Evaluating a GP Consultative Psychiatric Service in an Australian Metropolitan Hospital District

Abstract

Objective: The aim was to develop a psychiatric assessment and advisory service for local general practitioners (GPs).

Method: In July 2001, five full-time psychiatrists at Royal Brisbane Hospital each dedicated a 1-h appointment per week in their hospital private practice clinic to assess patients referred by local GPs. The ‘Psych Opinion’ clinic was advertised through the Division of General Practice Newsletter. After 12 months, the referrals to the clinic had been disappointing so two surveys were carried out: one to the GPs who had used the service and the other to those who had not referred.

Results: Feedback from the GPs who had used the service showed a high level of satisfaction with the service. The second survey of the GPs who had not referred showed a strong endorsement of the concept but there was poor awareness of the service's existence.

Conclusions: This model offers a way for public sector psychiatrists to provide timely assessments to local GPs without additional funding. There is strong support and willingness from the GPs to refer. However, the need to actively market the service both initially and on an ongoing basis is highlighted.

Keywords

consultation models GP collaboration primary care psychiatry service service delivery models

The Division of Mental Health Services, Royal Brisbane Hospital is an inner city mental health service with a range of hospital and community services. It has 134 beds, 290 staff, an annual budget of over $24 million and a catchment population of 260 000 people covering the inner northern suburbs of Brisbane.

The need for us to develop a consultancy/assessment service for general practitioners (GPs) arose from recently expressed local and national concerns. For example, the Australian Medical Workforce Advisory Committee (AMWAC) report identified timely access to psychiatrists as a major issue and recommended that psychiatrists look at ways that such a service might be provided.¹

In 2001, our mental health service had a meeting with the Mental Health Interest Group from the Brisbane North Division of General Practice at which the GPs identified a number of perceived deficiencies within our mental health services. Their chief concern lay with their inability to access timely psychiatric consultation for patients with a mental health problem whom they were managing. They stated that psychiatric emergencies were relatively well handled. However, it could take 4-6 weeks to schedule an outpatient appointment in either the public or private settings. The GPs felt that psychiatrists tended to ‘take over’ the management of their patients, did not communicate well with the GPs and, when they did communicate, the information given was of limited use. They requested a psychiatric consultancy service that would see their patients promptly and offer useful diagnostic and manage-ment opinions.

At this time, we were also part of a pilot General Practice Psychiatry Partnership Programme (GPAPP) that provided funding for 3 years for a part-time psychiatrist and clinical nurse to work with selected GPs in our district to help upskill the GPs and enable the transfer of patients from the Mental Health Service to these GPs. Although GPAPP provided a good service to the general practices that were involved in the project, it reached only 10 out of some 200 GPs in our district. The funding for this programme was due to expire in June 2002 so there was a need to develop an ongoing service for GPs. We therefore set out to develop a new service to support local GPs that utilized existing funding, such as Medicare, and to not be reliant upon special funding arrangements.

THE MODEL

All staff specialists in Queensland public hospitals have access to onsite private practice facilities. At Royal Brisbane Hospital, five staff psychiatrists agreed to make a 1-h appointment available on a weekly basis to assess patients referred from local GPs. All patients were to be bulk billed and the GPs would receive a typed assessment of their patient clarifying issues of diagnosis and management. If the GP requested, the psychiatrist would also phone the GP to discuss the case after consultation. The aim was to provide the assessment within 1-2 weeks of referral and not offer treatment services. Most patients were seen only once. We called our new service ‘Psych Opinion’.

SERVICE IMPLEMENTATION

The service began in June 2001. Based on the interest expressed by the GPs, it was decided to limit the service to a select group of 30 GPs until we could assess the likely number of referrals. These GPs were selected on the basis that they had attended our GP mental health training programme in either 2000 or 2001 and were felt to have an ongoing interest in mental health. Each GP received an information kit by mail explaining the service, a how-to-refer guide and referral forms. Over the first 3 months (July-September 2001) there were approximately 10 referrals. On this basis, we felt confident in increasing the size of our referral base to the other GPs in the practices of the initial 30 GPs. This expanded our referral base to approximately 60 GPs. Again we were not overwhelmed with referrals. By January 2002, we opened the referral base to all GPs (around 200) practising in our geographical catchment area. We advertised our service through the Brisbane North Division of General Practice Newsletter.

In the first 12 months we received a total of 30 referrals with one GP referring 10 people. The demographics of the referred patients are shown in Table 1. Most of the patients had a mood or anxiety disorder.

EVALUATION

Considering the professed need for a service, we were surprised by the relatively low number of referrals that the clinic had received. With this in mind, we decided to conduct a survey of the 15 GPs who had used the service to see if they were dissatisfied with the service we offered. Table 2 shows the results of this initial survey. Overall, the level of satisfaction with the service was high. The lowest related to how well Psych Opinion had been promoted in the GPs’ area. Items relating to the actual quality of the service provided were, on average, greater than 5 out of a possible 7. On the basis of this information, we began to consider the possibility that the GPs did not really want this type of service.

Table 1:

Demography of referrals to the Psych Opinion service

Table 2:

Opinions of GPs who had used the Psych Opinion service

To clarify this, we decided to assess the attitude of the GPs who had not used our service. We therefore developed a range of questions about the GPs’ attitudes towards patients with mental illness, knowledge about the service, and the level of mental health need in their area, as well as questions relating to the financial side of working with people with mental illness. The questions were all framed as true or false. The survey went out to a group of 120 GPs in our catchment area and 79 responded. The survey had a return rate of 65%, which seemed more than adequate to minimize the risk of system sample bias.² Table 3 shows the summary of the responses from these GPs.

The overwhelming message from this evaluation was that the majority of responding GPs had never heard of our service that we had advertised in the Division of General Practice's newsletter. This demonstrated that further marketing was required. On the positive side, however, there were several encouraging findings for the concept of a GP consultation model. Strong support for the idea, as well as a willingness to refer, demonstrated that GPs were keen to be part of this process. Interestingly, a significant minority of the GPs felt that they needed to improve their skills before they would feel comfortable working with people with mental illness, which suggests that an education component should be an aspect of our consultancy service.

It is also encouraging to note that although a majority of GPs did not consider that working with people who have mental health needs was financially viable, almost two-thirds of them reported that they actually enjoyed working with this population.

Several GPs also suggested that single appointments were not helpful and that, for some of their patients, they would prefer the psychiatrist to commence treatment and be able to review this over several weeks. This would be difficult to implement within the current framework of Psych Opinion, but could be something to be addressed in the future.

IMPLICATIONS FOR THE FUTURE DIRECTIONS OF PSYCH OPINION

Armed with the information from the surveys, there have been a number of initiatives and changes. First, we have changed the name of the service to ‘GP Psych Opinion’ to make its function clearer. Second, we have reviewed all our referral forms and developed a new information pamphlet on the service. Third, we have increased the number of psychiatrists from five to seven with the addition of two child and adolescent psychiatrists. Finally, and most importantly, we have undertaken a major marketing campaign to inform GPs of this service and how to access it. This includes further information in the Division of General Practice Newsletter, a mail out to all GPs in the district with brochures and referral forms, and an education session on the service to the support staff from the Division of General Practice who visit all GP surgeries in our district on a regular basis. We also intend to carry out ongoing marketing.

Table 3:

Opinions of GPs who had not used the Psych Opinion service

Following the renewed marketing, we intend to continue this service for a further 12 months and then reassess demand and evaluate the GPs’ views towards the end of 2003.

References

Australian Medical Workforce Advisory Committee . The Specialist Psychiatry Workforce in Australia, AMWAC Report 1999.7. Australian Medical Workforce Advisory Committee, Sydney 1999

Babbie

E R

. The Practice of Social Research. Edition, 4th edn. Wadsworth Publications, Belmont, CA 1986