Medicare should fund general practice psychologists: Professor Stephen Leeder
8 February 2006
This Friday's meeting of the Council of Australian Governments will have health care high on its agenda. The NSW and Victorian governments will take a $500 million healthcare reform package to the meeting in Canberra. The way we care for patients with serious and continuing chronic disorders needs to change and this package may help.
Like parents of children in a blended family, COAG members will seek ways to harmonise care that comes from different origins - hospitals, both private and public, community-based services including general practice, multiple professions, non-hospital specialty services and pharmaceutical benefits.
This is especially critical for the care of people with mental illness.
The new patterns of care demand flexibility and tolerance from COAG. They will require generosity of spirit among health professionals expressed as a willingness to work more closely together across professions.
On the COAG table will also be the report of the Productivity Commission on the health workforce. The report is critical of the tight preserve many health professions exercise over their territory. It acknowledges the value of maintaining clear professions that complement each other and does not advocate training generalists who have no professional heritage. But with too few people to do the work, it needs to be shared among professions better than at present.
For decades publicly funded aged care in Australia has demonstrated how health professionals of different persuasions - doctors, nurses, occupational therapists and physiotherapists - can work effectively together in teams.
But in the private sector, of which general practice is the largest component, collaboration is not so easily achieved unless paid for by the patient and their health fund.
But there are encouraging signs of change. Treatment studies in several hundred general practices have shown how mental health care can be shared between professions to good effect. Since 2001 federally funded treatment trials of collaborative care between general practitioners and primary care psychologists with certified skills have helped patients with common disorders including depression and anxiety.
More than 25,000 patients have received publicly funded treatment with success rates about 90 per cent. Treatment is short-term - up to six sessions, with six more if needed. The average treatment consists of four visits at a cost of $400.
Helen, a 37-year-old teacher and mother of two children, was referred by her GP to the local primary care psychologist for a severe panic disorder. Her first attack came out of the blue at a family party and led to her admission to hospital. She experienced severe palpitations, causing concern about a heart condition, but tests were negative.
While on extended sick leave from work, her GP referred her for four sessions of treatment from a clinical psychologist. She gained an understanding of the symptoms of panic and learned to recognise and counteract the signs of stress contributing to her attacks.
A long lead-up of cumulative distress and tension, including bereavement and financial pressures, had led to her condition, and this was explored. She was taught techniques to manage stress more effectively, to balance commitments and to set limits on demands. She had planned to quit her job but she returned to work within weeks. She received four treatments over two months and had two follow-up sessions.
The GPs involved in the collaborations seem to be generally well satisfied with the system and do not see it as stealing their income. Nevertheless, continued funding is far from secure.
At present only a minority of GPs can access these services. Detailed costing has not been done, and should be, but those responsible for Medicare may wish to check it out as an example that health service providers other than doctors can be reimbursed for care without cost blowouts and with good clinical results.
Beyond concerns with money, the trials also address a health workforce problem. Psychiatrists are a scarce commodity in unrelenting demand. Rural patients find it difficult to access psychiatric services located primarily in urban areas. Psychologists are more widely dispersed and numerous. There are at least 5000 psychologists in Australia with sufficient clinical expertise to function as mental health specialists and who could provide the style of non-pharmacological interventions that many persons with less severe disorders both need and seek.
The debate about the extension of Medicare to other health professionals is one that must be joined. In the US and Britain, primary care psychology is established as a mental health specialty in which clinical and health psychologists provide collaborative care with GPs and physicians.
The trials of similar services in Australian general practice described here suggest that this model might well be developed across Australia to good effect.
For patients with other serious and continuing illness such as heart failure, these trials give hope that better care can be provided to people in need without the different health professions sharpening their swords and going into battle over turf.
Professor Stephen Leeder is director of the Australian Health Policy Institute and Menzies Centre for Health Policy at the University of Sydney.