Report of the House of Representatives Select Committee on Mental Health and Suicide Prevention: Commentary on an expanded psychologist role and decreased GP/psychiatrist leadership in private multidisciplinary primary mental healthcare

Workforce Roles of Psychiatrists (Recommendation 15)

We suggest the recommendation that frontline psychiatrists work through multidisciplinary or consultancy function may potentially have the intent to ration psychiatrists and thus promote role-substitution by psychologists and allied health professionals. As the most highly trained mental health professionals, psychiatrists lead evidence-based expert medical, psychological and multidisciplinary care complementary to GPs, other medical specialists, nursing and allied health professionals. ² While psychologists have disciplinary expertise in psychological therapies, they do not have the requisite expertise especially for complex clinical presentations, for example, interpretation of medical pathology tests, recognition of comorbid medical conditions that may cause psychiatric symptoms or adverse reactions due to drug interactions, or liaison care with GPs and other medical specialists. In fact, psychiatrists are uniquely skilled to provide frontline specialist mental healthcare.

Tellingly, there is no recommendation on increased funding for training psychiatrists, other than a very modest AUD$ 11 million in the forecasted federal budget 2021–2022. Increased funding for psychiatrist training needs to be more substantive and embedded in both public and private sectors, especially for rural and remote regions through the federal Specialist Training Program (https://www.health.gov.au/initiatives-and-programs/specialist-training-program). Resource-constrained public sector services should have specific funding, and protected time, for supervision of, and participation in psychiatrist specialist training. There should be a focus on private specialist rooms and private psychiatric hospital specialist training to increase private practice psychiatrist capacity to work in multidisciplinary teams (MDTs), which includes the GP and allied mental health professionals. Private and public practice partnerships in MDT care should be implemented, based on previous models of shared care, case-conferencing, education and secondary consultation. ³ There is the welcome recommendation of mental health nurse support where psychiatrists and nurses could work effectively in conjoint care of patients in private practice.

Psychologists’ Role (Recommendation 17)

The Report simultaneously recommends the expansion of psychology into more direct gatekeeper primary care patient roles, and an increased scope of practice, while advocating enhanced funding for psychology training because of an actual shortage of psychologists. The aim of claiming a primary care role beside GPs is clear in the statement on page 144 of the report, attributed to the Australian Psychological Society, that psychologists ‘should be differentiated from medical and allied health professionals who provide mental health services as an adjunct to their profession’. This statement discounts GPs, who are trusted providers of primary mental healthcare, and other allied mental health professionals trained to provide psychological therapies such as occupational therapists and social workers. Furthermore, there is the following contentious statement from the Committee (p. 150) that: ‘Psychologists are the specialist workforce able to deal with the full spectrum of mental health problems, mental illnesses, and suicide prevention and postvention’. The professional scope of practice of psychologists is based on their expertise in evidence-based psychological therapies. They are non-medical experts. ⁴ Psychologists lack the medical examination and diagnostic skills to safely assess if there are comorbid, or causative medical conditions that may present with psychological symptoms, such as thyroid disease (depression or mania), diabetes (anxiety, depression and irritability) or Parkinson’s disease (anxiety, depression and psychosis). Also, psychologists are unable to comprehensively treat persons with mental illnesses that require additional medical interventions, including but not limited to pharmacotherapy, for conditions such as schizophrenia, bipolar disorder, severe post-traumatic stress disorder, eating disorders and psychotic depression.

If psychologists work outside multidisciplinary teams without medical support, and they are referred patients with complex needs, then they have no alternative but to refer to hospital emergency departments or public sector community mental health services when patients experience a crisis with increased risk of harm to self or others. The increase in private psychological services in Australia over the last decade through Better Access has seemingly had no significant impact upon population levels of very high psychological distress, hospital utilisation, or the suicide rate. ⁵ Over this period, increased mental health presentations have been a major contributor to the emergency department crisis around the nation. ⁶ Given these risks to individuals and the health system, the scope of practice of medical specialists such as GPs and psychiatrists should continue to include leadership of multidisciplinary care as well as direct provision of these aspects of acute and complex mental healthcare.

Psychiatrists with extensive training and expertise provide essential leadership to a multidisciplinary teamwork approach to both outpatient and inpatient care in public and private sectors. Psychiatrists work with GPs, nursing and allied mental health practitioners. Indeed, there is evidence that organisational leadership by medical specialists, including psychiatrists, due to their expertise across all aspects in the core-business results in higher-performing organisations, with better healthcare outcomes. ⁷ Analogously, expert psychiatrists can and do lead MDTs. In a recent systematic review, MDT care, in the form of case management, in Community Mental Health settings has demonstrated significant improvements in psychosocial outcomes, including independent living, employment and social support. ⁸ However, case management may not be as effective in addressing psychiatric symptoms. ⁸ GPs and psychiatrists can provide direction for necessary psychotherapeutic support that addresses these needs. A systematic review of MDT reviews and practice for patients with serious mental illness highlighted the important role of leadership, strong relationships and respectful communication. ⁹ Psychiatrists and GPs are trained and skilled in leading MDTs. Psychologists, with their specific expertise in psychological therapies, analogous to other allied mental health professionals, such as social workers and occupational therapists providing focused psychological therapies, are essential expert team members of MDTs.

There are also clinical governance and medicolegal considerations. In an MDT supervised by GPs or psychiatrists, clinical governance and medicolegal responsibility converge at the medical specialist level. If psychologists expand their scope of practice as autonomous primary healthcare practitioners, they will likely be responsible for clinical governance and medicolegal responsibility, without necessarily being part of an MDT. This autonomous practice may lead to disjointed care coordination for patients as well as greater medicolegal risks for psychologists.

Psychologist Capacity (Recommendation 30)

The extension of the annual cap on psychologist sessions may facilitate increased access to care. However, given limitations on psychologist numbers in some areas, it may also be the case that fewer patients are seen for longer courses of therapy. There is also the recommendation for 12-month referrals for psychologists for a similar referral process to medical specialists, such as psychiatrists. However, psychological care needs should be evaluated by GPs and/or psychiatrists who lead and coordinate the patient’s MDT care, making referrals as needed for specific interventions for specific disorders, as under the Better Access program.

Conclusion

The recommendations of the Report relating to an enhanced psychologist role in the mental healthcare workforce present promises of increased psychologist access and possible perils that focusing on psychological therapy will devolve private MDT care coordinated through a medical specialist (GP and/or psychiatrist). There is an elevation of the role of psychologists as private primary healthcare specialists, without adequate acknowledgement of limitations on their scope of practice. Autonomous psychologist practice is not necessarily sufficient or connected to MDT care, and psychologists would need to shoulder the increased clinical governance and medicolegal risk that this entails.

By contrast, there are recommendations that specialist psychiatrists be encouraged to work in consultative roles because of the workforce shortages, thereby decreasing access to frontline specialist care for patients. Psychiatrists provide direct private medical specialist mental healthcare for those suffering with especially acute, complex and severe mental illnesses. Psychiatrists are trained to lead multidisciplinary teams, working with GPs, nurses, psychologists and allied mental health practitioners. Clinical training of psychiatrists as leaders of multidisciplinary mental healthcare deserves more resourcing to enhance future capability.

The disproportionate focus of the recommendations of the Report on primary care psychologist roles imperils private sector GP and/or psychiatrist-coordinated comprehensive MDT patient care.