Evaluation of the Better Access initiative component C: analysis of the allied mental health workforce supply and distribution

4.4 Effect of Better Access on interactions between GPs and psychologists

Page last updated: September 2010

4.4.1 Expanding access to mental health interventions
4.4.2 Interactions between GPs and psychologists
4.4.3 Care plans

4.4.1 Expanding access to mental health interventions

General practice and psychology organisations agree that the Better Access initiative has expanded access to mental health interventions, particularly as psychologists are more financially accessible now that their clients can claim the Medicare rebate (chair of GPMHSC, GPMHSC, AGPT, APS, and ACCP). They report that the Better Access initiative has been successful in expanding access for common disorders, but attention is still required for the young, elderly, poor, Indigenous, and marginalised with mental health care needs (AIPA and chair of GPMHSC).

The APS reports that the effect of the Better Access initiative has been very positive in promoting collaboration between general practice and psychology and good clinical outcomes. They suggest it has fostered a collaborative approach to treatment which is in the best interests of the client. Similarly, GP organisations (ACCRM, and GPMHSC) report an increasing awareness of the clinical role of allied health practitioners resulting, at least in part, from the Better Access initiative. GP organisations such as the GPMHSC believe that the Better Access initiative has improved the ability of doctors to link their patients with psychological services, particularly for doctors who do not provide mental health treatment themselves.

There is concern among rural doctors from the ACRRM that the shift of allied mental health practitioners from the public sector into the private sector will further restrict access to public mental health services, especially for Indigenous and other disadvantaged populations who rely on public services.

4.4.2 Interactions between GPs and psychologists

The impact of Better Access on the effectiveness of the interaction between general practice and psychology in expanding access to mental health interventions was explored in the consultations.

According to the chair of the GPMHSC, the referral process consists of the GP examining the patient, diagnosing the patient, and referring to a psychologist (or other allied health professional) if appropriate. The GP then expects the psychologist to acknowledge the referral, return the patient to the GP for primary care, and detail treatment, which is the process that occurs in medical referrals. The chair of the GPMHSC noted that psychologists are not familiar with this model of treating the client and then returning management of the client back to the GP and prefer to maintain management of the client themselves. It is thought that this 'conflict' may be exacerbated by the strict confidentiality requirements for psychologists. However, both GP and psychologist representatives acknowledge that the occupational groups appreciate the collaborative care process, and individuals are developing processes for getting around these difficulties (APS, ACCP, and AGPT): the GPMHSC suggested that a set of feedback standards, developed and endorsed by the RACGP and the APS, would help to manage the quality of the communication between GPs and psychologists.

There was some concern from both GP organisations and the APS about the clarity of the role of each profession within the patient pathway. Currently both GPs and psychologists view their role as providing a diagnosis and that this repetition of tasks often creates conflict between the two occupations. GP organisations also report that the lack of knowledge that the two occupations have about each others' roles can have a negative impact on the client when assumptions are made other occupations roles in mental health impacts upon decisions about where to refer clients (AGPT).

However, both GP and psychology organisations report that there is improved communication between GPs and psychologists resulting from the increase in referrals under the Better Access initiative (APS, AGPT, and chair of GPMHSC). It has also been reported that a shared literacy is developing between the professions that is improving communication between GPs and psychologists.
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4.4.3 Care plans

GP organisations (including the chair of GPMHSC, AGPT, ACRRM, and GPRA) and the APS both reported that the quality of the use of mental health care plans varies greatly between individual practitioners. According to the accounts provided, some practitioners find the care plans to be a useful tool for patient care because it helps to engage the patient in the care process, and they complete the plans carefully; conversely, other practitioners view the plan as not necessarily useful to their client and complete only the minimum requirements. This variability in the quality of mental health care plans, as reported by the GP organisations that took part in the consultations, is of concern (chair of GPMHSC, AGPT, ACRRM, and GPRA). The chair of GPMHSC indicated that there are no benchmarks for good practice in developing a care plan and that GPs want training and support in this aspect of the Better Access initiative. One suggestion that arose through the consultations is that the development of care plans for mental health does not fit comfortably with the paradigm under which GPs are accustomed to working.

This is supported by the high degree of interest in outcome measures and in evidence that mental health care plans actually improve the client experience in the accounts provided by GP representatives.

There was also an almost unilateral concern amongst GP organisations that the quality of mental health care plans is compromised when the referral pathway is used incorrectly. GP representatives described a pattern in which clients are referred from psychologists to the GP in order to obtain a mental health care plan so that their treatment can be billed to Medicare (AGPT, GPRA). However, a lack of communication means that patients are not requesting the longer appointments required for developing a mental health care plan and GPs are forced to develop a plan without sufficient time or knowledge of the patient. One example of how GPs successfully deal with this situation is the use of the shorter session to explain the process and to provide the patient with fact sheets and homework to ensure their understanding of the process, before scheduling the patient for an extended appointment for developing the mental health care plan. This process has the benefit of empowering the patient and involving them in the care process. However, it also appears that there are problems with clients skipping stages in the referral pathway (AGPT, GPRA, and ACPM), suggesting a need for further information dissemination both to psychologists and to the general public about the referral process and GP requirements for the initial consultation and development of the mental health care plan.

The consultations sought information about whether GPs find the paperwork involved in care plans to be cumbersome and unhelpful and that they are instead using Level D consultations to provide mental health care to their patients. The accounts provided by the GP representatives indicated that paperwork was not popular with GPs (AGPT and GPMHSC).

According to the chair of the GPMHSC, the forms used in the mental health care plans are inflexible and restrictive in that they do not take co-morbidities into account. Although some GPs have reported that the care plans enable them to conduct a more thorough exploration of the patient's mental health status than would be possible through a normal GP consultation (GPRA). The following concerns were identified with the forms:
  • the patient's illness has to be framed entirely from a mental health perspective, and separate care plans must be developed for subsequent co-morbidities, effectively doubling (or more, depending on the number of co-morbidities) the work for the GP,

  • the forms do not allow for nuances to be recorded,

  • the forms place the GP in a 'tick the box' mode rather than allowing them to engage in quality patient care,

  • given the complexity of the system and the multiplicity of referral pathways (of which Better Access is but one), GPs find it confusing matching the form to the correct referral pathway, and

  • there is no evidence that the quality of the mental health care plan has a positive effect upon patient pathways or satisfaction, which makes them reluctant to take on the extra work involved in completing the forms.
However, despite GPs' apparent dislike of paperwork, GPs have indicated to their organisations that the major driver to use a Level D consultation is not the paperwork involved in developing a care plan, but concern about labelling clients, privacy, and the implications for patients of having a mental health diagnosis. According to GP representatives from ACRRM and AGPT, GPs are concerned that diagnosis with mental illness has stigma attached and may exclude patients from employment, or may prevent them from obtaining insurance. The emphasis on depression and anxiety in the Better Access initiative, which can lead to over-diagnosis of these conditions in order to meet referral requirements, is another reason cited by GPs for using Level D consultations rather than the Better Access Items.