidden values that unintentionally reinforce current inequities.
Australia leads the world in technology enabled mental health care yet only 4% of Australians needing mental health care use digital mental health services. This may be a question of access or literacy, but bears examination before we increase our substantial investment in technology enabled mental health products.
GPs are as diverse as our patients. We have the training, the skills and the insight to contribute meaningfully to the mental health discourse and the delivery of services. Now all we need is genuine collaboration from other services with narrower populations than ours. It is frankly offensive that specialist world views are held up as the most reliable solution for the care of patients they will never see.
What frustrates, angers and even harms us and our patients is the exclusion of our voices and perspectives from the medical discourse, policy design and treatment planning. Ignorance of our role, poor remuneration and negative portrayals of GPs are contributing to the early retirement and low recruitment of GPs, which will only worsen access to mental health care.
The GP workforce is growing smaller with an expected shortfall of over 11 000 FTE by 2032. We are the best value mental health care in the country using less than 3% of the total mental health budget to see the majority of the patients needing community care. Current underfunding added to rhetoric that alienates and misrepresents GPs seems a counterproductive strategy if we are to provide better mental health outcomes for all Australians.
Louise Stone, is a GP with clinical, research, teaching and policy expertise in mental health. She is Associate Professor in the Social Foundations of Medicine group, ANU Medical School and works in youth health.
Karen Spielman, is a GP who has worked in diverse settings with marginalised young people, youth mental health and is GP Advisor and Research Associate at InsideOut Institute. She is Advocacy Representative for the Australian Society of Psychological Medicine.
Tim Senior, is a GP at the Aboriginal Community Controlled Health Service in South West Sydney, and a Senior Lecturer in General Practice and Indigenous Health at Western Sydney School of Medicine
Michael Tam, is a Conjoint Senior Lecturer of the School of Population Health, UNSW Sydney, and the Director of the Primary and Integrated Care Unit of South Western Sydney Local Health District. His Unit provides specialist GP care to people living with severe mental illness in partnership with community mental health teams.
Johanna Lynch, is a GP with expertise in trauma specific care and domestic and family violence. She is a Senior Lecturer at the GP Clinical Unit and The University of Queensland and President of the Australian Society for Psychological Medicine.
Wei-May Su is a GP with an interest in complex care, family abuse and violence. She is Academic Lead (GP), HETI; conjoint senior lecturer Uni Notre Dame and leads the Master of Psychiatric Medicine Program.
Karen Price, is a Melbourne GP and President of the RACGP. She is Adjunct Clinical Professor Monash University.
Sarah Chalmers is a GP and Rural Generalist with experience working in very remote communities providing comprehensive primary and secondary health care. She is Senior Lecturer in General Practice and Rural Medicine at James Cook University, and President of ACRRM.
Gwendoline Burton is a Brisbane GP whose roles also include Chair of the Antenatal/Postnatal Specific Interest Group for the RACGP and Clinical Expert for the BSPHN Mental Health Team.
