Through the consultations it appears that the Better Access Initiative has been successful in encouraging more GPs to participate in early intervention, assessment and management of patients with mental disorders and streamline access to appropriate psychological interventions in primary care. The operation of the Better Access initiative in relation to the interface between GPs and psychiatrists appears to be working well and is effective in providing secondary consultation to support and improve the skills and confidence of GPs in managing patients with a mental health disorder. The interface between GPs and AHPs has been valuable in providing referral and treatment options for patients who would benefit from focussed psychological strategies.
The predominant message from the GP consultations was that GPs are doing more mental health work than ever before. This is also reflected in the Medicare data on the number of services funded through the Better Access initiative (Figure 1) and responses from AHPs, public mental health providers and NGO consultations. It was noted that the growth in mental health activity is occurring within the context of increasing and competing demand from an ageing population and other health priorities including asthma, cancer and diabetes.
It was acknowledged during the consultations that a component of the growth in the Better Access initiative services by GPs was partly an artefact of activity that was previously coded as a long consultation or Enhanced Primary Care (EPC) item now being coded as the Better Access initiative.13 However, the overwhelming indication was that there was a real increase in the number of mental health services provided.
Interviewees noted that, although all GP practices would have a high proportion of patients with mental health problems, prior to the Better Access initiative many of these patients would have received minimal mental health treatment or their GPs may have been reluctant to explore the mental health components of presenting problems. One carer commented that their experience prior to the Better Access initiative was that some GPs were reluctant to address mental health issues as it "moved them out of their comfort zone"14.
The Division of General Practice representatives in one state estimated that between 20 to 30 per cent of GPs provided minimal mental health care. Several psychiatrists and GP representative bodies that were subsequently interviewed reported that this appeared a reasonable estimate. The reasons for this were seen to include:
- inadequate remuneration for the time required to assess and develop a Mental Health Treatment Plan;
- a lack of skills and confidence by GPs to engage in mental health treatment;
- some overseas-trained GPs (particularly from non-English speaking countries) have a different cultural awareness of mental health and how it should be treated. This is compounded by mental health training not being a core requirement for accreditation in Australia and so being a lower priority for overseas-trained doctors studying for their Australian accreditation; and
- mental health was not a primary area of clinical interest to some GPs and these GPs may fail to recognise a mental illness underlying a somatic presentation.
- by providing a higher MBS rebate for Treatment Plans and Treatment Plan reviews, thus providing the incentive and financial viability for GPs to undertake mental health assessments and prepare Treatment Plans;
- by improving access to psychiatrists for patients' assessments and advice for ongoing patient management, thereby increasing GP confidence and skills to manage patients;
- where the GP did not feel they had the expertise to provide focussed psychological interventions, they could refer the patient to a psychiatrist or AHP; and
- the information, training and networking opportunities with other mental health service providers implemented concurrently with the Better Access initiative has increased GP awareness of, and focus on, the mental health needs of patients.
"This initiative is the single most important factor that has changed my working life in the past 5 years. Prior to this, dealing with mental health problems was nothing short of a titanic struggle for the average busy GP. Since referral to a psychologist with Medicare subsidy has been possible, GPs have not had to re-invent the wheel every time we saw a patient with high prevalence disorder (anxiety disorders or depression). I largely do not bother psychiatrists with these problems which are usually fairly straightforward for psychologists to deal with, often working with GPs as prescribers. Instead, psychiatrists are now used more appropriately to see people with mental illness that is more severe, or with psychotic disorders.15"
As GPs are the gatekeepers for access to psychiatrists and AHPs, changing their behaviour was perceived as a key component in improving overall access to mental health services. GPs, GP stakeholder groups, psychiatrists, allied health providers, NGOs and consumers all reported a perception that GPs appeared to be more aware of mental health service options for their clients. It was noted that this change has been progressive and would continue to develop as the Better Access initiative matured.
GPs and other stakeholders reporting improved access to mental health services noted:
- awareness of the Better Access initiative by Divisions of General Practice and GPs consulted;
- increasing referrals to psychiatrists;
- increasing referrals to allied health providers; and
- increasing numbers of patients driving referrals through the Better Access initiative by presenting to GPs and asking for a referral to an AHP.
A small number of GPs also questioned the level of awareness of the Better Access initiative among their colleagues and suggested that some GPs may be claiming the provision of Mental Health Treatment Plans due to the financial incentive of the MBS Item number, rather than reflective of the service being provided. A very small proportion of GPs, AHPs, consumers and carers consulted, also expressed this view.
A small number of individual GPs engaging in the consultations (not Division of General Practice or RACGP representatives) reported that some of their colleagues were not well aware of the Better Access initiative, the requirements to claim the Better Access initiative item numbers and referral through the Better Access initiative.
That some GPs may not be fulfilling the intent of the Mental Health Treatment Plan was also reflected in the perception by AHPs that many (possibly 20 to 30 per cent) of Mental Health Treatment Plans that they received contained insufficient information to inform the treatment approach, with some containing no information on diagnosis or reason for referral. Overall though the majority (73 per cent) of respondents reported the information provided in the GP mental Health Care Plan as good or fair and notably, 72 per cent of respondents reported that they had not received inappropriate referrals. (attachment 1)Top of page
Approximately a third of consumers and carers complained that their GP did not spend enough time with them and a smaller number (less than ten per cent) reported that they were not aware of their GP preparing a Mental Health Treatment Plan prior to referral to an AHP. Consumers and carers participating in the evaluation through the teleconference and online survey were also more likely to report that GP awareness of availability of the Better Access initiative remained an issue.
It should be noted that of those stakeholders expressing concerns about GP awareness of and use of MBS items through the Better Access initiative, nearly all reported that awareness of the Better Access initiative and quality of Mental Health Treatment Plans and information provided to consumers was improving. This was perceived as a natural maturing of the Better Access initiative over time.
13 The degree to which new item numbers are displacing activity which may have previously been coded differently is an area that may warrant investigation in Component B of the evaluation: Analysis of Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) Administrative Data.
14 Quote from rural carer participating in consumer and carer teleconferences in relation to problems in gaining services to treat depression experienced by their partner.
15 Comment received in the online survey.