Abstract
INTRODUCTION
‘Collocation’ is the locating of the private and the public mental health sectors in a symbiotic relationship. 1 It represents an agreement negotiated by the private psychiatrist with the public service for the provision of general information, customer services and transaction facilities such as billing and bulkbilling. 2 It is not the privatisation of the public service but the working together of the private and public systems. State 3 and Commonwealth 4 Policy has clearly identified increasing collaboration between the public and private mental health sectors to better meet the needs of the community.
The recent review of the Second National Mental Health Plan acknowledged the following:
‘Australia is experiencing a serious, if not critical, mental health workforce shortage in numbers, poor distribution of providers of all disciplines, and outmoded delivery models in practice and reimbursement that do not achieve the maximum services from the workforce that exists’ 5 (p. 14)
A persistent drift of psychiatrists from the public sector to the private sector has fuelled an already critical situation, namely the shortage of public sector psychiatrists. Individuals with complex psychiatric disorders are usually seen in the public sector and do not fare well with frequent changes of treating psychiatrist. These patients require experienced clinicians who have comprehensive knowledge of their history and good relapse prevention strategies. Fragmentation of service delivery systems has long been recognised as a serious impediment to the delivery of community based care for people with severe and persistent mental illness. 6
BACKGROUND
In 1999, our public mental health service relocated to new purpose-built premises. A number of rooms were identified as being under-utilised. With this is mind, the Service then commenced a process of auditing the number of private psychiatrists offering their services in its geographical area with the aim of reviewing consumer accessibility to the private sector and the viability of leasing rooms at the community health centre. This audit identified a full time equivalent of two private psychiatrists operating within the catchment area. Consumers who were receiving services from the private sector outside the Service's catchment area had to travel considerable distances with multiple changes of public transport to arrive at their destination. This confirmed the Service's view that an increasing number of its consumers were reluctant to move to other service providers due to the cost and the distance. This in effect was creating a significant block in the Service's ability to meet the needs of new clients and provide services to the existing long-term population who, due to their illness, were unlikely to be managed in the private sector.
The Service provides specialist mental health care to the residents of two Local Government Areas. It is located in a middle class suburban area in a Northern Area of Sydney. This area is distinguished by several features which make it different to the remainder of the more affluent suburbs:
Clients more often receive a disability pension.
Clients more often forget appointments (20% of community mental health centre appointments were missed). 7
There is a greater proportion of culturally diverse residents with a large proportion being born over-seas. 8 The figure is expected to grow significantly as indicated by the Department of Immigration and Multicultural and Indigenous Affairs Settlement Database 9 which found that between August 1996 and February 2002 approximately four thousand people from culturally and linguistically diverse backgrounds identified the local government area as their settlement area. The top six groups were from Asian countries.
There are two large state psychiatric hospitals in the catchment area (one of which is now closed).
A process of deinstitutionalisation has occurred, with a higher rate of placement in local settlement Department of Housing, non-government organisations and formal 24 hour supported accommodation.
There is a large number of Public Housing residences.
There is a large number of non-government organisations with beds (127 beds identified in the relevant area). 10
There is a large number of supported accommodation facilities for persons with a developmental disability and/or a dual diagnosis managed by a variety of organisations, the major one being the Department of Community Services.
The Service manages approximately 800 individuals at any one time with over 1,000 new referrals per year. The service has three streams: (1) an acute team which provides emergency psychiatry services, case management and assesses all self-harm presentations at the local hospital; (2) a rehabilitation team which is involved in the provision of services to around 160 consumers with a disabling mental illness; (3) an aged care team which is active in the community and local aged care facilities (boarding house, hostels and nursing homes).
Incorporated into the above streams is a work program which constitutes a commercial coffee shop, a nursery and horticulture program with a prevocational training program, a GP shared care arrangement, an early psychosis house, respite facilities and three residential supported accommodation facilities.
The following operational model demonstrates how a service has negotiated the structural and practical barriers which inhibit the formation of partnerships between public specialist mental health services and private psychiatrists, and documents the benefits for all parties involved in this arrangement.
OPERATIONAL MODEL
Individuals who utilise private practice can be in a number of different service configurations. These include being solely seen by the private psychiatrist and being jointly managed by the private psychiatrist and a case manager (or, for those more complex individuals who require medication or other monitoring, patients can be seen by the private psychiatrist, the case manager and have their medication monitored by a public medical practitioner). Other configurations include general practitioners being involved in mental health care provision to the consumers of the private practitioner. There is no one model.
Consumer Benefits
Benefits identified for consumers of the Service have been considerable. These include:
An increase in the number of private psychiatrists providing services in the geographical area. This, in turn, has improved access to specialist private practitioners with alternative methods of care, promoted a greater choice in care delivery and provided an extended range of available therapeutic options.
A flow-on effect by providing care that is more convenient, therefore benefiting overall care and increasing client satisfaction with health care. 11 It has promoted equity, that is, promoted the ability of consumers who usually have no ability to access private care access to private mental
health treatment. 11
Providing all parties with an ability to address the ‘well-intentioned concerns about patient confidentiality [that]…impede effective linked mental health care’. 11
Allowing staff psychiatrists to be more available for emergency cover and supervision of other staff.
Addressing consumers' concerns about the lack of continuity of care. Mental health services are usually the training ground for trainee psychiatrists. This often involves a rotation of registrars every six months, thus severing a consumer's relationship with the doctor. This results in the consumer starting over with a new health professional and frequently retelling their story. The new method of care provision partly addresses this problem, and makes for better integrated care which in turn is generally more effective. 12
Improving the coordination of care and communication between the two sectors of health care delivery, for those consumers who see a private psychiatrist and have ongoing case management provided by the public mental health service. This has improved outcomes for the consumer, including improving access to crisis care when required. It has been stated that the major predictor of collaborative treatment is the collocation of practices, suggesting that collaborative treatments are easier to develop and maintain if there is physical proximity. 13
Addressing the issue of ‘separation’ from the Service that consumers experience when the matter of referral to a new practitioner arises.
Providing consumers of the Service with the kudos of advising interested others that they have a private psychiatrist.
In our experience, for those individuals of the Service that have chosen to pursue the private–public mix, there has been nothing but praise for the model.
Benefits for Private Psychiatrists
‘Psychiatrists working in private practice do so in substantial isolation from most other parts of the mental health system. Their contributions are made largely to pre-planned out-patient sessions and they do not commonly liaise with emergency departments and crisis services and local mental health teams. This valuable resource could, therefore, be reallocated to contribute in a wider way to reduce the public health impact of mental disorders’ 5
Private psychiatrists working in a public setting have many of the above difficulties negated by this model. Benefits of working within the new model include:
Improved support with the provision of after-hours delivery of care to those consumers who are acutely unwell or who require additional supports that the private psychiatrist can not realistically provide. The private sector often does not have the ability to cope with emergencies 14 , 15 for either the consumer or the practitioner and therefore this model of care ensures that mental health emergencies are responded to rapidly.
Broadening access to the overall mental health treatment system, 8 including ease of access to disability and related support services and an ability to ensure the ‘systems’ are negotiated. 4 It decreases duplication of services with each service provider aware of the clinical services being provided, offers facility for effective communication between the different service providers, and reportedly improves adherence to appointments and medical regimes. 8
Decreasing the ‘working alone’ phenomenon that many private psychiatrists experience and ensures that they are able to access experienced colleagues when required.
Providing the practitioner access to a range of other benefits, including an ability to be involved in critical incident review processes when applicable, access to continuing education programs, including in-servicing, case conferences and GP forums that are offered by the Service.
Providing an immediate locum service for those clients registered with the Service while the private psychiatrist is away.
In our case, the Service is located next to a private medical centre which has onsite CT Scanning and other investigative procedures, including pathology, and is also next to the Public Hospital which has an emergency department which can provide necessary emergency services. It is also worth noting that rental for the rooms is below market rate to make it easier for the private psychiatrists to consider seeing more clients who can not afford the private fees.
Service Benefits
The benefits for the Service have been significant. These have included:
Significantly improved continuity of care and collaboration with the private sector. Communication, which is often problematic in traditional models due to the workload and time constraints of both care providers, has been improved by having both parties onsite. This has included messaging through a basic ‘pigeon hole’ system.
An income stream that permits ‘a better overall use of community funds in its capacity to increase revenue and reduce overheads’. 16
A capacity to attract subspeciality expertise not catered for by the service, for example, forensic and drug and alcohol. The increased consumer volume ‘provides the critical mass to develop a range and quality of services beyond the limitation of both [private and public practice] if they were independently based’. 14
The Service's expanded ability to respond to mental health emergencies.
An increasingly efficient use of government and community resources 2 and an acceptance of integration of the premises with the local private community in after-hours seminars, other educational activities, etc.
Societal Benefits
The ongoing benefits to society have been considered to be the following:
ISSUES THAT AROSE DURING THE PROCESS
The process of introducing private practice to a public facility has been, overall, relatively smooth but, to achieve this, close attention was needed in a number of areas:
Close review was undertaken of the Department of Health Policies with regard to the referral process between the public and private sector. Advice on the implications of these policies was sought.
Review of the Commonwealth/State funding agreements was conducted to ensure the model did not transcend boundaries and prove to be in conflict with the Medicare agreement.
Legal and financial advice were obtained with regard to referral processes and lease arrangements. The lease needed to ensure the inclusion of aspects such as facility fees, letterhead issues, hours of operation, maintenance of rooms, administrative services issues, public liability insurance, adherence to health service policies (specifically, smoking, fire safety, other occupational health and safety issues), professional indemnity insurance and indemnity of the health organisation against any actions or proceedings brought against the Licensee.
The impact on the Service's facilities and staff, including the ability of waiting rooms to accommodate the increased numbers of people, filing systems, appropriate filing and medical records management systems, and ensuring sufficient staff facilities.
Separate phone line.
The impact of the development on the administration staff, including the increased number of phone calls and the need to train the administration staff in cash handling, credit card payments, bulk billing, and appointment taking in new formats.
Having clear systems in place for consumer consent, including forms to address confidentiality and privacy laws for the private psychiatrist to document in, and review, the Service's file (if necessary), have dialogue with case managers, and have access to program test results, for example, for those patients on Clozapine.
The coordination of lease payments, the negotiation of ongoing leasing once the lease had expired, and ensuring that various requests are within the scope of the lease agreement.
The coordination of all aspects of the rental, including state of the room, fit-out of the room, tailoring the facilities to meet the doctors' needs, advertising for private psychiatrists, having a key person for applicants to contact, having a screening process for the applicants, taking into account suitability of practice needs.
CONCLUSION
Collocation has been a modest local initiative which has provided a partial solution to local psychiatric workforce shortfalls. As a model to increase cooperation between private and public sectors, it is successful and provides a ‘win win’ solution for both parties.