Provision of mental health services in rural Australia

1. Position

Specialist general practitioners (GPs) play a crucial role in the provision of mental health services for all Australians. In a rural or remote context, the GP may be the only accessible health professional, providing the first contact for mental health presentations in an environment where other specialist support is not immediately available, and other mental health professionals are scarce. GPs are the only specialist who can care for both a patient’s physical and mental health, whereas most specialists only care for one or the other. GPs are often relied upon to manage and provide care for patients who don’t meet the rigid referral criteria of mental health services, often due to concomitant substance abuse or disability. With psychological issues being the most common reason for patient presentation reported by GPs¹, the Royal Australian College of General Practitioners’ (RACGP) is calling on the Australian Federal and State/Territory governments to implement several recommendations to improve access and mental health support for people living in rural and remote areas. The RACGP is advocating for:

• A 40% increase to Medicare Benefits Scheme (MBS) patient rebates for longer consultations and a 25% increase in patient rebates for mental health item numbers.
• Decoupling of the GP Focused Psychological Support (FPS) items from the Better Access Initiative and a doubling of the session limit to 20.
• Commitment from all levels of government to improve the primary health workforce in rural and remote areas, with GPs playing an integral part in providing accessible mental health services.
• Commitment to ensuring equitable access to primary healthcare through all mediums, including digital, by improving internet access across the country.
• Accurate and dedicated data collection on mental health presentations within the general practice environment.
• State and Federal governments to expand and support community-based training rotations through the funding of the RACGP Pathways to Rural program.
• The Federal government to boost funding for GP training and address acute shortages of GPs in rural and remote areas through investment in the FSP and Practice Experience Program Specialist Program (PEP-Sp) to better support homegrown GPs and international medical graduates (IMGs) achieve fellowship.
• State and Federal Governments to improve access to stimulant medications through the standardisation of Drugs and Poisons legislation.

2. Background

Australia has one of the highest disease burdens in the world when it comes to mental and neurodevelopmental disorders, with specialist GPs taking on a high proportion of the associated workload.² The rural context provides a challenging setting for those providing mental health care, with the GP being the first, and sometimes only, contact for mental health presentations. Workforce deficits, including a lack of mental health specialists and support services, further impact access to support for both patients and GPs, contributing to inequalities in health access for those living in rural and remote communities. With rural GPs often being the only health professional able to provide in-person continuity of care, it is vital that we continue to advocate for the support and funding required to do so.

Mental health is a critical public health issue with 43% of the Australian population experiencing a mental illness throughout their life. This figure is amplified in rural and remote areas with an increase in rates of death by suicide when compared to their urban counterparts.³ The age-standardised suicide rate for those in major cities sits at 10.5 deaths per 100,000 people, compared to 24.5 deaths per 100,000 for those living in very remote areas.⁴ Whilst suicide risk increases with rurality, mental health incidence is reported as being consistent across the country. Whilst it may be that these comparable rates mask untreated and/or undiagnosed mental illness⁵, it is undeniable that those living in rural and remote areas also face a range of unique challenges which differentiate them from those in major cities. Rural and remote Australia has greater exposure and vulnerability to natural disasters, higher rates of smoking, drinking and illicit drug use, greater prevalence of chronic conditions and disability, and poorer overall health.⁵ The mental health burden in remote and rural areas is further compounded by barriers to access, including cost of attending services (e.g. travel and loss of income), reduced access to reliable internet connectivity, and attitudinal factors such as perceived stigma around mental health treatment.⁵

A greater proportion of people living in rural and remote communities identify as Aboriginal and/or Torres Strait Islander when compared to the Australian population living in urban areas. During 2015-2019, the age- standardised rate of suicide for Indigenous Australians was twice the rate for non-Indigenous Australians.

Additionally, 67% of Aboriginal and/or Torres Strait Islander people had low/moderate levels of psychological distress and 31% had high/very high levels.⁶ These statistics identify a need for culturally safe and accessible mental health and wellbeing support, focused in rural and remote communities.

Specialist GPs themselves also face a heightened risk of presenting with mental health issues when working in rural and remote areas. The risk is enhanced by lack of recognition, sub-optimal remuneration leading to financial stress and risk of practice closure, as well as isolation and burn-out. Increased complexity of consultations and poor referral pathways, coupled with restrictive funding measures and a high number of socio-economically disadvantaged patients put rural and remote GPs at risk of burn-out and fatigue.

GPs are involved in their patient’s mental health across the lifespan and are ideally placed to advise and treat patients. Mental illnesses often present with other physical conditions, requiring patients access to generalists who can best support them and their requirements. However, for such support and treatment to be provided to our rural and remote communities, significant changes need to be made that both support the most vulnerable in our communities, as well as those working on the front line who provide care to these population groups.

3. Issues and recommendations

Remuneration and recognition

Currently, the Medicare Benefits Schedule (MBS) mental health items are the only source of national data when seeking insight to the volume of mental health related services provided by a GP.⁷ Given not all mental health presentations coincide with, or are billed to specific MBS items, there is likely to be an underestimation of total mental health services provided by GPs. Accurate and dedicated data collection, which is made publicly available, would provide for a more realistic overview of the mental health landscape within Australia and help to identify differences between urban and rural and remote regions. This information would be able to be used in research and reform activities to ensure equitable access to healthcare across the country is delivered.

Furthermore, current rebates for longer consultations (Level C and Level D), including those for mental health presentations are insufficient, with poor remuneration a barrier to the delivery of high-quality mental health care in rural communities. With 71% of GPs reporting psychological concerns as one of their top 3 presentations, they are being underpaid on a substantial portion of their weekly work due to the lower value of Medicare rebates for longer general consultations.¹ Furthermore, female GPs are at a disadvantage as they have been shown to spend more time with their patients, with a higher number of Level C and D consultations being claimed. This results in lower overall remuneration as Level C and D consultations are paid at a lower hourly rate when compared to the shorter Level A and B consultations. RACGP calls for a minimum 40% increase to patient rebates for Level C and D consultations, as well as a 25% increase to patient rebates for mental health consultations. Increased funding for these consultation types will support rural GPs to address the growing mental health crisis in our rural and remote communities and keep government service costs to a minimum by keeping patients out of costly tertiary healthcare settings.

Another service barrier for patients and GPs alike is the coupling of GP Focussed Psychological Strategy (FPS) items to the Better Access Initiative. Whilst the Better Access Initiative is advantageous for patients in rural communities, who can access Medicare-rebated psychological services from FPS-trained GPs where they ordinarily might not have access to other mental health professionals due to remoteness and workforce constraints, there are issues with this initiative. Namely, the 10-session Medicare-rebated limit available to patients for psychological services reduces GPs’ use of the corresponding MBS items, with a report from the General Practice Mental Health Standards Collaboration (GPMHSC) finding that 23% of GPs claim a non-mental health MBS item as they don’t want to reduce a patient’s allowance for a set amount of mental health consultations each year.⁹ Accordingly, RACGP calls for the decoupling of GP Focussed Psychological Strategy items from the Better Access Initiative, as well as a doubling of the Medicare-rebated session limit from 10 to 20. To do so would support mental health care in general practice without impacting access for patients to other mental health professionals.

In addition to these structural and funding challenges, GPs must navigate Medicare billing requirements when delivering mental health care. Ensuring compliance with billing rules is essential when claiming MBS mental health items. While co-claiming mental health items alongside other services, such as general attendances, is permitted, it is only allowable when both services are clinically relevant and clearly distinct. Moreover, all components of an item must be completed in full before a Medicare benefit can be claimed. These administrative requirements can contribute to the complexity of providing mental health care in general practice, particularly in rural and remote areas where time and resources must be carefully managed.

Training enablers

In the rural and remote context, where referrals to mental health specialists may not be immediately available, specialist GPs must have access to the ongoing training and education they need to competently, confidently and safely address the mental health needs of their population. This need is affirmed by rural GPs, who perceive mental health advanced skills to be among those most prominently acquired and practised to address patient/service needs within their communities.¹⁰

Through the provision of ongoing training opportunities to rural and remote GPs, more mental health conditions can be managed locally at a significantly lower cost the government.¹¹ This will also allow patients to access mental health support closer to home and provide visiting or digitally accessed mental health professionals more time to deal with the most unwell patients for whom they are the best service provider. Access to grants and subsidies in order to enable GPs to complete mental health training and maintain their skills are crucial to ensuring the GP workforce is providing optimum mental health care. The General Practice Mental Health Standards Collaboration (GPMHSC) currently offers GPs a training subsidy that covers part of the costs associated with completing Focused Psychological Strategies Skills Training (FPS ST). However, places are limited and funding is not permanent. RACGP would like to see the Federal Government commit to an increase in the number of funded subsidies as well show ongoing commitment in providing funding for these subsidies.

Adequate recognition and remuneration for specialist GPs who have acquired additional mental health training, such as FPS and Advanced Rural Skills Training (ARST), is critical. RACGP Rural supports the introduction of the Workforce Incentive Program - Rural Advanced Skills Stream which provides GPs with advanced skills in mental health, and working in MMM3-7, with an incentive of $4,000-$10,500 per annum.¹² These types of incentives are a great start to capturing the service complexity associated with mental health consultations, which are currently undervalued and underpaid by MBS, but it is imperative that such programs continue to exist and expand to support our rural and remote GPs to deliver care to those most vulnerable in our communities.

Patient-centred care

Supporting children and adolescents

The overall presence of mental illness is similar within rural and urban Australia; however the suicide rate is considerably higher in rural areas, with rates increasing the more remote the community. Of note, populations with the highest suicide rates include young men, elderly men and Indigenous people,³ however mental health services for this cohort are limited in rural and remote areas. As well as expansion of existing supports for these groups, improved information sharing between mental health providers and GPs would be of benefit, with expedited discharge summaries and improved handover of patients to GPs in order to enable better continuity of

care. Ongoing relationships between mental health providers and general practice teams can facilitate early intervention, system support/maintenance, assessment of suicide risk and effective monitoring of chronic mental illness.

ADHD diagnosis in all areas by GPs

The high incidence of Attention Deficit Hyperactivity Disorder (ADHD) as per the DSM-V also requires a particular focus in rural and remote areas. Not all children require treatment with stimulants but for those who do it is essential that regulations concerning prescription of stimulants, which currently vary between Australia’s states and territories, are extended to enable GPs to initiate stimulants in children where there is a lack of access to other specialists (Paediatricians or Child Psychiatrists). This issue is prevalent across the nation, however is further exacerbated within rural and remote areas. Specialist GPs are well-positioned to improve medicine accessibility for population groups requiring stimulant medications. The RACGP calls upon the State and Federal Governments to improve access to stimulant medications through the standardisation of Drugs and Poisons legislation, with an amendment to include GP prescribing rights for stimulant medications

Technology and Telehealth

The utility and centrality of technology as an enabler of mental healthcare in rural and remote settings cannot be overstated. Through telehealth, geographical barriers faced by patients in these settings can be minimised but not eliminated completely. Telehealth provides easier access to specialist care delivered by psychiatrists and other mental health professionals, where workforce constraints are considerable in rural and remote regions.

Whilst telehealth should not be the only option available to patients, RACGP Rural recognises that it is a critical component of delivering high-quality mental health services to patients.

Whilst there is no doubt that telehealth has resulted in improved access to GPs, significant barriers to its utilisation exist in rural and remote areas due to poor internet connectivity. Such unreliability is compounded in Aboriginal and/or Torres Strait Islander communities, with 43% of these communities having no mobile service available to them.¹⁴ Additionally, GP initiated mental health treatment plans must be provided face to face or via video conference, they cannot be provided via telephone. This further exacerbates access issues for rural communities where video calls are often not possible or practical due to intermittent internet connectivity. Access to telehealth is critical in ensuring equitable access to mental health care, and the RACGP calls for increased investment and a commitment by the Federal Government to ensure that all communities across the country have access to affordable, high-quality internet and mobile connectivity. Until such time, the RACGP also calls for the protection and expansion of MBS items allowing mental health services via telephone.

Wellbeing of GPs

The prevalence of mental health issues associated with rurality are not exclusive to patients. Specialist GPs working in rural areas at risk of burnout due to a variety of factors, including long working hours and reduced workforce coverage that can prevent them from taking leave. In rural areas GPs wear many hats, one of these being the responsibility of debriefing and supporting staff members, patients and families in the event of a traumatic accident or unsuccessful resuscitation. However, rural GPs often find themselves unable to afford the time required, nor appropriate access to face-to-face resources in order to debrief and recover both emotionally and professionally. Advocating for measures to increase workforce availability in rural and remote areas is a crucial component of preventing fatigue and burn-out for GPs. The RACGP is committed to supporting the primary care workforce, and the RACGP calls for both levels of government to ensure rural and remote communities have equitable access to high-quality general practice through advocating for:

• The Federal government to boost funding for GP training and address acute shortages of GPs in rural and remote areas through investment in the FSP and Practice Experience Program Specialist Program (PEP-Sp) to better support homegrown GPs and international medical graduates (IMGs) achieve fellowship.
• The Federal government to undertake structural change to training pipelines to set and meet general practice quota of 50% of medical students choosing general practice as a speciality.
• The Federal government to extend the Rural Locum Assistance Program to include GPs to ensure funding assistance in obtaining locum GPs for planned annual leave.
• State and Territory governments to provide workforce incentives to encourage junior doctors to train as GPs in regional, rural and remote areas via the Australian General Practice Training (AGPT) program and the FSP.
• State and Territory governments to expand and support community-based training rotations through the funding of the RACGP Pathways to Rural program.

The RACGP’s key advocacy asks of both levels of government have been further outlined in the 2024-25 Advocacy Plan.

As well as strongly advocating for workforce changes, the RACGP provides all members with access to wellbeing resources and a dedicated GP support program, both of which can be accessed free of charge via the embedded links. Acknowledging the impact natural disasters such as floods, cyclones and bushfires can have on rural and remote GPs and their communities, information for GPs in disaster-affected areas is also available free of charge to members here.

RACGP Mission statement

The RACGP's mission is to improve the health and wellbeing of all people in Australia by supporting GPs, general practice registrars and medical students through its principal activities of education, training and research and by assessing doctors' skills and knowledge, supplying ongoing professional development activities, developing resources and guidelines, helping GPs with issues that affect their practice, and developing standards that general practices use to ensure high quality healthcare.

Author: Rural Faculty

Contact: rural@racgp.org.au

Review date: 2026