GPs concerned by proposal to scrap Mental Health Treatment Plans

A PROPOSAL to scrap Mental Health Treatment Plans in favour of online assessment tools has sparked concern, with GPs seeking more clarity around the plan.

The proposal came in the final report of the Productivity Commission’s Mental Health Inquiry, which was released last week on 16 November.

The long-awaited, three-volume report addresses a broad range of issues in Australia’s approach to mental health care, from improving gateways to care, to the influence of broader social determinants of health, such as employment and homelessness. The report’s central vision is for a “person-centred mental health system”.

Overall, the report calls for a $2.6 billion overhaul of the mental health system, which would lead to more than $17 billion in benefits, mostly relating to improvements in quality of life.

Ms Christine Morgan, CEO of the National Mental Health Commission, said the vast scope of the report considered the significant social and economic consequences of mental ill health and presented a “balance sheet approach” of the need to invest money for future returns.

“We are spending money on peoples’ mental health and wellbeing to ensure they can contribute to society and live the best life they can,” she said. “There is not only a moral imperative for us to get this right but there is a very real social and economic imperative.”

Dr Caroline Johnson, spokesperson for the Royal Australian College of General Practitioners, said the College welcomed the report’s aspirations to improve mental health care and to improve funding in this “historically underfunded area”.

However, she said, a key concern for GPs was the need for more clarity around proposal to scrap Mental Health Treatment Plans (MHTP) in favour of an online assessment tool.

“The MHTP was designed to represent best practice mental health care for primary care … and 90% of GPs in Australia have done training and come on board with great enthusiasm,” she said. “It’s not really fair to say we don’t think they work.”

Dr Johnson said it was a good time to look at how these plans may be improved and adapted to current circumstances, noting that help seeking was significantly better today than it was 20 years ago when Better Outcomes was first launched.

But, she said, the MHTP was one of the few funding mechanisms that enabled GPs to spend longer times with patients with mental health concerns.

“We know that fee-for-service encourages short consultations, whereas MHTPs encourage GPs to spend more time with patients,” said Dr Johnson, who is a GP and Senior Lecturer in General Practice at the University of Melbourne.

If MHTPs were no longer funded, GPs may resort to using more Chronic Disease Management Plans, given that many mental health conditions lasted for longer than 6 months. This, she said, would be a more costly option.

The Productivity Commission report also recommended that the Better Access program be “rigorously evaluated to ensure that it is delivering cost-effective benefits for those who need it”.

The report recognised the critical roles played by GPs in Australia’s mental health system.

“All GPs need to be competent in treating people with mental illness,” the report stated.

“In any given year, at least 5 million Australians see their GP for assistance with their mental health, including treatment of a mental illness. Of these people, 6 in 10 are prescribed medication by the GP; 3 in 10 receive some counselling, education or advice. Only 2 in 10 receive a referral to a psychologist or a psychiatrist; about 400 000 people see private psychiatrists and 1.3 million people see psychologists.”

The report did note, however, that many GPs received “minimal training in mental health” and called for GP mental health training and professional development to be “re-oriented”.

Concerns were also raised in the report about the appropriateness of prescribing in some cases.

Dr Johnson said Australia was known to be one of the highest prescribers of antidepressants in the world.

“What are the drivers of that prescribing? It’s a really important question for us to consider,” she said, adding that medication could be “an important part of the package for many people”.

“But I do think, in the next 12 months to 2 years, we will hear a lot more about social prescribing and other approaches that don’t involve giving patients a script for medications.”

Dr Johnson said it was pleasing that the report recognised the strong relationship between physical health care and mental health care.

“There is a huge morbidity gap for people with serious mental illness. It’s a national disgrace that people with mental illness die 20 years younger than people who don’t have serious mental illness. And they don’t die because of their mental illness, they die of physical health issues,” she said.

“That the report recognised this link is important for us in ‘GP-land’ because general practice is the place that people can get both types of care.”

Dr Johnson said the profession was in for much “debate and discussion” over the coming months.

“This is certainly contributing to that discussion through a new lens,” she said. “Highlighting the financial benefits of getting people with mental health conditions proper treatment, is a great place to start.”

President of the Royal Australian and New Zealand College of Psychiatrists, Associate Professor John Allan also welcomed the opportunity to evaluate Australia’s mental health system through an economic lens.

Associate Professor Allan said it was encouraging to see a focus on the broader social determinants of health.

“Many of the plans and reports from previous years have just focused on the health system,” he said. “But we also need to approach mental health in a holistic way that changes the trajectory of people’s lives. Poverty is a huge contributor to mental health problems and it’s not going to get fixed by the health system.”

The report also looked at the role of housing, the justice system and employment on people’s mental health, he noted.

Associate Professor Allan said the report’s emphasis on early intervention and care was important.

“We know that’s where we get the biggest bang for our buck, we need to start at the peri-natal stage but also in early infancy and childhood. We know that we can prevent a lot of disorders that start in the early stages of life, and we can prevent those disorders becoming much worse which can be costly economically and, of course, emotionally,” he said.

The National Mental Health Commission’s National Suicide Prevention Adviser,  Ms Morgan, agreed that specifically addressing the mental health needs of ageing Australians was crucial.

“Our older Australians do have specific needs. And that includes those in residential aged care as well as those living in a community setting,” she said.

She said next year the National Mental Health Commission would release a National Children’s Mental Health and Wellbeing strategy – the first such strategy for those aged under 12 years – and a dedicated strategy was also required for older Australians.

The Productivity Commission report also charged the National Mental Health Commission with implementing a national stigma reduction strategy.

“Social views of mental illness have improved but still trail a long way behind our knowledge of how mental illness affects people’s lives,” the report said. “This stigma creates barriers to individuals seeking care and can reduce the effectiveness of that care.”

Ms Morgan said the past year had seen some inroads in reducing the stigma associated with mental illness.

“In 2020, we have made significant strides to have Australians recognise that their mental health is just as much a part of their health as their physical health,” she said, noting that dealing with cataclysmic bushfires and a global pandemic had helped people become more comfortable with discussing mental health impacts.

Still, she said, some personal stigma (a perception of mental ill health as a weakness) and attitudinal stigma (societal reluctance to accept or support someone with a mental illness) remained.

But, she said, the most challenging issue to address was structural stigma, where mental illness may be required to be disclosed on a visa form or when applying for life insurance.

“In the workplace, many people feel that if they disclose that they have a mental illness that it will impact upon their ability to be promoted,” Ms Morgan said. “Structural stigma is the sleeping evil because it is deeply embedded in our system.”

The Australian Medical Association (AMA) said the proposal to replace MHTPs with an online tool would “undermine the holistic approach needed to care for patients with mental health concerns”.

“The AMA welcomes the report’s aspirations for a person-centred mental health care system, focusing on prevention and early help – both early in life and early in illness,” AMA President Dr Omar Khorshid said.

“But we cannot accept recommendations that take away support for GPs at a time when the burden of mental illness is growing.”

The AMA would have liked more emphasis on the patient-centred medical home in the report as the ideal model for people seeking care for their mental health.

“Under this model, psychologists, mental health nurses and social workers can all be integrated into the patient’s health care as part of a well-coordinated and holistic model of GP led care,” Dr Khorshid said.