Main outcome measures: Patient referrals, satisfaction among GPs who had referred, and awareness and opinions of the service among GPs who had not referred, compared with results of a similar survey conducted before marketing.
Results: In the 6 months after marketing, 43 patients were referred by 23 GPs, an average of 7.2 patients per month, compared with 2.5 per month in the first 12 months of the service. Survey responses were received from 13 of 36 GPs who had referred patients and 97 of 282 GPs who had not (response rate, 35%). Satisfaction among GPs who had referred remained high, and 12/13 felt the service should continue. Among GPs who had not referred, 76% were aware of the service, up from 26% in the previous survey, and 99% liked the concept of the service.
Conclusion: Given the ongoing low utilisation of this service, we question whether this model is accepted by most GPs in our district. Possibly, they prefer more traditional models, where treatment is taken over by psychiatrists in the public or private system. We believe there is a need to increase the capacity and scope of publicly funded services to treat mental health problems.
In 2001, Royal Brisbane and Women’s Hospital (RBWH) Mental Health set up a service to provide timely psychiatric consultations for patients treated by general practitioners. This was in response to concerns expressed by the Mental Health Interest Group of the Brisbane North Division of General Practice that, while psychiatric emergencies were relatively well handled, it could take 4–6 weeks to schedule an outpatient appointment for patients with less severe mental health problems in either the public or private systems.1
Evaluation of this service after its first 12 months of operation revealed high levels of satisfaction among GPs who had referred patients to the service, but overall poor referral rates and poor awareness of the service among GPs. After some modifications, the service was republicised and relaunched in February 2003.
RBWH Mental Health is an inner city mental health service with 131 beds, 320 staff, a budget of $28 million, and a catchment population of 260 000 in inner northern Brisbane. It provides a range of hospital and community services.
GPs requested that we establish a psychiatric consultation service to ensure their patients were seen promptly and to provide diagnostic and management recommendations.1 This request coincided with the Australian Medical Workforce Advisory Committee report on the specialist psychiatry workforce,2 which recommended that psychiatrists look at ways to improve timely access and support to GPs.
The new service had to be sustainable within the existing budget and to serve as many of the 318 GPs in the district as possible. An attachment model3-5 or special liaison arrangements with particular practices was therefore not suitable. As we also wished to provide the service in a non-stigmatising environment,6 we developed a model based around the on-site private practice clinic of the hospital, which is available to all staff specialists.
“Psych Opinion” began in July 2001 with five staff specialist psychiatrists who each set aside a 1-hour appointment each week to assess a GP-referred patient. Consultations were “bulkbilled” through Medicare, with no patient out-of-pocket expenses. The aim was to provide an appointment within 2 weeks of referral, and to assess patients but not to offer ongoing treatment. We expected that most patients would need only one appointment, or, in some complex cases, two. The GP would receive an assessment of the patient and recommendations focusing on diagnosis and/or management. There was also the option to discuss the case with the psychiatrist by telephone, if the GP wished.
The service was trialled for 12 months. As the referral rate over this period was poor, we conducted a survey of GPs in the catchment area to assess the appropriateness of the model (June to September 2002).1 This evaluation found strong support for the service and very high levels of satisfaction from GPs who had used it. However, only 26% of the GPs assessed were aware of the service, probably accounting for the low referral rate.
the addition of another general psychiatrist and a child and adolescent psychiatrist (total, seven psychiatrists, each contributing 1 hour per week);
change of name to “GP Psych Opinion” to make its function clearer; and
redesign of the referral and information forms.
The service was also further “marketed”, based on the advice of the Division of General Practice, by mailing information packs (containing the service brochure, sample referral forms, and sample psychiatrist reply proformas) to practice managers, rather than to individual GPs, in January and February 2003.
The service was re-evaluated by a postal questionnaire-based survey of GPs between September and November 2003. The survey parameters were designed in consultation with the Division of General Practice, while the specific items were designed by our senior research and evaluation psychologist, to ensure their robustness.
GPs who had referred patients to the service were sent a questionnaire comprising 11 items that assessed satisfaction with the service on a 7-point Likert scale (Box 2). GPs who were eligible to use the service but had not done so were mailed a brief questionnaire comprising 16 true/false items to assess awareness of the service and endorsement of the model. Included with each survey was the information brochure describing the service and a copy of the referral form to the service.
We also determined the number of referrals to the service and the demographic characteristics and psychiatric diagnoses of patients referred in the 6 months after re-marketing (March to August 2003). Mental health conditions were diagnosed by the consultant psychiatrist according to the criteria of the Diagnostic and statistical manual of mental disorders (4th edition).7
In the 6 months after re-marketing of the service in February 2003, 23 GPs referred a total of 43 patients. These GPs included 21 who had not previously referred patients. In contrast, in the first 12 months of the pilot project (July to June 2002), 15 GPs referred a total of 30 patients, with one GP referring 10. The average monthly referral rate after re-marketing was 7.2 patients per month, compared with 2.5 in the pilot period.
Of the 43 patients referred after re-marketing, five (11%) failed to attend. The 43 patients comprised 26 women and 17 men, with mean age 36.6 years (range, 18–54 years). Their diagnoses are shown in Box 1. Diagnoses for the five who did not attend were obtained from the GP referral form. Anxiety and depression predominated. There was a significant level of comorbidity, with 46 primary psychiatric disorders recorded for the 26 women, and 21 for the 17 men. Of the 18 women with an anxiety disorder, 16 (90%) met the criteria for at least one other major clinical disorder.
The opinions of the 13 respondents who had referred patients are shown in Box 2. Satisfaction with different aspects of the service remained high, including the level of information provided, waiting time, usefulness and practicality of the psychiatrist’s advice and patient “improvement” after the consultation. The GPs’ overall rating of the service remained high, and 12/13 (92%) felt the service should continue.
Opinions of the GPs who had not referred patients to the service are shown in Box 3. Comparison of results from the first and second evaluations showed that awareness of the service had increased from 26% to 76%, indicating that the marketing strategy had raised awareness. However, fewer respondents (about 50%) were aware of the referral process and what to expect if they did refer. There continued to be very high support (98%) for the model and willingness to refer.
About two-thirds of respondents (68%) enjoyed working with patients with mental illness, but 25% felt they had inadequate knowledge. More than half (58%) believed it was not financially viable to work with people with mental illness, and only 10% intended to do more work with people with mental health problems because of the higher Medicare rebate introduced as part of the Better Outcomes in Mental Health Initiative.8 Over 63% of respondents reported a large number of patients with mental illnesses in their areas.
Our study found that awareness of GP Psych Opinion among GPs who had not referred to the service had increased from 26% after its first 12 months of operation11 to 76% after a focused marketing campaign. Although the response rate to the survey was low (35%), this threefold increase demonstrated the success of marketing. The referral rate also increased approximately threefold, from a mean of 2.5 per month to 7.2 per month, indicating a strong relationship between awareness and referral.
We also found that GP respondents who had used GP Psych Opinion were still highly satisfied with the service it offered. Both the GPs who had referred, and those who had not, clearly indicated that they felt this service was useful and that they would like it to continue.
This raises the question of why the referral rate remained so low. Although the average monthly referral rate increased to 7.2 patients per month, this still seems poor utilisation of the 28 consultant psychiatrist hours set aside each month.
It is unlikely that the low rate of referral represents a low prevalence of mental health problems in the catchment area of the service, as the National Health Survey found little variation in the pattern of mental illness nationwide9 (Box 4). In addition, the distribution of mental health problems among patients referred to the service was similar to that found by the National Health Survey of Mental Health and Wellbeing of Adults.10,11
In light of the low referral rate, it should be considered whether the service provides what GPs want. Our catchment area is well supplied with over 100 private psychiatrists, and it is possible that GPs in the area prefer the traditional referral pathway to a private psychiatrist who takes over the treatment. This may reflect GPs’ heavy workloads, or lack of confidence or lack of interest in treating mental health conditions. However, patient access to private psychiatric treatment is limited by cost. The question remains, who should provide service to patients who cannot afford private psychiatry when over 40% of our GPs believe that treating mental health problems is not financially viable? We believe there is a need to increase the scope and capacity of the public mental health system. The new Better Outcomes in Mental Health Initiative Medicare items were designed to encourage GPs to treat more people with mental health problems. However, GPs in our sample overwhelmingly felt that these items would not induce them to increase the number of patients they treat for mental health problems.
An alternative explanation for the low referral rate is that the GPs who have been lobbying for psychiatric consultation both locally and nationally represent a minority. Indeed, our study represented only 35% of GPs in the Brisbane North district. Nevertheless, the need for more psychiatrist consultation services to support GPs in managing mental health problems in their patients has been accepted by the Australian Medical Workforce Advisory Committee, the federal government and the Royal Australian and New Zealand College of Psychiatrists.2,12 Our study and experience must bring into question whether such consultation services represent a generally accepted need of metropolitan GPs. It may also highlight the need for educational strategies, not just marketing, to improve utilisation.
1 Diagnostic categories of patients referred to GP Psych Opinion*
2 Satisfaction of general practitioners who had referred patients to the service (mean score on a 7-point Likert scale*)
3 Opinions of GPs who had not used the service (percentage who stated the statement was true)
4 Prevalence of mental health problems in Australia (National Health Survey)9
Received 19 October 2004, accepted 19 May 2005
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