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Some lessons from rural innovation in mental health care (and why it can be harder to work together in cities…)

My recent article about mental health reform (a joint production for Inside Story and Crikey) highlighted some of the divisions in the sector.

Earlier this year, I did this story for Australian Rural Doctor magazine profiling some of the positives that can come from collaboration in mental health service delivery, at all sorts of levels.

One such example came from Mudgee in central western NSW, where many benefits have flowed from a clinic established as a partnership between a general practice and the local community mental health team.

The clinic, which is jointly conducted by GP Dr Peter Bryant and community mental health nurse Teresa Lulund, was established about five years ago because of concerns that many people with chronic mental health problems were not accessing GP services.

Under an informal agreement with the Greater Western Area Health Service (GWAHS), Dr Bryant sets aside one day every month or so for the community mental health team to book in patients for bulkbilled, double consultations. The patients are also offered help with transport to their appointments and receive reminder phone calls. The clinic has helped reduce hospital admissions, crisis casualty presentations, and scheduling of patients, while improving communication between services.

Another positive spin-off has been the establishment of a community garden – a boost not only for healthy eating and activity, but also for helping to forge social connections and break down isolation.

Thanks to Twitter, I subsequently came across Dr Charles Alpren, who helped establish the Mudgee clinic, and now works in Melbourne.

Below he writes that the Mudgee model shows the benefits of flexible, patient-centred approaches to service delivery – something that often seems to be easier to achieve outside of the big cities.

***

Some lessons from rural innovation in mental health care

Charles Alpren writes:

In 2007, whilst working in Mudgee, NSW, I set up a clinic with the local Community Mental Health Team (CMHT). It basically comprised a day per month when a member of the CMHT would work with me at the private medical centre I worked.

Consultations were conducted together and my timetable for the day was set by the CMHT. Mudgee is a town with a population of about 9000, and a further 15,000 living in the surrounding enormous catchment area. The clinic came into being after a chance discussion in a corridor. There was never any intention to break new ground or adopt new care models, it just made good sense to work that way.

What was created, however, turned out to be whatever was needed at the time: if close liaison between different providers was required it was arranged in the appointment; if carer support was needed, it happened; if there was a physical health complaint that needed attention, it got it and as physical health checks were due, they were performed.

The reception from patients was extremely positive and we soon found that many people quickly lost the need for the structure of the clinic and instead gained the confidence to engage with a GP and other health workers on their own.

I immensely enjoyed working closely with other people and achieving far better standards of patient care than I had been before. A more detailed account of the clinic can be found here (Abstract – login required for full text) http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1584.2010.01159.x/full

When I left Mudgee for Melbourne in 2008, one of my colleagues, Dr Peter Bryant, took over the clinic from me and has developed it further since (amongst other things setting up a community garden).

On moving to Melbourne I was keen to continue the model in my new practice. I thought, perhaps naively, that similar simplicity could be repeated.

However, whilst an approach to the local CMHT was met with a welcome, there was no agreement to set up a GP-based clinic, and I have only been able to set up close working relationships with the CMHT with a few individual patients since. Consultations with more than one professional in the room are rare. Approaches to more senior management in an attempt to foster a more formal arrangement were met with little interest.

It is a shame that city health services lack the flexibility of their rural counterparts, but understanding the city healthcare structure now as I do, it is not surprising.

Melbourne, or at the least the bit of it I work in, is full of different services for different people. Each has its own focus, catchment area and niche. There are a huge number of dedicated people working to support people with mental illness, but no overarching umbrella network in which all the services operate.

CMHTs are under a huge amount of pressure to address the needs of people with very severe mental illness, and too often I think, their role becomes one of ‘crisis aversion’, distracting their attention from the longterm and general health needs of their patients.

That said, there has been a lot of effort spent over the last 3 years or so on development of frameworks to ensure better physical healthcare of people with severe mental illness (for example, see this report examining the role that specialist mental health services should play in physical health.)

My experience is that within the CMHT the task of ensuring physical health checks and tests happen falls to the registrar medical staff at the CMHT or to the most local GP service, which may not be the one with the particular interest, expertise or patience to engage with people with severe mental illness.

Large, publicly funded bureaucracies cannot be seen to support one private clinician over another without a formal arrangement in place, so as a matter of policy, advising patients to see a particular GP is not possible.

Hence, many patients see the GP available most easily at the time, and do not develop a doctor-patient relationship or any continuity of care.

Perhaps this is one of the reasons Mudgee worked so easily. There was no potential for stepping on toes – the visiting psychiatrists were delighted their patients were seeing a GP and I was delighted to have a structure provided that granted an easy opportunity to do what I’d been trained to do.

There was no question of the clinic being set up as a business venture to build a practice (although, from a business point of view it was surprisingly easy to justify bulk-billing due to the ease of fulfilling the criteria for all the various extended Medicare items that are out there), and so little alternative for the patients that the CMHT could hardly be accused of preferring one doctor over another (all the 10 other doctors in town were aware of and supportive of the clinic).

I will also confess to some stubbornness in how I feel inter-professional frameworks such as these should be constructed. It would be simple for a GP to work with a CMHT at the Community Health Centre seeing patients as they attend to see their case workers. However, I feel that this only serves to perpetuate the difference between mental and physical healthcare, and sends a message to patients that they require a parallel service to attend to their needs. Why should this be so?

Surely the focus would be better spent empowering and enabling people to integrate within the overall health system, something the Mudgee clinic did very well.

I did my training (undergrad and postgrad) in UK, and have been struck since moving to Australia at the way the mainly private fee-for-service model (which has many advantages over the UK system) has created a disjointed system in which all the providers are doing the best they can for their patients.

This way of thinking centres on the service and who would benefit from it.

Completely by accident in Mudgee we started to work with the system’s focus on the patient. The model was flexible and the providers allowed the freedom to alter their work to the needs of the individuals.

It was this flexibility, I think, that lead to integration, and with that integration the focus shifted from a provider-centred healthcare system to a patient-centred one.

And everybody (myself included) got better.

Previous posts in this series

• Suggesting some long-term goals for mental health reform

• Important for mental health: a fair society and a good start to life

• Don’t rush the roadmap for national mental health reform: Alan Rosen

• What matters for people living with psychotic illness

• More effort needed to strengthen shared care arrangements for people with serious mental illness

 

 

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2013 conferences
Australian Centre for Health Services Innovation Forum 2013
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Closing the Credibility Gap 2013
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Health Workforce Australia 2013
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