| Project Objectives / Summary:
This project was conceived in response to a comment made by a client at a community psychiatric centre: he expressed a desire to have a "real" doctor available at the centre for advice about physical health problems. The target group, people with a serious mental illness, do not generally access GP services. The notion of providing GP services within a community psychiatric setting seemed the easiest way of reaching the target group and offering direct clinical services. The Top End Division had already established strong networks with the Top End Mental Health Services.
There were two project aims:
1. To improve access to primary and preventive healthcare for people with serious mental illness in Darwin:
(a) Within the community psychiatric centre
(b) With mainstream community GPs.
2. To improve collaboration and integration activities between Darwin GPs and Top End Mental Health Services.
Project Collaboration:
Top End Mental Health Service (TEMHS)
Project Outcomes:
The main achievement of the project was the increase in delivery of general health services to a very disadvantaged group of people. Particularly notable were the high number of preventive activities performed. It is beyond the scope of this project to determine whether this may ultimately translate into better health outcomes for people with serious mental illness.
The other significant achievement was the level of collaboration / coordination achieved between the clinic GPs and the public mental health system which occurred with co-location of the clinic. This was based on a genuine shared commitment to improve the overall health care of people with serious mental illness. Studies have suggested that when primary care and mental health practitioners are physically in the same area, referrals and outcomes improve, as does the satisfaction of the patient and the practitioner (Goetz R. et a11999)
The project was innovative in demonstrating a reverse model of service delivery to other mental health shared care programs such as the CLIPP program in Victoria and the GP AP program in Queensland.
In our pilot, GPs were the "experts" in their field of primary health care with something to offer the public health system and this seemed to be valued by the overstretched mental health services. In our part of Australia the GPs were more able to be portable than the psychiatrists.
Working within the mental health system also led to the clinic GPs having significant attitudinal shifts with regard to their understanding of the role of case managers, and their level of comfort in dealing with people with serious mental illness.
Recommendations:
There were also some areas of operation that may be able to be improved even further. Case managers experienced similar problems with communication with patients about their general health, as did GPs with patients about their mental health. There is a need for processes and possibly formal structures to improve on-going two-way communication between GPs and Case Managers. The development of a referral sheet assisted flow of information to doctors. A similar feed back sheet may assist information flow back to case managers.
Doctors and case managers raised lack of continuity of staff. Doctors mentioned the change over amongst case managers, while case managers commented on the number of different doctors involved. Given the need to establish trust and understand the often-complex health problems of this patient group, any ways of establishing greater stability of staffing would be desirable.
If a clinic were to continue, the establishment of a dedicated room and access to computer information would be desirable.
An unintended outcome was the health promotion effect achieved by patients motivating each other to better care for their physical health. This suggests that group programs in conjunction with a co-located clinic may be able to enhance health outcomes.
Lessons:
The project also demonstrated that there for the majority of people with severe and persistent mental illness their mental disorder is their defining condition and most of their health care is organised around this condition. These people will never be easily shifted into mainstream primary care settings, and they may well be better serviced by provision of ongoing primary health care within the public mental health system.
The main factors influencing the success of the project include prior collegial relationships between the GP project officer and mental health professionals, experienced GPs with a prior interest in mental health and co-location of the clinic. Factors which contributed to underachievement of the project aims were firstly the lack of interest of community GPs generally and particularly the lack of uptake of EPC opportunities. Secondly, wider interface issues within the public health system interfered with the development of a shared information system.
An ongoing GP clinic within the public system could be sustainable if Territory Health Services were to fund a GP position. There could also be a contribution to this cost from Medicare as occurs in some rural and remote GP clinics in the NT. Such a clinic could also become a useful special skills training post for GP registrars. Further moves to integration at the primary care-mental health care interface in the public system provides an opportunity to practice more preventive and population based care. This could also utilise other sectors of the public health system, such as Communicable Diseases, Alcohol and other Drugs and the Health Promotion Unit in addressing the high level of substance abuse and hepatitis C.
The project could have been improved by shared clinical records and greater community GP interest. Shared clinical information is already being explored in a wider context by our Divisional IT working group and an existing GP-hospital liaison project. The Division has a very active mental health working group which has so far concentrated most effort on providing members with resources on the management anxiety and depression. Divisional mental health education could be expanded to include psychotic illness, and the Division will continue to provide support to GPs in the use of EPC items numbers.
The project concept is readily transferable to any other Divisions where there is some initial willingness for collaboration between public outpatient mental health services and general practitioners.
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