Scrapping GP mental health plans a path to fragmented care, GPs say

Anastasia Tsirtsakis

15/03/2022 5:07:02 PM

Dr Cathy Andronis says psychological presentations need a holistic approach and that properly funding mental health care consultations would be much more effective than widescale reform.

Patient speaking to GP.
Increasing numbers of people are seeking mental health care support, but GPs say referrals remain an essential part of the system.

As we enter a third year of the COVID-19 pandemic amid natural disasters and troubling global events, an increasing number of Australians are finding themselves in need of mental health support.
Now two peak bodies for psychologists – the Australian Association of Psychologists Inc (AAPi) and Australian Psychological Society (APS) – are calling for the Federal Department of Health to review the Better Access Scheme to allow people to self-refer themselves to a psychologist, and still access a Medicare rebate, without obtaining a mental health plan from their GP.
But Dr Cathy Andronis, Chair of RACGP Psychological Medicine, is concerned the move would significantly fragment care and, in some cases, even lead to further barriers.
‘This [would be] a major paradigm shift in how we operate in the Australian healthcare system,’ Dr Andronis told newsGP.
‘We’ve created a pretty sacrosanct system that’s reliable, predictable, secure and that people understand – and at the cornerstone of it is the GP.
‘As the primary contact, GPs can take a holistic biopsychosocial approach to coordinate care, help the patient navigate the system and advocate for the patient. So it would be unwise to go back to this very fragmented system, which is also a lot more expensive and completely unsupported.’
Under the current Federal Government scheme, people can receive up to 20 Medicare-rebated sessions with a psychologist per year. However, the patient is required to create a mental health plan with their GP prior to their initial appointment.
APS President Professor Tamara Cavenett told Nine Newspapers that the requirement is leading new patients who are offered last-minute appointments to delay care.
‘There’s a lot of people who additional red tape is potentially stopping from getting treatment or stopping them from getting treatment as early as they would otherwise,’ she said.
However, Dr Andronis says GPs are often very accessible for patients, and are better equipped as a first point of contact to manage mental health presentations in a ‘very timely and affordable way’.
The Melbourne GP says the prospect of separating psychological care from standard healthcare also carries the possibility of there being a bias.
‘Sometimes there are biological determinants for the distress, like poor diet or lack of exercise, or there are social issues,’ Dr Andronis said.
‘But when you fragment a system, you narrow the focus of the lens through which you view that problem, and so the answer will come out with what you often want it to be, rather than what it really is.
‘Medicine is about viewing things from every angle – biological, social, and psychological – and being able to assess the best way to help somebody really to help themselves. And that’s what GPs excel at; having a wide-angle lens and the capacity to take their time and to review things holistically.
‘So there’s a huge place for the generalist. In fact, it’s essential.’
RACGP President Dr Karen Price agrees. She told Nine Newspapers that many patients who present with mental health issues, also have chronic health conditions that require a holistic approach.
‘We do whole-of-person care,’ Dr Price said.
‘[And] patients can already access psychologists without a referral [and claim it] on their private health insurance.’

In addition to scrapping GP referrals, the AAPi is advocating for the number of Medicare-funded sessions to be doubled from 20 to 40 per year, alongside an increase in the rebate to $150 per visit.
Further to that, both the AAPi and APS are calling for the requirement that patients have their mental health plan renewed after the sixth session be removed.
Dr Andronis, however, says the review process is ‘essential’.
‘When the GP reviews in the case of a mental health issue, it’s about working out if the person is on track – is this the right [therapist]? Is this the right treatment modality?’ she said.
‘The assumption that it is, is not always correct.
‘I see it quite frequently in psychological medicine where people have seen the psychologist and it’s not until the review that it becomes obvious that either they haven’t actually engaged very well or they’ve stopped seeing them.
‘Or they go out of a sense of duty or wanting to please the psychologist, but aren’t actually improving.’
In response to the pressing need for access to mental health care, the RACGP is instead calling for the current system to be better funded, with higher Medicare rebates for longer GP consultations to ensure doctors can respond to their patients’ needs.
Dr Andronis believes the core problem goes back to the ‘gradual and severe underfunding’ of mental health, and the deskilling of GPs. But says recent Government initiatives over the past two years to educate GPs are a step in the right direction.
‘GPs are affordable and accessible, and more likely to bulk bill than most psychologists, certainly in urban areas or areas when there’s high demand,’ Dr Andronis said.
‘And most of the problems we see in general practice have a mental health basis and we actually manage them.
‘So GPs need to start recognising that they can do this work, they are doing this work, and most of the time they’re doing it well enough, and they can learn to do it even better, rather than letting our system fragment and our sense of ourselves as GPs be dictated by other people’s assessments of how we do our work.’
Rather than being focused on person-centred care, Dr Andronis believes the peak bodies are instead ‘taking advantage’ of stress in the community in the lead up the Federal Election.
‘It seems to me that people are taking opportunities really to protect their small territory and to become very narrow focused in their work,’ she said.
‘It’s a reality of the political system; we’re closer to an election and, unfortunately, we live in a very competitive system, and it makes people fearful, and the more fearful people will become the more competitive and protective of their turf.
‘But really, why are we fragmenting a system we know works?’
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Dr Alexandra Bernhardi   16/03/2022 9:03:41 AM

I do agree with the essence of Dr. Andronis's statements.
However, I believe simplifying the referral process for GPs would allow for much more clinical and problem-solving time that we GPs can spend with our mental health patients.

Grumpy Old Doc   16/03/2022 9:58:27 AM

I fully anticipate being howled down for this opinion, but Medicare can't afford to offer 40 rebated sessions with a psychologist for everyone who feels psychologically distressed. Recently the expectation has become " I need a mental health plan" when in reality I've found a lot of people actually just need someone to listen, give some simple CBT tools, and direct them to a few good books and evidence based apps. Followup in 2 weeks - they are feeling much better, in 1-2 months are doing well. Thousands of dollars saved for the Government. Of course there's a subgroup of people with severe distress (developmental trauma/abuse, , PTSD etc) but a good assessment by GP should identify and appropriately triage them to clinical psychologist. If the low acuity stuff is managed by GPs we might actually be able to get those who really need it to a psychologist soon. We just need the time and funding to do it

Dr Jaqueline El-Masry   16/03/2022 10:02:08 AM

It may be that we move to an annual review of patients and annual referral for psychological care, as we do with our medical specialist colleagues.

Or at least one review with a GP at some point in the psychological care of patients. This may support psychologists who have concerns that there are medical/ or concerning diagnoses.

If the compromise is access to 40 sessions rather than 20, that is a win-win for our patients health and our purpose as medical practitioners.

Dr Gregory Alan Wyatt   16/03/2022 1:39:45 PM

I agree that simplifying the referral process (a letter rather than MHP) would be of benefit. There needs to be some sort of review and re-referral process.
Of more benefit to all would be educating/enforcing communication from psychologists back to GPs - despite being a requirement, my experience is that a letter back (even when we do a review) is the exception rather than the rule.
Psychiatrists are not much better!

Dr Robyn Swinbourne Fried   16/03/2022 2:04:43 PM

Another issue that must be addressed is the inability for GPs to bill Medicare for a Mental Health Care Plan and another consultation at the same time, despite there so often being MANY components to a consultation which are all equally important. Yet again GPs are subsidising "the system".

Dr Kate Frances Douglas   16/03/2022 7:22:56 PM

PLEASE can we drop the need for a MHCP review?? Female GPs are bogged down with enough MH consults as it is without patients having to come for what is mostly an administrative appointment. Some patients have seen the same therapist for years and waste their time and money coming in for the 'my psychologist told me to come and get the piece of paper for the next 4 sessions' - I get it's meant to co-ordinate care but I"m yet to pick up anything on a mandated review that the patient wouldn't have come in for when necessary anyway. If we're trying to normalise mental health as a chronic health problem like asthma or diabetes why can't refer for care in the same way without having to jump through hoops with the 'requirements' of a MHCP (which let's be honest, most people ignore while the dutiful amongst us put the effort in to complete as it is dictated to fulfil Medicare requirements? It adds nothing to pt care