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02 Mar 2018

The AMA has been in discussion with the Australian College of Mental Health Nurses (ACMHN) regarding funding for mental health services. It’s been reported that some PHNs are offering a 40-50% pay cut to mental health nurses (MHNs), resulting in nurses returning to the public system, and leaving the PHN to claim that there is no MHN workforce available and that they are ‘forced’ to use a less qualified workforce. Mental health patients whose mental health service needs fall somewhere in between the low intensity, ‘brief’ services (of which there are already many - including web/phone based services, Better Access, ATAPs model), and acute/crisis services have used mental health nurse services in primary care (the Mental Health Nurse Incentive Program was established to fill this gap).

According to material provided to the AMA by ACMHN, in some PHNs, people who have been referred by their psychiatrist or GP to a mental health nurse for clinical therapeutic mental health care are being transferred into the care of a support worker without any specialist mental health qualifications or training in therapeutic interventions. They may not even be AHPRA registered.  In excess of 200 GP and psychiatry practices and their patients with severe and complex mental illness are losing their access to the mental health nursing workforce and the specialist clinical mental health therapeutic treatment it provides. There is currently no clear governance mechanism to prevent this from happening and expanding into other services and geographical areas.

If a referral to the PHN funded mental health service originated from a psychiatrist or GP, there is no clear information about who exactly the client is being the referred to. A referral to a commissioned Mental Health service funded by the PHN means a referral is to an organisation, not a specific health professional or person.  For example, if a psychiatrist refers an individual to PHN commissioned mental health services, then in many regions they cannot inform the client who they are being referred to, or what type of service they are likely to receive.  The psychiatrist can inform the patient that they will undergo further assessment by the PHN intake service to ascertain the service they may be able to access, but even then there will be no guarantee that the person they end up seeing for mental health treatment will have any formal clinical mental health training or qualifications at all.

Summary of issues: Removal of mental health workforce qualifications and standards

There are no boundaries for PHNs around maintaining quality and ensuring that services are delivered by people with the right skills and qualifications relative to the clinical needs of the people needing the service.  Currently, PHNs have flexibility to judge for themselves how to best balance the need to maintain service quality and safety against stretching the funding to get more people into a (any) service.  Workforce shortages are being managed in a wide variety of ways, and there is evidence of quality and safety being compromised, particularly in the face of pressure to stretch the limited funding further.  Given funding constraints are likely to remain, these pressures are likely to increase over time.

Some PHNs are replacing mental health clinicians with post graduate qualifications in mental health who are delivering services at the severe and complex end of stepped care with “mental professionals”, who have no mental health expertise apart from mental health first aid training and possibly a short (e.g. 2 days) CBT workshop.  This is happening directly and also indirectly (i.e. by remuneration being set so low that it becomes impossible to maintain a clinical workforce with specialist qualifications in mental health). 

Models such as New Access by Beyondblue provide non-clinicians with basic CBT training, but the program is intended to service people at the very low intensity end.  The reports are that PHNs are applying this kind of model to people at the severe/complex end, and then saying people can access the ATAPs type service for “brief psychological intervention” if they need clinical care.

Addressing these gaps in care, particularly at the more severe/complex end, is the main concern. What is being reported is a large gap in care between acute/crisis care needs and low intensity/brief psychological interventions, which are widely available online, be telephone and face-to-face under Better Access and ATAPs. But the problem seems to be that PHNs are investing the majority of their funding into low intensity services, which are cheaper and therefore more people can listed in reporting to the Department of Health as ‘accessing a service’.  PHNs have the flexibility to do this, and the situation put to the AMA is that the Department is not looking for anything other than evidence there is something (‘anything’) happening at the severe/complex end. 

There does not appear to be proper assessment, oversight or evaluation of whether PHN commissioning models and funding decisions are actually improving or reducing care quality. PHNs are required to demonstrate they are providing “a service” and “meeting need”.  But the assessment is more at the level of “deliverable met/not met” and there is no judgement involved about what might be being sacrificed (e.g. specialist qualifications and skills); or seeking to determine whether the service provided was actually what people clinically needed (e.g. they were formerly seeing someone who could provide DBT, but now only have access to “brief intervention” CBT; or they were referred to the ATAPs type service when clinically they needed something more intensive).  

Finally, there are job advertisements seeking people for positions in primary care with titles such as ‘mental health practitioner’, although no clinical qualifications are specified in the job requirements. This is a substitution of a clinical mental health service delivered by qualified health clinicians for non-clinical support workers who are expected to deliver the same level of care, often after receiving only two days training in CBT or a related area. There is anecdotal reporting that many psychiatrists and GPs are feeling ‘disempowered’ by the idea that their patients will be referred to such a service.

Comment

This issue has broader implications of scope creep by non-clinical support workers, which has already been flagged as an issue in aged care. Substituting non-clinical workers with trained health clinicians is not an optimum approach in the delivery of health care.  There are concerns that the Government is not adequately supporting PHNs to deliver holistic mental health care, and that they are taking a ‘hands off’ approach. Alongside the ACMHN the RACGP has also reportedly voiced concerns about these reports after the ACMHN reached out to them.

There is an opportunity now for the AMA to assist Government and PHNs in getting the model correct.

Concerns for Psychiatrists and GPs

A significant concern for psychiatrists and GPs is confidence in referring patients who then receive non-clinical care and intervention. A broader implication from these reports is that the definition of ‘access to a service’ is being defined quite literally, rather than that service being attuned to the patients’ needs and clinical presentation. If success is being defined and measured incorrectly, it suggests a compromise on quality and safety. For example, patients with severe mental health are being defined as having access to a service when they are referred to a non-clinical support worker, despite that worker having only had training through workshops.

Next steps

AMA Federal Secretariat (Public Health and General Practice are working together on this) is continuing communications with the Colleges and ACMHN on this issue. Secretariat is seeking the opinions of GP and psychiatrist members on the matter. At a recent phone meeting of the Colleges and a support organisation for PHNs, it was proposed that a joint letter could be written to the Minister to highlight the importance of this issue and raise concerns directly with the Minister. The strategy would be to ask the Minister to put this on the agenda of the Ministerial advisory committee. Support for such a letter is contingent on CGP’s view on the issue and not all parties present at the meeting have yet agreed to sign it.

The group also discussed the option of integrating mental health care into general practice, specifically integrating MHNs in general practices. There was an independent evaluation of the MNIP which provides evidence that this strategy is useful in delivering mental health care within primary care.


Published: 02 Mar 2018