Dr Jayne Ingham* discusses how the government’s process for the tendering and commissioning of primary health care services - in this case, mental health services - may not be for the benefit of Australian GPs or their patients.
Our GP Network, GPpartners, like that in the Northern Rivers, is a former division of General Practice which following the national restructure process (Medicare Locals, Primary Health Networks) has continued to function as an entity. GPpartners supports our local GPs with advocacy, relevant education (non-Drug company usually) and other assistance.. Over the years it is fair to say that our local GPs have come to appreciate us.
When we learnt about the change of funding for the Mental Health Nurses working in several practices in our area, and received an approach from nurses concerned about the funding and model changes, our GP network decided to enter the world of bureaucracy and tender for provision of the Mental Health Nurse program in our area.
The tender went through an electronic tendering system on behalf of the PHN which is responsible for the commissioning of services on behalf of the Federal Department of Health.
Being GPs we approached the process from a clinical perspective within a context of patient centred care, ease of access and referral through General Practice for the patient and rapid response from the Mental Health Nurse. We expected to have a ‘foot in the door’ because the Mental Health Nurse in General Practice Program had been running for eight years with an external evaluation showing a significant reduction in hospitalisations to Mental Health facilities.
We had lengthy discussions with the Mental Health Nurses and the practices employing them, and checked that the model and wages fitted with the expectations of the College of Mental Health Nurses.
On a personal note I might add that I work in a practice with a Mental Health Nurse. It is very satisfying as we can now offer a comprehensive service to our high end mental health patients. Instead of causing havoc with long unbooked appointments at times of crisis the GPs can manage the patients more effectively and even look after their physical health more proactively. We find our chronic pain patients easier because their psychological needs are better met. Unfortunately after June 30th we will lose our nurses.
Similar to your GP network we work on a tight budget with a virtual office and a very part-time admin assistant. We thought it worthwhile to approach someone more experienced in the tender process than us, and engaged a person experienced in budgets. This of course cost money. The tender had several criteria to address and a budget to fit the funding.
To cut a long story short it was a steep learning curve. The electronic process was not easy. The criteria were strict, with no room for innovation for building a model with any alternative sustainable model of care or close association with General Practice.
We failed on all accounts as we didn't have a building to house the nurses. All the General Practices in our area did not count. We did not provide direct physical supervision of the Mental Health Nurses, only regular meetings with them and the GPs involved plus the other mental health care providers. We supposedly had few links - according to feedback from the tender - with the Mental Health Units at the hospital and NGOs.
That was surprising as we do try to interact regularly with the local hospital’s Mental Health Unit, although not with much success, as the beds are usually all occupied.
The successful tenders were awarded to a private psychology practice, a private mental health hospital and a Non Government Organisation. I am sure they run very successful organisations and have the best intentions for the welfare of their clients. The missing link to me is General Practice, easy access for patients, doctors who understand severe mental health illnesses, can prescribe as well as look after the patient’s physical health and mental health nurses who work closely with the GPs.
I was interested in Dr Bastion Seidel’s (RACGP President) address to the National Press Club in Canberra, which contained some very interesting statistics about Primary Care costs and Hospital costs. The part that caught my eye was “Looking at the most recently funded health programs, it struck me that it has become commonplace to talk about consumer centric mental health packages and client based aged care services.
“Primary Health Networks are now commissioning bodies for some forms of health services. And I sometimes wonder whether these services will be chosen by a computer algorithm and then delivered by a remote controlled drone. There may even be an app for all this.”
I don’t know who was responsible for selecting the criteria for the tender, presumably it was officials from the Department of Health and/or Brisbane North Primary Health Network. So far the commissioning process hasn’t really affected General Practice but I worry that this will be the way of the future.
It may be good for business and to control spending but I fear that the doctor-patient relationship and the various relationships we have with our other local health care providers, as well as the positive outcomes we achieve in General Practice, will be compromised because we will not be able to use the health providers that we know and trust.
To some extent this has already happened in our area with referrals to the ATAPs (psychology program) for children. After GPs refer to the program the psychology service commissioned by the PHN takes the referral. The GPs do not know to whom the child is referred. Fortunately we have the alternative of referring though Medicare but there is often a gap fee for the parent, althoughs they seem to understand when the GP says they recommend a particular psychologist.
A further quote from Dr Siedel: “Payments to practices should incentivise systems that support continuity of care. The benefits are obvious to the patients and practitioners. Payments should also incentivise better access to care in order to support the drive for continuity. Payments should be flexible”.
It would be better - as has worked for a long time in General Practice - to fund GPs directly rather through the bureaucracy of tendering and commissioning of services. As with any area of expenditure, there needs to be checks and balances but I do believe that General Practice, with some guidance, is capable of measuring and reporting on outcomes. This was done in the “Collaboratives” which were funded some years ago. There is room for “Appreciative Inquiry” where models are built on what is already working.
* Dr Jayne Ingham is a GP at North Lakes in Brisbane and Chair of GPpartners, an independent membership organisation for General Practitioners (GPs) in the northern and western surburbs of Brisbane.