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We are the best value mental health care in the country using less than 3% of the total mental health budget to see the majority of the patients needing community care. Current underfunding added to rhetoric that alienates and misrepresents GPs seems a counterproductive strategy if we are to provide better mental health outcomes for all Australians.
IN recent years, we GPs have seen a steep increase in mental distress, and the cracks in the system that fail the most vulnerable are familiar to us all. We are well aware of the enormous unmet need for mental health care at this time and we agree with Rosenberg and Hickie, who wrote in InSight+ recently that primary mental health care reform is long overdue.
Where we disagree with Rosenberg and Hickie is in our understanding of the problem and in particular, the role of GPs in contributing to the current mental health crisis and its various solutions. While they are entitled to question the efficacy and efficiency of all players in the system, we feel that Rosenberg and Hickie have misinterpreted the GP data.
As a group of diverse GPs with significant shared expertise in mental health care, we would like to take the opportunity to correct these misconceptions. Without an accurate understanding of the data we use to inform policy, solutions are likely to be ineffective.
MYTH: GPs do not review their patients and are therefore providing poor care
Rosenberg and Hickie state that “GPs wrote more than 1.2 million mental health plans for Australians in 2020–21 but of these, only just over one-third (36.8%) were reviewed, meaning patients’ ‘ progress was largely unmonitored by their GPs”. This argument has been used before by Rosenberg and Hickie (here and here). It was wrong then, and it is wrong now.
Counting mental health item numbers has always been a poor proxy for quantifying the mental health care that GPs do. GPs must use mental health plan item numbers, such as MBS item numbers 2700, 2701, 2715 or 2717, if patients need to access psychologists, social workers or occupational therapists under the Better Access program. However, the other mental health item numbers (the 2712 mental health review, the 2713 mental health consultation and the focussed psychological strategies numbers) are optional.
A review item number has a lower rebate than a consultation item number. A mental health review number offers a rebate of $75.80 while a consultation item number for an equivalent length of time is $76.95. If patients and GPs are financially penalised when mental health item numbers are used, why would we choose to utilise them?
Patients are rightly concerned that evidence of mental illness in the medical record may impact access to insurance, particularly if their mental health concern is self-limiting and short term Anecdotally, the authors are aware of patients who prefer not to use mental health item numbers because of privacy concerns. This is particularly problematic in children because the mental health treatment plan must include a diagnosis. Parents may be reluctant to “label” their children with a “mental health disorder” due to reasonable concerns around stigma and the pathologizing of normal stressors in childhood.
GPs are actively discouraged from using mental health specific item numbers by the Department of Health. The recent nudge letters from the Department of Health threatened “compliance action” if the mental health item numbers were billed alongside consultation item numbers “inappropriately”. The Department actively targeted GPs who were statistical outliers, without any evidence of inappropriate practice. The fear of the “nudge” and the weight of the Professional Services Review is likely to have changed the billing practice of all GPs. Many GPs feel it is safer to avoid using these numbers at all.
GPs see 82% of the Australian community every year, with over 65% of GP consultations involving a psychological issue. Only 8.8% of patients receive a mental health item number. MBS mental health item numbers suggest that only 36% of mental health consults are billed as such. In other words, for every consult involving mental health billed using a mental health item number, there are another 1.8 consults addressing a mental health concern that are billed using another item number. Using mental health item numbers as a proxy for clinical activity is deeply misleading.
MYTH: GPs operate as solo clinicians, and would get better outcomes using multidisciplinary teams
General practice would not manage without the diverse skills of our health professional colleagues. However, mental health specific multidisciplinary teams are not the answer for many of our patients. There is also evidence that they may not be as effective as we expect in GP settings. In the UK, the introduction of multidisciplinary teams into primary care increased cost, reduced patient satisfaction and reduced quality of care.
Complex systems can harm patients with complex needs. Our patients do not always experience the collaborative, patient-centred care these teams espouse. In fact, there are some suggestions that patient centred care can increase inequity. As Dr Tim Senior writes:
“When we claim that the patient is an essential member of the team, it must sometimes feel like their role is akin to the role of the ball on a football team, kicked back and forward between the team members in search of that elusive goal.”
We also know that a long-standing therapeutic alliance improves outcomes in therapy. This is particularly important in vulnerable patients with a history of trauma. We also know that long term therapeutic relationships reduce healthcare cost. Outsourcing and modularising this relationship may have unintended consequences that should be carefully considered to ensure the benefit of such an approach exceeds potential harm.
There are plenty of multidisciplinary teams that already exist in this sector. Unfortunately, most of our patients face a series of closed doors when they try to access care — not unwell enough for public care and too unwell for private services; rural patients who cannot access or do not relate to metrocentric services; patients who have co-morbidities that restrict them from utilising siloed services; patients living with mixed emotional and physical symptoms who have experienced so much invalidation in the healthcare system they quietly disengage; patients with physical health needs who already have so much multidisciplinary team input they and their carers face a full-time job just managing appointments, and the associated bureaucratic requirements; patients who are too poor, too geographically isolated, too unsupported, too culturally and linguistically diverse or simply too tired to face the navigational complexity of care.
It seems inequity in mental health care is rising. However, patients who live with systemic disadvantage access general practice more commonly than other health services.
GPs treat populations who present with a broad scope of clinical presentations. Individual disorders like depression and anxiety are only a small part of the scope of our practice which is why our curriculum is so broad. Our work includes crisis to chronicity, cradle to grave, primary to tertiary prevention, single disorder to multimorbidity, community to tertiary care and remote to urban populations. Given the diversity of care we provide, we expect that we will collaborate with a variety of individuals, institutions and teams to provide care. These are bespoke teams, involving informal support networks, peer workers, individual health professionals, non-government organisations, public and private outpatient and inpatient services and social services.
Good GPs integrate their understanding of context, relationships, meaning, life story, and bodily health alongside what the psychiatric model separates out as “mental health”. This fundamental difference in how we see people means that strategies developed for psychiatry and psychology led segments cannot be generalised into our context. Using evidence justified in one context to drive policy in another is poor science and poor practice.
MYTH: Technology is fundamentally “good”
Technological solutions, particularly when used to analyse patient-centred outcomes of care, are a growing resource, but are currently best suited to single disease modelling. There are ethical concerns about the use of artificial intelligence in mental health care that bear examining, particularly around privacy and transparency. AI algorithms incorporate hidden values that unintentionally reinforce current inequities.
Australia leads the world in technology enabled mental health care yet only 4% of Australians needing mental health care use digital mental health services. This may be a question of access or literacy, but bears examination before we increase our substantial investment in technology enabled mental health products.
GPs are as diverse as our patients. We have the training, the skills and the insight to contribute meaningfully to the mental health discourse and the delivery of services. Now all we need is genuine collaboration from other services with narrower populations than ours. It is frankly offensive that specialist world views are held up as the most reliable solution for the care of patients they will never see.
What frustrates, angers and even harms us and our patients is the exclusion of our voices and perspectives from the medical discourse, policy design and treatment planning. Ignorance of our role, poor remuneration and negative portrayals of GPs are contributing to the early retirement and low recruitment of GPs, which will only worsen access to mental health care.
The GP workforce is growing smaller with an expected shortfall of over 11 000 FTE by 2032. We are the best value mental health care in the country using less than 3% of the total mental health budget to see the majority of the patients needing community care. Current underfunding added to rhetoric that alienates and misrepresents GPs seems a counterproductive strategy if we are to provide better mental health outcomes for all Australians.
Louise Stone, is a GP with clinical, research, teaching and policy expertise in mental health. She is Associate Professor in the Social Foundations of Medicine group, ANU Medical School and works in youth health.
Karen Spielman, is a GP who has worked in diverse settings with marginalised young people, youth mental health and is GP Advisor and Research Associate at InsideOut Institute. She is Advocacy Representative for the Australian Society of Psychological Medicine.
Tim Senior, is a GP at the Aboriginal Community Controlled Health Service in South West Sydney, and a Senior Lecturer in General Practice and Indigenous Health at Western Sydney School of Medicine
Michael Tam, is a Conjoint Senior Lecturer of the School of Population Health, UNSW Sydney, and the Director of the Primary and Integrated Care Unit of South Western Sydney Local Health District. His Unit provides specialist GP care to people living with severe mental illness in partnership with community mental health teams.
Johanna Lynch, is a GP with expertise in trauma specific care and domestic and family violence. She is a Senior Lecturer at the GP Clinical Unit and The University of Queensland and President of the Australian Society for Psychological Medicine.
Wei-May Su is a GP with an interest in complex care, family abuse and violence. She is Academic Lead (GP), HETI; conjoint senior lecturer Uni Notre Dame and leads the Master of Psychiatric Medicine Program.
Karen Price, is a Melbourne GP and President of the RACGP. She is Adjunct Clinical Professor Monash University.
Sarah Chalmers is a GP and Rural Generalist with experience working in very remote communities providing comprehensive primary and secondary health care. She is Senior Lecturer in General Practice and Rural Medicine at James Cook University, and President of ACRRM.
Gwendoline Burton is a Brisbane GP whose roles also include Chair of the Antenatal/Postnatal Specific Interest Group for the RACGP and Clinical Expert for the BSPHN Mental Health Team.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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The authors need to address the glaring issues within their own profession before casting aspersions on the dedicated tireless work carried out by GPs.
As a psychologist working with an outstanding team of GPs in a medical practice, we have struggled to find a psychiatrist in private practice who is prepared to bulk bill or at least provide a sliding scale of fees for patients who need a comprehensive psychiatric assessment / treatment but cannot afford it.
In the time it lakes for me to relate “the myths” about mental illnesses, I could be educating people (already aware of the myths) to the realities.
Reailty One: They are not “mental”, of the mind, that is the realm of psychology.
Reality Two: Our knowledge of the brain is and has been severely limited, our understanding has not expanded much.
Reality Three: When we put more effort (and monies) into research, as we have with many other illnesses, we will learn more.
I am disappointed that my UK colleague should think that there is the slightest utility in diligently completing the paperwork for a GPMHCP. I spend the prescribed 20 mins teasing out the problem: man presents with tremor, wanting referral – actual problem, his father committed suicide weeks ago; introducing the idea of anti-depressants; helping him find a psychologist; providing reassurance that there is hope. I stopped doing K10s at least 15 years ago, complete waste of time, no tangible patient benefit.
I send the patient out with a letter to a psychologist, and “the nonsense bit of paperwork that enables the psychologist to bill Medicare”.
Anyone who still believes in the value of paperwork in the “patient journey” should read about the rise and fall of the Liverpool Care Pathway.
I do very few formal mental health item numbers with my overwhelming geriatric general practice cohort of patients but mental health issues and concerns make up a part of everyday consulting. I deal with Mental Health for the Elderly teams in the public system. No Medicare data will show any of that work.
A BEACH style data analysis will.
Patients hate the out of pocket expenses for mental health already.
For example $15 for a GP consult and $80/session for the psychologist ($160 for 2 sessions a month) would be a “good” outcome.
The realistic comparison is
$45 for GP and $100 for psychologist ($200 a month).
Medicare is failing both the healer and the patient
What concerns me about the group reply to concerns about GP’s performance in relation to mental health is the “rebuttal” context of the response. Those of us who are the consumers “in the middle” are looking to all sectors for a collaborative approach to our overwhelming assertion WE ARE NOT BEING LOOKED AFTER IN MENTAL HEALTH AND SUICIDE PREVENTION. Seems to me the reply is cherry picking specific matters raised, but not acknowledging consumers have long complained of real assistance in mental health matters. Many mental health consumers feel theres an implied significant sector of GP’s who are great at primary health diagnosis and remedies, but poor in dealing with mental health. This article seems to come from high quality GP’s in mental health skills protesting their personal innocence. Consumers see thousands of GP’s. Can we please look at collaboration and not rebuttal?
This is a terrific article but not entirely sure I totally agree. Firstly a little perspective: I am a UK based GP but worked as a GP in Australia from 2005-2020. During that time, I was level 2 mental health trained and worked for Headspace for several years as a GP. I consequently produced a lot of mental health care plans and also reviewed quite a few.
My personal approach to this work was to use the assessment appointment to clearly assess a patient’s issues. I would then formulate a diagnosis and spend some time identifying what the patient wanted from their therapy so that we could identify meaningful goals.’I want to feel better’ was not enough for me. I was conscious that I had a mandate for review and wanted to have some specific questions to ask to identify how things were going. It was more than ‘how are you please fill in the K10’ review.
Reviewing others mental health care plans was however a little soul destroying. I often got care plans reading ‘problem:depression, goal: feel better, treatment: psychology’. Not exactly a clear management plan but understandable for doctors with limited skills and appetite for mental health work
I am delighted that the RACGP is looking at providing some recognition for GPS with advanced psychological skills. I hope that Medicare comes to the party to remunerate and encourage this special interest area. We can have something special to offer in this area but there are a variety of skills. That diversity needs to be acknowledged while not preventing patients access to the MH item numbers that they need.
I agree. And it is most heartening to see that so many of us in General Practice appreciate the depth of the humanity of our patients – they are not a diagnosis; they are feeling, struggling, suffering, people. However, isn’t it also important to recognise we are treating the tip of a much bigger problem that is not being addressed?
Yes, General Practice needs more funding, recognition, and prioritisation. Every area of mental health needs more qualified, kind, caring, compassionate people. But if we don’t plug the massive hole in the dam we will continue to see a growing uncontrollable flood and drown under the deluge.
Am I the only one seeing a growing epidemic of loneliness and disconnection? GPs and mental health workers are no substitute for a close community of good friends. I spend over 75% of my practice offering psychological therapies. I have sadly recognised most of them would have better mental health – and probably not be so unwell – if only they had more trusted friends – it is sad so many are so lonely. I wonder, is it cheaper to keep paying for an ever-growing level of mental illness or to finally get honest about the predominantly social reasons for so many being so sick?
Are we ready to get real about mental illness yet? Or are we going to continue to focus on the symptoms?
And if society expects us GPs to continue to be the front line of a growing mental illness plague and all the stress that entails shouldn’t we at least be better trained and paid for it? I almost never charge mental health item numbers, for many of the reasons outlined in the article.
I hope soon we can stand back and look at the bigger picture. I’d prefer those of us treating mental distress didn’t all drown doing it. Don’t you?
–due to reasonable concerns around stigma (sic)
Had you said “reasonable concerns about discrimination”, you would have been professional.
Please be professional.
Harold A Maio
This is an excellent response to yet another GP bashing exercise by two psychiatrists. PSYCHIATRY IS THE PROBLEM because of its history of attempting to apply to highly subjective, uncomfortable human emotions a physical disease model. There is no evidence that so-called “mood disorders”, the overwhelming mental health presentations in general practice, are diseases. Rather, they are are the product of people feeling, in many complex ways, disconnected, out of control of their lives, fearful and/or unvalued/unworthy because of developmental, social, financial, physical, educational, environmental, occupational and relational factors in society that do not or have not worked for them. There is always a reason if only we listen carefully, compassionately and non-judgmentally to what is being experienced. From this, patients can be empowered and supported to find ways to deal with such factors, the most important element being the quality of the therapeutic relationship.
I was surprised and horrified when Medicare separated out mental and physical health item numbers and then told us the order in which the patient had to present them in order to “ qualify” for a rebate And then sent nudge letter Ms to colleagues trying to deal with an overwhelming series of interconnected problems in a consultation
It shows that without BEACH and other such studies, no partial field of medicine really understands what generalists do, nor do they make allowance for funding access to services for our patients
It also devalued a 20-39 minute consultation about complex trauma with a lesser rebate than a consultation with a diabetic about an in growing toenail.
Measuring rebates does not measure what a GP does, it measures what a government agency is willing to pay for
Rural GPs would be very happy to have an available team with whom to collaborate
Our patients, however, have to have the right diagnoses for the team to take on, need to not have a history or brain injury, can’t have background ADHD persisting more than 18 years and 1 minute and need to be assessed by a rotating team located 200km away
The ones who are too difficult, too complex or undiagnosed get turfed straight back to the remote area GP. There is no alternative publicly funded service for these patients till they get sick enough to be flown out or certified
And if they also have persisting physical cap ailments, they still have to mention the ingrown toenails first, or Medicare doesn’t rebate them
This is well written & a concise summary of the mental health issues. It also alludes to the overall issues with our health system.
As a hospital based rural generalist (GP) in a small rural town, we see the fall out of inadequate funding to GPs in our ED, as I am sure all ED clinicians would attest to. Decreased GP numbers due to lack of support from the government leads to busier hospitals.
The overhaul to funding for GPs is long overdue. Without good primary health care, our EDs will get busier & busier. For good primary health care we need GPs!! GPs are absolutely imperative to our health system!!
I completely concur with the words Louise has written, and the sentiment from the fantastic group of signatories, I worry however, that these words are simply not heard. Again.
RACGP and AMA are doing a nice job of bringing the issues in GP now to the public radio audience. What MP is influenced by this? I worry that the government solutions currently publicised look a lot like adding another silo/ mob/ bureaucracy to the bending back of GP.
Thank you Louise et al. for all of this.
“Counting mental health item numbers has always been a poor proxy for quantifying the mental health care that GPs do”, for all of the reasons you listed.
In addition, patients usually present with a number of concerns. They rarely say “I am here for my Mental Health Consultation”. The requirements for using Item 2713 are specific – for example, a 30 minute consultation addressing fatigue, brain fog, poor sleep, low libido, and crying may not qualify, because the delineation between what is general health and what is mental health blurs.
Also, the 20+ minute time-requirement for item 2713 excludes some consultations – I would charge item 23 for a 19 minute consultation on mental health.
At least 50% of my consultations have a mental health counselling component. The other 50% provide an interaction with another, caring, human being.
Our ability as GPs to integrate “context, relationships, meaning, life story, and bodily health” in a long-term relationship is irreplaceable.
Many thanks for this excellent insight into general practice care, and explaining why arguments based on Medicare billing numbers are simply invalid. Let’s support our general practitioners and our local general practice teams to do what they can do well. They have the lived experience of this space, the skills, and the long-term relationships to deliver for Australia in these challenging times.
Kindness is not only the cure but also the prevention for nearly all mental health problems. A kind caring GP is at the heart of mental health care.
However, the time taken to be kind and caring must also be remunerated adequately.
Spot on
Could not agree more : “Good GPs integrate their understanding of context, relationships, meaning, life story, and bodily health alongside what the psychiatric model separates out as “mental health”. This fundamental difference in how we see people means that strategies developed for psychiatry and psychology led segments cannot be generalised into our context. Using evidence justified in one context to drive policy in another is poor science and poor practice”. As a 30 year health professional with a history of depression, my GP has provided excellent care , understanding the context of my life in conjunction with the serious illness of other family members and supported by specialist care.
Currently working on the frontline in a COVID service I have seen the amazing work of GP’s in supporting their patients to access care and support.
We continue to undervalue and underpay GP’s at our peril.
Everything that the authors say concurs with my experience over 42 years in general practice.
When the funding and organisation of mental health services are being discussed and planned, those responsible need to act on this advice from the authors:
“GPs (…) have the training, the skills and the insight to contribute meaningfully to the mental health discourse and the delivery of services. (…) It is frankly offensive that specialist world views are held up as the most reliable solution for the care of patients they will never see.”
Dr. Oliver Frank MBBS PhD FRACGP FAIDH
Specialist general practitioner
Oakden Medical Centre
132-134 Fosters Road
Hillcrest
South Australia 5086
Patients are whole people. They don’t compartmentalise their problems and their mental health impacts their whole body. Who else but the GP will manage the patient when appointments for psychologists are weeks or months away, and the cost of both psychologist and a psychiatrist is prohibitive for so many.
This is an accurate and concise summary of the critical role GPs play in mental healthcare. Policy makers, fundholders and Psychiatrist colleagues should reference this article as the foundation of all future decisions in this space.