SWSLHD and Bowral's Health - 50

Senate inquiry ignores GP role in mental health: AMA

2nd Nov 2011 Byron Kaye   all articles by this author

Medical Observer

THE undermining of GP involvement in mental health care through the slashing of Better Access rebates has been ignored by a key Senate inquiry examining the impact of the government’s cuts to the program, the AMA has claimed.

The claims follow the tabling late yesterday of a report from a Senate committee investigating mental health funding – the same day the controversial changes, which include substantial cuts to GP mental health rebates, took effect.

While the long-awaited report made no specific recommendation on the MBS cuts, it questioned moves to reimburse only 10 visits to psychologists under the Better Access program. Previously, up to 18 visits could be reimbursed.

AMA president Dr Steve Hambleton said the report, including dissenting reports from the Coalition and the Greens, presented a “mishmash of views” that largely overlooked the impact on GP patients of cutting MBS rebates.

“I think GPs are entitled to be disappointed,” he told MO.

“It has missed a lot of issues. I think that the department of health really didn’t assist the committee with the evidence it provided. It seems that the department has listened to the advice of bureaucrats, not doctors.”

The government’s mental health funding overhaul was however broadly attacked from both sides of the political spectrum following the release of the Senate committee report, with the Coalition saying the government had “not fully considered” the impact on patients and the Greens calling for a postponement.

The report questioned whether the alternate Access to Allied Psychological Services (ATAPS) program – which is to receive more funding and be administered through the yet-to-be-operational Medicare Locals – could be expected to service patients previously treated under Better Access straight away.

Greens senator and committee chair Rachel Siewert wrote in the report that she was “greatly troubled” that “there will almost certainly be a substantial period where Medicare Locals and GP divisions will not be fully engaged with the ATAPS program, and consequently will not be able to deliver appropriate mental health care for consumers”.

She added in a statement today that cutting the number of psychology sessions under Better Access “is likely to, in the immediate term, exacerbate existing service gaps for people with severe and persistent mental illness.”

“The current system is not ready for the government’s proposed changes. The government should revise its scheduling for the 2011–12 federal budget changes to ensure continuity of care,” she wrote.

The AMA, along with other general practice groups under the umbrella organisation United General Practice Australia, had called for a one-year moratorium on the MBS rebate cuts for GP mental health visits. Senator Siewert’s remarks did not directly address that demand – one of the key concerns that led to the inquiry in the first place.

Liberal senators also gave no recommendation on the GP rebate cuts in the dissenting report but wrote that any MBS cut “ought to have been discussed and fully canvassed with key provider groups and stakeholders before being arbitrarily inserted into the budget purely as a cost-saving measure”.

Both the Coalition and the Greens said the inquiry aired concerns about problems attracting GPs to work for youth mental health initiative headspace, which told the inquiry its staffing problems would be made worse by the rebate cuts.

Senator Siewert wrote that since headspace was getting more funding, it could “employ GPs directly, ensuring a guaranteed funding base that provides a buffer”.

In its section of the report, Labor repeated its claim that the Better Access changes would “achieve a better balance between the Medicare fee-based model provided through Better Access and the low- to no-cost services directly targeted to hard-to-reach groups through ATAPS”.

 
Tags: Mental health, MBS, Better Access, ATAPS, United General Practice Australia

SWSLHD and Bowral's Health - 33

McGorry’s mental health minefield

17th Oct 2011 Jodie Thomson   all articles by this author

Professor Patrick McGorry is fending off a barrage of bitter and very personal dissent over his approach to mental health.

AT THE eye of the stormy debate around mental health funding sits one man: the 2010 Australian of the Year, Professor Patrick McGorry.

While he’s lifted the profile of mental health among the general public – and been referred to as ‘the most powerful psychiatrist in the world’ – many of his peers have showered him with criticism since the 2011–12 federal budget.

That’s when funding was diverted from  the GP-led Better Access program to early intervention youth services, leaving GPs concerned that there would be a gaping hole in primary care services for mental health patients.

Professor McGorry, an adviser to the government on mental health funding and founder of the Early Psychosis Prevention and Intervention Centres (EPPIC) and headspace programs, has been accused of bias towards his early intervention models and conflict of interest over his advisory position to the government.

There is also doubt about the stated benefits of EPPIC and headspace, which have scored almost a quarter of the $2.2 billion mental health package.

And there’s concern around early intervention treatment that involves giving antipsychotic medication to young people merely at risk of psychosis.

“We need to get broader advice to government, we need the right advisers, who truly understand developmental principles and a lifespan approach,” says Professor Louise Newman, director of the Centre for Developmental Psychiatry and Psychology at Monash University.

The criticisms have grown increasingly personal in recent weeks. Professor McGorry was attacked by a prominent American psychiatrist, Professor Allen Frances, chair of the DSM-IV Task Force, who accused him in the Psychiatric Times of having a “messianic blind spot” and being an “unreliable evaluator of scientific evidence”.

Professor McGorry says these kinds of criticisms are “false and baseless” and “those making them have not been able to substantiate them in the face of facts”.

He vehemently refutes suggestions of a conflict of interest over his advisory role with the government.

“It is unclear exactly what improper behaviour I’m being accused of here,” he says.

“It is also unclear what criteria would disqualify my participation in the expert group due to my involvement in non-profit youth mental health organisations that would not also disbar all other members of the expert group on the grounds of their professional or organisational affiliations.”

The government says Professor McGorry was just one member of the Mental Health Expert Working Group, which was made up of experts from a range of health and non-health sectors, plus consumer and carer representatives.

“While these consultations helped to inform the development of the government’s record mental health package, decisions on the specific content... were solely a matter for the government,” said a spokesperson for Mark Butler, Minister for Mental Health.

With regard to claims of bias over the high proportion of funding that youth mental health received in the budget, Professor McGorry said three-quarters of the mental health budget went to areas other than youth.

“I would also note that when the Independent National Health and Hospitals Reform Commission considered this issue, they made early intervention models the first two of their 12 mental health recommendations.”

Most psychiatrists’ criticisms concern whether the benefits of the early intervention programs have been overstated. Nearly two-thirds of pyschiatrists in a recent poll thought the government’s focus on EPPIC was inappropriate.1

Professor Frances has described it as a “massive new experiment in early intervention”. Others question Professor McGorry’s claims that the programs are backed by solid evidence.

“They’ve made a lot of promises and raised a lot of expectations and these have not been borne out in the studies,” says Professor David Castle, head of psychiatry at Melbourne’s St Vincent’s Hospital.

In response, Professor McGorry argues early intervention programs like these have been used in hundreds of centres internationally for many years with great success.

“Consequently, there is very good evidence that early intervention for first-episode psychosis is more humane, effective and cost-effective.”

Adelaide University Associate Professor Jon Jureidini says he is concerned the early intervention programs have been misrepresented.

“I don’t think there’s anything wrong with either EPPIC or headspace as models, but there are other approaches to youth mental health, and these two approaches have not been proven to the extent where they dominate the funding,” Professor Jureidini says.

Concerns about the efficacy of the early intervention approach are not shared by the Royal Australian and New Zealand College of Psychiatrists (RANZCP), which has called them “essential” in a recent Senate submission on mental health funding.

“The government must commit to the full implementation of a national youth primary care service (headspace or similar) and a national network of Early Psychosis Prevention and Intervention Centres,” the RANZCP submission stated.

One controversial issue is whether the EPPIC treatment model involves giving antipsychotic medication to young people at risk of psychosis.

A trial by Professor McGorry of antipsychotic drugs on people aged 15–40 who were “at risk” of psychosis was recently cancelled.

“A lot of people are very, very concerned about the potential for over-labelling, over-medicalising and over-treating youngsters,” says Professor Castle.

“In America there’s been a 400% increase in bipolar diagnosis in children, and these kids do not all go on to get bipolar disorder. There’s a danger this sort of stuff will happen here.”

Professor McGorry, however, has repeatedly stated that antipsychotic medication will not be used as a first-line treatment option.

“A key goal of youth mental health models... is to address the over-medication of people with mental ill health in our overstretched and under-resourced mental health system,” he wrote recently on his website.

AMA president and GP Dr Steve Hambleton supports the need for early youth intervention.

“In general we want to intervene early and it doesn’t necessarily mean early use of medication,” he says. “We don’t want to label people too early, but services like headspace are appropriate for young people. We don’t want to put people on medication up front and Professor McGorry doesn’t want to do that either.”

For many GPs, a crucial issue is whether Professor McGorry’s influence has seen funding diverted to early intervention services at the expense of the Better Access program.

“Everyone would applaud his bringing youth mental health issues to the fore, but we have a right to be very angry about the diversion of funding,” says Dr Brian Morton, chair of the AMA Council of General Practice.

While the RANZCP and AMA acknowledge there may have been problems with evaluating Better Access properly, GPs believe the cuts will be devastating.

“The mental health cuts are going to disadvantage patients, in particular those who have more chronic and difficult issues,” says Perth GP Dr Stephen Wilson.

Professor McGorry describes Better Access as an “excellent program” that has been a “building block for mental health reform”.

“While I personally did not advocate the changes made in the recent budget – nor did I have prior knowledge of the changes – now that this has occurred, we need to review what is really required to provide appropriately skilled care for those with more complex mental disorders for which Better Access was designed,” he says.

“In the very next federal budget, the federal government [should] fund a more specialised tier of service which would draw in clinical psychologists – who are clearly required if the problem is more serious and persistent –  psychiatrists in many cases, and other disciplines as well, notably social workers and occupational therapists.”

Some argue the real need is for more independent analysis of all areas of mental health and a more involved discussion on which ones have the greatest need.

“I would implore people like Patrick McGorry to understand they are a part of a much bigger system,” says Dr Wilson.

“They need to take a step-back view of policy and realise it’s not just their area of work that needs a lot more funding.”

Professor McGorry says his core recommendation is that mental health policy should ensure all Australians of all ages have the same access to quality care for mental ill health, as for physical ill health.

“Those criticising the decisions of the government on mental health reform are perfectly entitled to do so, though it would be good to learn what their alternative plans are, if any, especially for the million young people with mental ill health,” he says.  

Reference

1. Psychiatry Update, 6 October 2011, http://enews.psychiatryupdate.com.au/cgi-bin19/DM/t/nMCS0FVx0FM0j7tF0E7