Mental health care in general practice

Position

The Royal Australian College of General Practitioners (RACGP) aims to support general practitioners (GPs) in providing mental health care by advocating for:

• recognition of the central role of general practice
• interprofessional collaboration
• high-quality education and training in mental health
• Medicare reform
• wellbeing of the general practice team

Background

General practice plays a central role in the provision of mental health care in Australia. Easily accessed without referral, people in distress frequently turn to a general practice team for help. General practice is key to providing equitable access to care for mental health issues. People talk to their GP about mental health more than any other issue¹ and the majority of mental health services in Australia are delivered by GPs².

Mental health care is often integrated into routine general practice consultations and the scale of mental health delivered by GPs may be underestimated in Medicare mental health specific data.

In certain circumstances, a general practice may be the only point of care for people who require mental health services. In rural and remote areas, GPs and their practice teams may manage a high volume of mental health work as a result of geographical barriers and a lack of local mental health practitioners. Furthermore, individuals who might not otherwise have contact with the health care system for various reasons such as people of low socioeconomic status, Aboriginal and Torres Strait Islander people, and people from culturally and linguistically diverse backgrounds, might have contact with a general practice. General practice also bridges the gap between the community and institutions such as hospitals, mental health outpatient services, drug and alcohol rehabilitation facilities, and prisons.

Through general practice, patients receive comprehensive care encompassing both mental and physical health needs. Unlike many other public and private health care settings, general practice does not draw a distinction between mind and body systems. Assessment and treatment of mental illness is informed by a holistic, whole-of-person approach.^3,4 GPs generally manage mental illness using a multi-tiered stepped care approach to ensure patients receive the appropriate level of care dependent on the complexity of their condition⁵.

GPs oversee patients’ mental health across various ages and stages. They are ideally placed to advise patients on how to best maintain and monitor their mental health. This creates an ideal climate for population-based mental health promotion activities and stigma reduction⁶. Ongoing relationships between patients and practice staff can facilitate early intervention for emerging symptoms, assessment of suicide risk, and effective monitoring of chronic mental illness.

Recognition of the central role of general practice

The RACGP believes that a patient-centred medical home model establishes the conditions for optimal mental health care. Bypassing general practice fragments care and undermines the medical home model, contributing to poorer outcomes for vulnerable patients. When patients have an ongoing relationship with a general practice and a ‘personal doctor’ for the provision of continuous, interconnected care, it can decrease the use of inappropriate services⁷ and improve overall health outcomes.⁸ Where possible, general practice should be the central point of contact for patients, their families and their care team.⁹

Initiatives that support interprofessional collaboration

The RACGP champions a GP-led, patient-centred health system in which each member of the care team has specified roles and responsibilities. Timely, respectful and relevant communication between professionals assists patients to navigate a complicated health system and improves the quality of their care.¹⁰

Where possible, mental health professionals, including mental health nurses, peer support workers and carers, should be embedded within general practice to encourage strong communication between practitioners, facilitate a ‘no-wrong-door’ approach to mental health for patients, and allow for more effective use of each practitioner’s time and skills.

The RACGP also believes in the importance of GP access to support and advice from mental health specialists, such as psychiatrists, on the management of patients with mental health issues. Early career GPs and practitioners in rural areas may find particular benefit in these consultation services.

The physical health of people living with mental illness requires integration of mental health and physical health care, across the public, private (including general practice) and community sectors and financial support for national, cross-sector coordination is therefore important. The RACGP is a signatory to the Equally Well National Consensus Statement, which puts forward a vision for how this can be achieved.

The RACGP works with a number of multidisciplinary bodies acting to improve communication and collaboration between health professionals, including the Mental Health Professionals Association (MHPA), General Practice Mental Health Standards Collaboration (GPMHSC), Mental Health Professionals Network (MHPN), and Mental Health Australia (MHA).

High quality education and training in mental health

The RACGP is committed to the development of mental health training initiatives to support its members in all stages of their career, from student to senior practitioner. Mental health is firmly embedded in both the RACGP Curriculum for General Practice and the Advanced Rural Skills Training (ARST) Curriculum. The RACGP also manages the General Practice Mental Health Standards Collaboration (GPMHSC), a program funded by the Australian Government to establish and maintain standards for continuing professional development in mental health care for GPs. The high uptake of Mental Health Skills Training (the GPMHSC’s entry-level competency for assessment, diagnosis and management of mental health issues) reflects a strong commitment to this field of practice within the profession.

Many GPs choose to build on their existing skills in mental health as part of their lifelong learning, for example through courses in mental health first aid, focussed psychological strategies skills training, or a postgraduate qualification. Research indicates that GPs practising in rural and remote locations would like to engage in advanced mental health training but are deterred by the financial cost and the time away from practice¹¹. Incentive schemes equivalent to those for procedural skills would support GPs to develop or refresh advanced skills in mental health¹².

In general practice, there are also opportunities for suicide prevention within the community¹³. GP training in this area has been identified as a key factor in reducing suicide deaths in Australia¹⁴. The RACGP is supportive of training initiatives that aim to support GPs in providing care to help reduce the incidence of suicide.

Medicare reform

Payment systems for the provision of primary health care such as the Medicare Benefits Schedule (MBS) should accurately capture the time spent caring for individuals with mental health needs¹⁵. This includes the time GPs invest in face-to-face and telehealth consultations with patients as well as in coordinating care – that is, consulting and sharing information with other members of a mental health care team. There should also be recognition of the additional time and skill required in the management of patients with complex needs, particularly those with severe mental illness, comorbid conditions, socioeconomic disadvantage, and a lack of social support. Medicare benefits paid for GP mental health care services should be commensurate with those for the assessment and treatment of physical health issues.

The RACGP continues to present the case for MBS reform to better support the needs of patients, both face-to-face or via telehealth, in accessing evidence-based, cost-effective mental health care.^8,16

Telehealth and e-mental health

Government initiatives for telehealth services need to be strengthened and supported to enable patients to access mental health care. Telehealth has the ability to reduce the barriers of stigma, distance, service availability and cost which can affect patients and professionals, especially in rural and remote communities and in disasters such as pandemics.¹⁷

E-mental health treatment options often relate to online interventions for the prevention and management of mental health illness. While there is evidence to suggest that e-mental health can be used effectively to manage mild to moderate depression and anxiety, consideration must be given to the patient’s literacy skills and mental capacity before they are enrolled for e-mental health and other online interventions.¹⁷ The RACGP supports the intention of e-mental health as a complementary activity to face-to-face services, but not as a substitute for all patients. Additionally, support of e-mental health should not be at the expense of adequate funding for other types of interventions, in particular those done face-to-face. More information is available in the RACGP’s e-Mental health – A guide for GPs.

Wellbeing of the general practice team

The health and wellbeing of all those working in a general practice setting is crucial to delivering quality care to the community. Doctors and nurses experience higher rates of psychological distress than the general community¹⁸.

The responsibility placed on GPs can lead to a high risk of burnout with increased psychological distress, rate of suicidal thoughts and in some cases substance abuse¹⁹. The RACGP provides support and advocates for investment into mental health and wellbeing for general practice to ensure GPs and their teams are supported to continue delivering quality care to their patients.

More information on where to find support is available on the RACGP Self-care and mental health resources page.