These key informants discussed multiple barriers and enablers to consider, and we identified several themes relevant to conducting health assessments for young people in general practice.
Empowering young people’s healthcare
Participants emphasised their hope that offering a health assessment would contribute to young people’s empowerment in participating in and managing their own healthcare. Participants noted that planning health assessment appointments should consider the time and pace that suits young people, and the invitation should be distributed using non-traditional methods, such as social media, to engage young people from the first point of contact. Participants discussed experiences where they attempted to communicate with young people ‘on their level’ while simultaneously considering medico-legal and parental concerns:
I’d try a variety of things. I would certainly offer it like a text message. And the way I would frame it is along, you know, have half an hour or three quarters of an hour with your GP to ask any questions about life, the universe or anything. But offering them a set time. This time is for you to ask questions that you may have and at the same time we’ll do a health check. [GP9]
Empowerment went beyond the initial assessment and into engaging young people with primary care, as one participant described:
I’m a big fan for empowering young people. I think we can tell young people and maybe they can open that discussion up with their parents if they want to. Maybe they don’t want to have that discussion and maybe that’s just what they needed is to have that opening … ‘Oh, I can actually make my own appointment’. [GP10]
Current logistics
Participants discussed how preventive health assessments in their practice work and the importance of considering existing clinic logistics, including limited staff resources and time, as well as nurse confidence and capability to pivot to conduct and manage young people’s health assessments in the general practice environment. Further concerns included the impact of COVID-19/telehealth and the ability of a practice to introduce health assessments for young people within their patient population. As one GP described:
Most of [my appointments] are face to face. I just don’t like asking about intimate sort of stuff [via telehealth], because you can’t see the reaction you’re getting. And stuff like mental health, I think that I can come across more harshly on Zoom. I think I’m reasonable picking up cues, but I’ve made a few blues myself on telehealth picking up cues. And so, I would feel devastated if I asked some questions and then you’re not there to then safety net the person properly if you’ve brought up some issues that distressed them. [GP8]
Participants also discussed their confidence in their colleagues’ and staffs’ abilities to facilitate any changes required to conduct these assessments, including new software training, scheduling and patient recruitment:
I’m at a private practice and I actually do a lot of work behind bringing people in for health assessments. So I will do it several ways. Often the GPs, I’ve a very close relationship with all our GPs, so they know that’s my sort of role, one of my roles in the practice. So they’ll do a quick … referral to me and then I’ll actually ring the patient. I’ll have a look at their history and make sure they’re eligible first. And then, ‘cause sometimes the doctors won’t realise that they’ve had an assessment, so then I’ll, once they’re eligible, I’ll ring the patient and explain what it involves, that they don’t have to pay, and the benefits for them. [PN1]
Funding of a young person’s health assessment
Participants noted that the ability of the clinic staff to deliver care would be affected by the nature of general practice, in which various funding and payment structures exist (eg bulk billing [no out-of-pocket expense for the patient] vs some out-of-pocket payment for the patient). Furthermore, how practices managed other rebated health assessments (eg whether or not nurses are involved or how rebate payments are distributed within practices) would affect the implementation of the young person’s health assessment. As one GP said:
Well, I guess from our perspective also, [GP8] and I both work in private clinics, so we have to make sure that it’s financially viable is the other thing. If doctors working in private clinics are not bulk billing everyone, wouldn’t necessarily want to do it if they’re not making enough money, which is the unfortunate reality. [GP7]
Young people themselves might face financial barriers to attending a health assessment. Participants highlighted that even a small out-of-pocket fee might discourage a young person from attending. Further, for some populations without access to Medicare, such as international students, even a small assessment fee might discourage young people from attending:
… the young people I work with are quite vulnerable … even if a clinic is only asking for a sort of $10 payment, often that’s enough to sort of turn them off. Particularly when you think about how tricky things like that you aren’t an ‘independent’ in Centrelink’s eyes until you’re 22 if you’re living with your parents, regardless of whether they give you funding or not, I think it can get really complicated for that age group. [PN3]
Assessment design
Participants spoke at length of the importance of considering the potential harms and benefits of a young person’s health assessment. Ensuring patient safety and follow-through to care were perceived as essential steps to prevent harm:
I think if you were doing them separately, you know, a nurse on one day and a GP on another day, I think that you would come into have trouble if you’re doing a HEEADSSS [Home, Education/Employment, Eating/Exercise, Activities, Drugs and alcohol, Sexuality and gender, and Suicide, Depression and Self-harm; Red Book–recommended domains] assessment and there’s not someone that you can say, right, you actually need to go and talk with the GP now. So I think there needs to be that GP support there or some other, I guess a bit like the DiSS [Doctors in Secondary Schools] phone line or something like that. Although, the DiSS phone line, someone doesn’t normally answer at the time. I guess you need to be able to put them onto a clinician that’s suitable for what the issue is. [PN5]
The doctor–patient relationship was of concern, particularly considering the different context if the young person was consulting with a particular GP for the first time or attending a GP they had seen since childhood. Establishing rapport with the patient, ensuring and explaining confidentiality, asking sensitive questions, adequate signposting and other safety-related design issues should be considered:
Say you’ve set up your clinic, where you’ve got your nurse running 45-minute assessments across a day and all of a sudden, your first patient says, ‘Well, I’m suicidal right now and I have a plan, and I know what I’m going to do’ … You would stop and you would have to either hand that person over to another capable nurse to support them or do you step out? I guess it’s the logistics of that. Same with safety. If they disclose something to you around their safety, again, you have to then manage that. And if you’re completely booked up over your six to eight hours, full of adolescents. I don’t think that it would work. [PN6]
Clinician support
Not all participants had training or practice experience providing medical care for young people and thus discussed a range of confidence in doing so. Some expressed a need for ongoing support to providing a health assessment, including resources/referral pathways and initial/ongoing training. This training should include upskilling staff, including PMs, to participate in the health assessment and ensure the health service is youth friendly. Beyond training at trial participation onboarding, participants expressed a need for resources available at-hand during an assessment, for both the clinicians and the young people, and requested advice regarding how to share these resources with young people in a timely manner:
I would have a resource that they [patients] were given with all the links. Because you may have brought something up, like their sexuality, where they don’t want to talk to you about it. But you’ve given them a link so that they might then access the link and come back to you at some stage or another and say, look, I saw this on here. I’ve had a few people with postpartum depression who’ve come back and said, look, when you were doing my check before I had the baby, you told me that if I ever felt upset or unhappy, and these things, and so, I’ve decided I’m coming back to see you to talk about it. [GP8]
Although the motivation was evident, a champion or expert in youth health would be of value for training and ongoing support:
And I’d actually love to see a GP who has real expertise around adolescent health. How they start off engaging some of these adolescents in a good health assessment. Almost like being a fly on a wall, watching them doing a videotape of a consultation that I suppose demonstrated the various techniques that they could use to actually engage with the adolescent themselves … Because, again, look, I must admit sometimes I have a conversation and I just think, I know they have something going but I never got to the bottom of it. You just had that feeling sometimes. So, I just would like some expertise, developing how I reach out to some of these adolescents. [GP9]
Templates for health assessments
Participants described comfort with templates being available to them within their practice software and noted they would appreciate these being created to record and manage young people’s health assessment data, not only for their (clinic staff) benefit, but to encourage participatory healthcare with young people:
So, it needs to be reader-friendly for them. So, we have decided that when I’m doing a mental healthcare plan, I’m typing everything out as I go with the patient. Because it’s theirs. So, it needs to be structured. But also, I believe, something that the patient can be involved with and that they can see the benefit from it as well. [GP10]
However, while enthusiasm was prevalent, some participants preferred to tailor their discussions directly from the concerns raised by the young person rather than being held to a template, particularly when what to discuss is negotiated between the clinician and young person:
I don’t necessarily do it exactly in order because it depends on what’s organic in the conversation. Sometimes ‘Home’ [from the HEEADSSS template] can actually be a very difficult one for people to answer, is the other thing. It’s interesting that that’s first but then also, for a lot of our kids with DiSS that’s a very sensitive topic. [GP6]
Discussion
The views of these key informants highlighted both barriers and enablers to achieving effective young person health assessments in general practice in Victoria. The concept of young person health assessments was accepted enthusiastically by most participants, and the barriers they identified were in keeping with what is already known about lack of time for consultations and the potential value an MBS rebate might offer to counter this concern.26 The views of the primary care professionals supported previous trial findings that young person health assessments have the potential to achieve tangible benefits and identify risk behaviours and should be part of the core work of general practice.11,27
The focus group and interview data provided valuable insights into the structure of potential young person health assessments. Ongoing issues to explore in future research include current practice logistics; the role definition of GPs, PMs, and PNs; as well as the capabilities and capacity of each team member to contribute to issues such as engagement, rapport building and risk management, which includes important issues regarding confidentiality and parental consent for young people aged 14–15 years. Participants also highlighted the contextual issues regarding practice funding and billing and whether an MBS rebate is an adequate reimbursement for such an assessment; this is likely to affect acceptability to both the young people and the business model of the general practice. Practice location may also have affected the acceptability and availability of resources and referral pathways.
Limitations to this study included the recruitment method (snowballing), which led to input from a relatively motivated group of providers with a specific interest in young people’s health. Participants came from different practice settings, including community health and school-based practices, which are likely to receive funding from other government agencies in addition to Medicare. Nevertheless, these participants had important feedback on conducting adolescent health assessments to guide our future trial. Given that the trial will be set in general practice, we did not recruit any representatives from Aboriginal Community Controlled Health Organisations, so our findings cannot be generalised to that setting. Participants were more likely to be female; as such, our results are unlikely to be representative of all general practice staff across Australia. Two members of the research team are practising GPs, and as personal and professional networks were used for recruitment, this may have had unintended bias. However, initial analysis of data was conducted by a research officer who had no role in participant selection nor recruitment. Finally, applicability to health systems funded via different models outside of the Australian context (eg Medicaid in the USA) cannot be assumed.
Conclusion
Key informants’ perspectives echoed the understanding of the nuances of general practice already known and provided additional, substantive findings. While supportive of the intervention, key informants identified the importance of addressing key barriers and facilitators to conducting young person health assessments in general practice in Victoria. If a rebated health check for young people is to be implemented in general practice, this preliminary research identified that empowering young people and establishing clinic systems (software, billing, young person recruitment and appointments) are key facilitators influenced by geographic and funding contexts. Further, providing clinicians with appropriate training and support to conduct the assessments is helpful. Complementary research should investigate young people’s perspectives about the potential benefits of and hindrances to conducting health assessments in general practice.
Key points
- GPs can address young people’s health needs, but barriers exist.
- An MBS rebate for a young person’s health assessment may facilitate GPs’ time and be a financial incentive.
- An annual young person’s health assessment is acceptable to key informants participating in this research.
- Current clinical logistics and staff roles should be considered when implementing young person health assessments in general practice.
- Key informants’ perspectives aid the planning and implementing of young people’s health assessments.