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‘To my respected psychiatry colleagues’


Andrew Leech


23/08/2023 4:12:57 PM

A near-constant stream of referral rejection has prompted one frustrated GP to address an open letter to Australia’s psychiatrists.

Frustrated GP
GPs report that their patient referrals are being increasingly rejected by psychiatrists.

To my respected psychiatry colleagues,
 
Firstly, I want to thank you for the hard work and dedication you have provided to some of our most vulnerable patients.
 
I can’t imagine what it is like to deal with the massive uptake in patient referrals, emergency presentations and increased complexity in diagnosis and treatment. Likewise, the stress that this can lead to and the pressure you must be under both in the public and private sector needs acknowledgement. 
 
However, we’re all on the same journey, and with mental illness prevalence surging in Australia right now it can sometimes feel like we’re fighting a losing battle.
 
In general practice we’re seeing escalating levels of risk, more acute crisis situations, longer consultations, ADHD presentations, eating disorders, increased self-harming behaviours, higher rates of drug use and social problems, more anxiety and a huge demand for appointments with a general sense of stress and burnout in patients of all ages.
 
So, it’s within this context that I wish to raise a few concerns that have become ‘the norm’ in my experience when referring patients to psychiatrists over the past year or so.
 
Below are the top five responses I’ve received in recent times, all of which were part of a generic rejection letter: 

  • The psychiatrist does not accept referrals for patients with a history of ADHD/autism/eating disorders/personality disorders/PTSD and so on
  • The psychiatrist does not accept referrals for patients under the age of 15/16/17/18 – or vice-versa, they don’t accept referrals for patients over 15/16/17
  • The psychiatrist does not accept a referral for a patient with a history of suicide attempt, recent hospitalisation or who is currently at risk
  • The psychiatrist will see the patient once for an assessment, but not prescribe and send the patient back to the GP (prompting a subsequent search for another psychiatrist)
  • The group of psychiatrists have reviewed your referral and don’t have any suitable for your patient at this time 
Then, at the bottom – ‘please inform your patient of this outcome’.
 
I need to say, these letters leave me with mixed feelings. Confusion, frustration, helplessness and ultimately sadness for the patient, who deserves better care. 
 
These are people we know well and for whom we have used everything in our general practice ‘toolkit’ to manage. By this point we’ve usually already tried the first-, second- and third-line treatments just to avoid the need to refer. We’ve hit a wall and so has the patient.
 
Which brings me to my point: I know you are busy – but why are we getting these answers? 
 
Whether it be that books are full, or psychiatrists are sub-specialising, I feel GPs need to understand why this is happening and how we can work to help you, so that you can help us.
 
When I receive rejection letters, I often ring specialist rooms to explain the importance of getting help, to advocate and explain the urgency.
 
And I’m not going to lie, by this point I’m frustrated. But the hardest part is having to then explain it to the patient.
 
They are often deflated, naturally feeling it is their own mental health diagnosis that is part of the problem when it comes to getting help.
 
I like to write detailed referrals for all specialists, to make it easier and reduce the need for doubling up of work. However, talking to colleagues, perhaps providing this level of detail is actually to our disadvantage, and a ‘dumbing down’ of the referral would have more chance of getting accepted.
 
What would allow us to be heard so that we can get help when we need it? Is psychiatry now a sub-specialised field, similar to orthopaedics, whereby they cannot see anything even remotely outside their scope of practice?

These are questions that come to mind as I grapple with these ever-increasing challenges.
 
In any case, I hope this letter helps you see things from our side and leads to solutions, whether it be greater use of the Medicare item 291 (allowing a one-off visit and management plan), or more reliance on telepsychiatry services, at least in the interim until more specialists become available to help the workforce.
 
I’m not trying to complain, I have many psychiatrist friends and respect them highly.
 
Rather I want to understand the situation and what we need to do, so we can work together to make the lives of our patients easier. 
 
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M Chiu   24/08/2023 6:30:59 AM

I am so glad that someone has written an article about this issue. I share the same frustration. Rejection of referrals is a huge issue. The more information I provide on the referrals, they more likely they get rejected. How about the cost of consultations? Patients with mental health issues are more likely to be socially disadvantaged, unable to afford and access psychiatric care. In my view, psychiatric care is only for those who can afford. That is why the public system is unable to cope. Patients often get rejected by both public system and private psychiatrists. We do our best to manage these patients often with very limited support.


Dr Kane Treble   24/08/2023 7:22:36 AM

I imagine this will resonate with GP's across Australia.... Particularly those of us in rural Australia where there simply isn't a local option. I've hit a point now where I have patients who were assessed, diagnosed with ADHD and commenced on medications, discharged with the presumption I would continue prescribing (often with letters with insufficient detail to allow me to apply for permits) and in a few cases refuse to review the patient at 12 months to allow continued prescribing. Inpatient services declare the patient too low acuity for their services, outpatient services declare the patient too high for theirs. Where does the patient go?

We'll still be there.


Dr Robert Yoong Shian Choong   24/08/2023 7:26:29 AM

I couldn’t agree more. I am facing similar experiences. What irks me more is demanding a referral letter first up and the response takes up to several weeks. If the books are closed then the clinics should be upfront about it. Ironically a lot these clinics still send flyers about their services and how many psychiatrists they have in their group. I can’t help the suspicious feeling the clinics are cherry picking referrals.


Dr Louise Marie Edwards   24/08/2023 7:26:54 AM

Hi Andrew,

Thank you so much for sharing your experience of the access block to specialist Psychiatry referral pathway . Your story entirely matches my experience over recent years in my work as a GP and also as an Occupational Medicine Trainee.

Each referral to a Psychiatrist (or any referral for that matter) is built on a relationship of trust between GP and patient and constructed in the spirit of hope for a better outcome. When these referrals are rejected this compounds patient's distress and risks disillusionment of patient and practitioner... and burnout.

I have tried to fill the gaps by doing extra training - I highly recommend the Level 2 focused psychological skills. I have learned so much from the mental health professional network and the society for psychological medicine. Despite this, the need for a Specialist referral pathway remains.

Alongside tertiary prevention, primary prevention research and sociological, population level solutions are urgently needed.


Dr Philip Ian Dawson   24/08/2023 7:33:02 AM

The article doesnt mention a name or location for this GP, but I can say from a Rural Tasmanian GPs perspective, at least he seems to have some psychiatrists to refer to and ring, even if he gets rejected. We have a couple of private psychiatrists who charge heavily and have long waiting lists, making referrals for our mainly poor patients pointless. hey cant afford large fees and cant wait a year for an appointment! Referring anything other than acute psychosis or suicidality to the public clinics results in triage by a social worker and a message " we dont think we need to see this patient". We are left with telehealth from remote Psychiatrists who have shorter waiting times and some bulk bill. Not ideal in an area with 100,000 residents! However, same problem with all "not procedural" medical specialists. Most of the General Physicians now work in pubic only due to financial considerations. Same problem for ENT and Dermatology.


Dr Mitchell Steven White   24/08/2023 8:00:56 AM

Well put. Even better is when they do manage to see a psychitrist after waiting months, and you get a letter back stating that the "failed to develop rapport with patient, will not be able to continue"


Sanjeevan Nagulendran   24/08/2023 8:11:25 AM

If a psychiatrist behaves in such a way is that not professional misconduct? If they are advertising themselves as a psychiatrist this kind of response is odd. Would it not be akin to a cardiologist saying they don’t treat chest pain or a Gp saying they cannot treat alcohol dependence, unstable mood disorders or chronic pain? Is it not a departure from professional standards? Given the changes to the cosmetic industry would we have to do the same for all other branches of medicine in terms of ethical conduct ? According to WHO australia has double the suicide rate of the uk. This may explain why. If the doctors who are meant to be looking after these patients are not and getting deskilled we have a bit of a problem. Let’s not mention the Medicare fraud when the psychiatrist sees the patient charges them and Medicare but never writes back to the Gp? Do we dob them all into Medicare and ahpra? Is that the only way to change this legal but unethical behaviour of cherrypicking?


Dr Michael Lucas Bailey   24/08/2023 8:32:01 AM

I just had a psychiatrist reject a referral for a patient they hadn’t seen in a few years because they don’t specialise in the condition. Depression. Patient didn’t medically need to see a psychiatrist but family court specified they see one for review.

So psychiatrist won’t see a patient for review of a diagnosis they had made before for a patient they had seen before at the request of a court.

And the patient is a very passive young woman.


Dr Sean Colin Chesson Stevens   24/08/2023 8:57:02 AM

Well said Andrew, we really need a dialogue with our psychiatry colleagues as this is a nationwide problem and patients are getting caught in the middle.


Dr Annabel Kain   24/08/2023 9:38:13 AM

I hope Dr Leech that you have actually asked the College of Psychiatrists to publish this for you. Every now and then I have the same urge to write something for whatever their newsletter is, usually about the lack of communication with GPs even for the most basic things, like what medication the patient is taking. This is of course not across the board and there are some wonderful Psychiatrists who write detailed reports with comprehensive plans and are accessible to GPs to discuss patient management. These are the ones we always try to refer to but of course we quickly book them out.
It's interesting that a certain high-profile Psychiatrist has a strongly-held view that GPs want to be the gatekeepers for mental health and hold on to all these patients, where in reality we are drowning and being asked to stretch beyond our skillset constantly.


Dr Elana Anne Roseth   24/08/2023 9:55:07 AM

Love your letter. I feel your frustration.


Dr Maureen Anne Fitzsimon   24/08/2023 9:59:11 AM

That is, indeed, the situation when trying to access help for people who are not too economically disadvantaged. Those in lower socioeconomic groups are left with almost zero specialist psychiatric care. Often, the reason that they have no money is because they have poor mental health!


Dr Peter John Meulman   24/08/2023 10:26:19 AM

Another important element is that oftentimes these rejections are far from immediate leading to long periods (sometimes months) of silence then the rejection, wasting everyone's time and delaying help unnecessarily. Having to send the same referral to multiple psychiatry practices is also a timesink. My experience has absolutely been that detailed referrals are much more likely to receive rejection.

The public MH infrastructure can only deal with psychosis, suicide or acute and very brief interactions. Assessment for ADHD (for example) is just not possible in the public system. Despite that I do feel that things are improving of late with delays in finding help for people in the mental health arena generally reducing in my region, for which my thanks.


Dr Timothy Paul Shannon   24/08/2023 12:57:22 PM

Great letter and in Queensland the same situation. I have have also realised that putting assessment for ADHD leads to massively increased fees and one wanted a UDS and a second psychiatrist to review as well. Also no appointment provided. So dumbing down the referral to symptoms only and a standard referral and let them diagnose ADHD and suggest treatment. I think GP’s who have done extra training with level 2 FPS should be able to prescribe for ADHD for their own patients. Like there are methadone prescribers and that’s a massively more dangerous drug.So authorised GP prescribers for ADHD. There would need to be a credentialing process. I emailed HARU and asked them about this possibility and got an immediate response citing the 2019 poison’s act. So any medical practitioner can prescribe stimulants for narcolepsy (according to the act) but only psychiatrists for ADHD over the age of 18y.
It needs political pressure as would require a change in the act.


Dr Samuel Christopher Ognenis   24/08/2023 1:44:31 PM

Brilliantly said Andrew, really appreciated.
Sam


Dr Sanjeevan Nagulendran   24/08/2023 5:56:01 PM

I hope everyone is using the national GP psychiatry line- it is free and I believe it is available across the country for GP's from the 1/7/23. One can call and get advice from a psychiatrist. A lot of advocacy went into this at the federal level following lived experience of patients and doctors so pls use it! www.gpsupport.org.au. Since it became available in my PHN approx 1 year ago it has been very helpful and provides a good medicolegal back up to the important mental health work GP's do for the most vulnerable in our communities.


Dr Kathryn Josephine Oaten   24/08/2023 6:43:39 PM

A most excellent account of this extremely problematic situation.
Thank you for putting precisely my experiences into an articulate article. Completely agree that the more information you provide in a referral about background and complexity of the patient's situation that I need help managing, the more likely it will be rejected. There is so much cherry picking going on. And definitely it is so often the case that a patient is too young for some( one recently was too young at age 23 as psych only started from age 25.)...., or too old.....or recently -" too high risk for private clinic care"... yet not high risk enough or urgent enough to access public MH psychiatry help.
It is immensely disheartening and enormously frustrating. Oh and yes the very poor rates of letters send back to me is abysmal.


Dr Alison Jane Piper   24/08/2023 7:24:32 PM

Thank you for detailing this very frustrating situation Andrew. Despite contacting rooms to confirm appointment availability prior to sending a referral letter, a rejection arrives, commonly 4-6 weeks later. Could the RACGP please raise the enormous difficulties we are experiencing with the RANZCP.


Dr Puja Gupta   24/08/2023 9:42:44 PM

I am so glad that someone has brought this issue up and it’s good to know that other GPs are facing similar dilemma as what’s been the case in my practice.
In fact it’s even worse in Northern Territory.

I believe there should be more accountability from our Psychiatrist colleagues


Dr Sean C   24/08/2023 10:15:22 PM

It’s the price society pays for the boom in self-made adhd diagnoses. We need psychiatrists to be available , but not for adhd assessments, we need them for our patients with schizophrenia, bipolar, ptsd and crippling depression.


Dr Penelope Ann Martin   25/08/2023 6:35:34 PM

I am impressed by the respectful presentation of the frustration that so many GPs have with their psychiatrist colleagues. There is certainly a culture of psychiatrists cherry picking patients, of them having extraordinary long wait times and finally , a long standing issue of no or little feedback following assessment or review of our shared patients (despite this being a medicare requirement)
I am wondering where this excellent open letter was published and how many psychiatrists may have seen it?


Dr Shalini Nilakshi Wickramasinghe   26/08/2023 7:33:43 AM

Exactly what I am going through. Many a time,I even contemplated writing to the college of Psychiatrists, about this issue. I have to do the job of the 'psychiatrist' now. I also feel stro gly about 'telehealth' psychiatry consults that diagnose adult patients with 'ADHD' in one consult. The 'fees' are so unaffordable my poor patients cannot get the service they want.


A.Prof Christopher David Hogan   27/08/2023 5:42:28 PM

It is time to be blunt.
There are not enough psychiatrists or psychologists & the incidence of diagnosed mental illness is increasing.
There are not enough GPs available. It has been estimated in the past that GPs managed roughly 80% of mental illness in the community.
A logical solution is to provide shared care utilising the combined skills of GPs & Psychiatrists for patient benefit. Shared care arrangements have worked in Obstetrics as I can personally attest
It will require upskilling of GPs & Psychiatrists,
In the 1990s I was part of a group of GPs & Psychiatrists which produced a Masters course in GP Psychiatry- it faded after 3 years because of lack of interest- there was no financial benefit in doing it.
The introduction of mental health. Item numbers did not have ready access to psychiatrists.
It is time for the emerging interactions between GPs & Psychiatrists on this matter to be supported & funded nationally


Dr Rob Kielty   28/08/2023 4:20:22 AM

This is not a strange phenomenon. For years many specialists have had long wait times and been difficult to get people in to see. To do this has required what I call ‘the ring around’: somebody in the team who can find me someone who has space with the right skill set. Somebody who is not me. A good way of describing them would be a ‘broker’.

It’s a definite role within a team and something we maybe need to recognise and incorporate. Over the years this role has been taken by a practice secretary, a practice manager or a receptionist. Occasionally in a large specialist group practice, there will be someone who does this for you which is always helpful.


Dr Manal Matty Saka   30/08/2023 8:37:45 PM

Thank you so much for sharing your experience of the access block to specialist Psychiatry referral pathway . I have the same experience. It is hard when you can’t get your patient to access services as quick as you wish


Dr Suzette Julie Finch   2/09/2023 6:58:19 PM

In Perth Metro in the past, it was the low socioeconomic group who could not afford the Psychiatry fees that had to suffer my "make-do-GP- non-specialist" skills & hope the result wasn't a disaster. Now our nurse routinely rings multiple psychiatric group practices and the most outrageous issue is the initial appointment fee between (the cheapest) $550 & (most expensive) $1000+. This is for a condition that has in part been basically diagnosed & we now need help legally accessing or medico legally accessing the commonly accepted best treatment. It really is a little bit plug-and-play for most of these cases. I need to stop now because discussing it further is making me oscillate between fury & despondency! But obviously good on you "frustrated GP" for taking it on, I will cheer for you, but expect ..... 'crickets'!


Dr John Walton Dearin   2/09/2023 10:50:44 PM

Dr Leech refers to his “respected Psychiatric colleagues “ who politely refuse to assist with managing his patients. This is an attribution of respect for which I have little regard.
I referred a patient for review to a local psychiatrist recently who would only see him on condition that $830 be placed in his practice account before her would even consider opening the door to see him. I regard this as outrageous gouging of patients who cannot afford such fees. Psychiatry has lost its moral compass, being only available for the well heeled “worried we’ll” who can afford these exorbitant fees whilst those in greatest need are left to struggle with their inner psychic turmoil, cast upon an overextended public health system and their GP’s who are desperately trying to support them on a paupers Medicare refund. It is clearly evident that Psychiatrists at large are not interested in the well-being of the community at large but rather the lining of their pockets with fees of $500 per hour.


Dr Simon Holliday   23/09/2023 12:40:58 PM

I was having a chat to a psychiatrist colleague who advised me increasing numbers of his colleagues are conducting all their consultations by telehealth. The reason given is their safety, specifically from formal allegations of sexual impropriety if they refuse prescribing as patients demand! One complaint to the regulator can end or truncate their career.
If this is indeed a common driver of change, it is as if the unaccountable health care standards regulators have becoome the tail that wags the dog.