Mental health system is a “Jackson Pollock painting”

GPs are the least likely to have large gap payments, but the most likely to be under-remunerated by Medicare for their work.  We need to take a long, hard look at why a GP spending 40+ minutes on assessing and designing a management plan for a patient under a Mental Health Care Plan has a scheduled fee of $141.00, ($3.33 per minute for 45 minutes, or 35 minutes, just $96.25) and a psychiatrist undertaking an item 291 assessment and management plan of over 45 minutes has a scheduled fee of $485.70 ($10.79 per minute), almost 3.5 times the GP fee

IS there a doctor, nurse or allied health professional anywhere in Australia who thinks that our current mental health system is doing fine? The recent InSight+ article by Rosenberg and Hickie has been marred by their misunderstanding of how GPs work, how we bill, and how we actually engage with our patients, but has usefully caused me to reflect on the state of the system as a whole.

The mental health care system comprises primary healthcare (GPs and allied health professionals), secondary healthcare – outpatient services (psychiatry, nursing and allied health, both private and public), and hospital care, (again, both private and public).  The system is completed by myriad programs operated by non-government organisations, not-for-profits, and charities.  Some of them operate under commissioning by primary health networks (PHNs), some by commissioning from state health departments, and some operate quite independently, funded through donations, direct government grants and/or bequests.

The “system” is a Jackson Pollock painting, with coverage dripped and splashed, reaching most of the canvas, but not visibly planned and definitely not orderly.  (Disclaimer – I quite like Jackson Pollock art, but don’t recommend it as a method of strategic planning).

In reality, we have a non-system, cobbled together by sticky tape and paper clips. The complexity and disconnectedness of it makes it difficult to get a picture of the overall state of the system. If I find this non-system bewildering, what hope is there for a patient with severe depression or ADHD, whose executive functioning and motivation are compromised?

The day-to-day work of general practice brings me into contact with the entire spectrum of mental health need; from the high functioning but depressed executive to the chronically psychotic and undertreated; from those who have never had any contact with the mental health care system, to those who have endured involuntary admissions and long term morbidity.

It doesn’t seem to work optimally for any of them, and among all the discussion about funding and who should be working in the mental health space, it's important that we continue to be focused on what works for the people who need services.

Our system does have some strengths. We have an enormous amount of good intent, and we have high levels of community engagement and interest.  We have made huge inroads in addressing stigma and denial, acknowledging that much remains to be done.  We have a government that is interested to improve things (here and here), and we do have (and I can say this with more authority than most) some of the best trained mental health providers in the world. So, what is going wrong?

The weaknesses of our system include the fragmentation, a fee-for-service model (that is inadequate even for physical health, let alone mental health) the reliance through this fee-for-service model on private business to deliver, and the unaddressed mismatch between access and need (here, and here).  We also have a lack of consensus on the roles and responsibilities of the different health professionals, which can play out as an unedifying turf war, to the dismay of observing mental health consumers.

Fragmentation occurs both through service and professional silos, but also through service models. We have multiple entities and programs, and there can be completely different service providers depending on the intensity of need. Not just different teams in the same organisation, but completely different organisations. Fragmentation inevitably leads to gaps, as each program stakes out its territory, unfortunately excluding those outside its remit.

The fee-for-service model creates disincentives for engagement with patients whose needs are complex, because above all, the Medicare system rewards throughput.  It punishes longer, intensive work, incidentally, contributing significantly to the gender pay gap.  Forty-five minutes on one mental health care plan remunerates $3.33 per minute for a GP.  Four 10- to 12-minute consultations in 45 minutes generates $4.86 per minute, and significantly more in a mixed-billing practice, or even if bulk billing incentives are included. The model rewards the practice of superficial medicine and reactive care.

Doctors and allied health practitioners in private practice understand that they are small business owner-operators. They must make a profit if they are to survive, if they are to make payroll, keep the lights on and pay the rent. Everyone else seems to forget this.

Quite bluntly, the entire Better Access to Mental Health Care Program relies on autonomous for-profit businesses – general practice, allied health and psychiatrists. While underpinned by Medicare, our pricing structures are not constrained by it, so the program is operating in an environment that is, to all intents and purposes, a free market that relies on individual acts of altruism to rescue the system when that free market fails. Demand and workforce shortages have driven prices up, but supply has not increased.

As a result, it has become normal for the private mental health sector to decline referrals, or price themselves out of common access. The current intake approach of private mental health facilities in my area is that the GP must send a letter and they circulate it to their panel of specialists and see if there was anyone who was “willing” to take the patient on.  This is not just one facility, it seems to be almost universal, in my experience. Some don’t bother to answer at all, some revert and say “no sorry, nobody will take that patient”, and some are actually helpful, responsive and give a timeline for when they will contact the patient.

When I prepare a GP Mental Health Care Plan, if I refer to private providers for psychological therapies, the waiting time is usually in the order of 3 to 6 months, and the block-funded (free to consumer) programs are booked out to the extent that they often decline referrals. The financially neediest or patients at high risk of suicide may be able to access support through PHN commissioned services, but this leaves a lot of people not really covered.

But when all avenues fail, no private practitioner or facility will accept the referral, and the public system assesses them as not “severe” enough, there is nowhere to go.  This is in a metropolitan area – I cannot begin to imagine how things go for colleagues in rural and regional Australia.

There can be very large financial barriers.  Accessing private psychology services under a mental health care plan has an out-of-pocket per session of approximately $100 or more.  For many people this is exclusionary, but they don’t meet the criteria of financial hardship to access any of the free programs.

GP remuneration is not the core issue here, but it is an important part of the system failure and if GPs were to join psychiatrists and psychologists with large gap fees, those most in need would be left in desperate circumstances.

GPs are the least likely to have large gap payments, but the most likely to be under-remunerated by Medicare for their work.  We need to take a long, hard look at why a GP spending 40 + minutes on assessing and designing a management plan for a patient under a Mental Health Care Plan has a scheduled fee of $141.00, ($3.33 per minute for 45 minutes, or 35 minutes, just $96.25) and a psychiatrist undertaking an item 291 assessment and management plan of over 45 minutes has a scheduled fee of $485.70 ($10.79 per minute), almost 3.5 times the GP fee.

The nuances of minutes aside, this difference entrenches the government (and the public) view that GP work is low value, and that other specialists deserve far better remuneration than general practice specialists.

That’s just the private system.

The public system (at least in Queensland) is very clear that their scope is “severe and complex mental health morbidity”.  Note the and.  I can’t think of many other conditions where the public system denies care for moderately severe disease.

I have patients who are financially compromised because their condition has cost them their job.  The public health system will do acute assessments, but if the person is not a risk to themselves or others, they are invariably handed back to me.

One of the hallmarks of general practice is recognising that while you may not be the best doctor for the job, you may indeed be the only doctor available for the job.

With that mindset, in this current operating reality, I have expanded my scope of practice in mental health significantly and somewhat uncomfortably.  I enjoy mental health work, and I can see that I make a difference.  But I am uncomfortable, because unlike every other part of my practice, I cannot count on my other specialist colleagues to help me when I am faced with a problem I cannot manage.  The inability to get psychiatry review is without question contributing to the GP discomfort in stepping up in mental health.

I have completed online training (even looped back and did it a second time to work out what I missed), read countless online resources, studiously avoided drug company marketing materials and initiate medication in a shared decision-making model with my patients and sometimes involving (if they have one) their psychologist in that decision, using only authoritative clinical guidelines. I refer to psychiatry colleagues when it is indicated, but this is often a thankless endeavour, with wait times of many, many months, and often, closed books.

We need some urgent reflection by the Royal Australian and New Zealand College of Psychiatrists on the models of care being promulgated by the available psychiatry workforce, to see if there is any way additional appointments can be opened up.  GPs need our patients to be able to access specialists to help us maintain safe scope of practice.  We need much better access to item 291 and 293 psychiatric reviews.

The data presented by Rosenberg and Hickie shows the widening gap between GP plans, psychology reviews and specialist psychiatry under the Better Access Program. There is a clear financial incentive to do these, as the Medicare fee is higher for the 291 than 296 (the standard initial consultation fee), so something is not working, and any review needs to understand what the barriers are and how they can be overcome.

If the private sector cannot meet this demand, then we need the public system to step up and help us manage those patients who might have historically been outside their remit.

So, what do we need from a review of the Better Access Program, but more importantly, from reform of the entire mental health care system?

The Productivity Commission report of 2021 was released by the former federal government, along with a “national mental health plan”, but it is concerning that only one of the recommendations of the Productivity Commission has been fully supported – the rest have been either “support in part” or “support in principle”.

Table 1- summary of Morris Government Response to Productivity Commission Report.

Rec Description	Morris Government Response.
Create a person-centred mental health system	Support in part
Focus on children’s wellbeing across the education and health systems	Support in principle
Support the mental health of tertiary students	Support in part
Equip workplaces to be mentally healthy	Support in part
Support the social inclusion of people living with mental illness	Support i part
Take action to prevent suicide	Support in part
Increase informed access to mental healthcare services	Support in part
Expand supported online treatment	Support
Address the healthcare gaps: community mental healthcare	Support in part
Improve the experience of mental healthcare for people in crisis	Support in principle
Improve outcomes for people with comorbidities	Support in principle
Link consumers with the services they need	Support in part
Increase the efficacy of Australia’s mental health workforce	Support in part
Improve the availability of psychosocial supports	Support in principle
Support for families and carers	Support in part
Tailor income and employment supports	Support in part
Supportive housing and homelessness services	Support in principle
Improve mental health outcomes for people in the justice system	Support in principle
Best practice governance to guide a whole-of-government approach	Support in part
Funding arrangements to support efficient and equitable service provision	Support in part
Drive continuous improvement and promote accountability	Support in part

The same applies to the Final Advice of the National Suicide Prevention Advisor – only two recommendations were supported, the rest meeting the same fate of “Support in part” : or “Support in Principle”.   I have worked in bureaucracy enough to know that the pile of “support in principle” is where good work goes to die.  It’s the place where you put things you have no intention of implementing, but lack the courage or support to say so.

Table 2:  Summary of Morrison Government Responses to Suicide Prevention Advisor’s Final Advice

Rec Description

Morris Government Response.

Leadership and governance to drive a whole of government approach	Support in principle
Lived experience knowledge and leadership	Support
Data and evidence to drive outcomes	Support in principle
Workforce and community capability	Support in principle
Responding earlier to distress	Support in part
Connecting people to compassionate services and supports	Support in part
Targeting groups that are disproportionately impacted by suicide	Support
Policy responses to improve security and safety	Support in principle

My challenge to federal Health Minister Mark Butler and his team is to prepare a new government response to the Productivity Commission report and the National Suicide Prevention Advisor’s final recommendations.  They were urgent enough for him to put out a press release about them in March 2021, so they should now be important enough to warrant a clear statement from government of what we are going to do.

It does not matter if the report was commissioned by a previous government – its findings and recommendations are non-partisan and are clearly aiming for a system that better meets the needs of mental health consumers.  At the end of the day, that is what should underpin all the discussions, not turf discussions, not rebates, and not the federal-state divide.  Every decision should be interrogated to the standard of “how is this good for the consumer”.  Plans need implementation targets and KPIs, so that we can actually implement reform.

The piecemeal solutions of splashing more funds, like Jackson Pollock’s paint, are not going to fix a system that is fundamentally broken.  A clear roadmap and a staged, transparent implementation plan are needed.  It is possible that we will have a Labor government for at least two terms, and an unprecedented situation of mostly Labor state governments.  If ever there was a time to take a national approach, it is now.

Dr Jillann Farmer is a Brisbane-based GP and former Medical Director of the United Nations.

 

 

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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