Letter to Dr Andrew Leech, and our respected GP colleagues

Dr Angelo Virgona, NSW Branch Chair has responded to a GP’s open letter describing his increasing frustration over rejected referrals. You can also read his response in this AusDoc article.

"You recently wrote a letter to psychiatrists.

While I don’t speak for all psychiatrists, I have over three decades’ experience in the mental health care system — I’d like to capture what many of us are saying from the front line.

I want to start, as have you, with an unequivocal acknowledgment of how valued you are. We see GPs’ tireless dedication to your patients and the community. We hear your frustration. We, like you, are alarmed by the escalation of mental health presentations in the community.

People, our patients, are doing it tough.

Right across Australia people are finding it too hard, too complex or too expensive to get the mental health care they need. The workforce is burnt out and in despair.

In your letter, you described calling specialists’ offices to advocate for your patients. I’d like to share an experience of my own.

One of my long-term patients and his wife come to see me. He’s experiencing episodic severe depressive disorder, with psychotic features.

This means he’s having a really tough time. It’s also a high-risk condition.

He can’t sleep, he’s ruminating, he feels helpless and hopeless. He’s talking about suicide, which he hasn’t voiced before.

His wife is scared. With support, she’s been phenomenal at helping him manage his episodes, but she doesn’t feel she can keep him (safely). 

If they’re scared, I’m scared.

In no uncertain terms, this is a mental health emergency, and we organise for her to take him to the ED for admission.

I write a detailed letter, with management recommendations. There’s a clear diagnosis, a high risk of suicide, and he needs to be admitted. I share my mobile number for further information.

One hour later I get a call from his wife, and they were driving home after being told he was okay to go home and instructed to follow up with me.

I tell them to turn around and go back. I call the hospital, and speak to the clinical nurse consultant in the ED. I want to know: who saw him? Who did they talk to? What’s happening up there?

Despite being a large and busy mental health service, there’s no psychiatrist. I was informed he was seen by a junior staff member. As a senior psychiatrist, with considerable experience managing risk, when you refer a seriously unwell patient for admission, you don’t expect them to be turned away.

He was admitted. But he shouldn’t have been turned away. It shouldn’t be this hard to get a patient the help they need.

I’ve been a psychiatrist for 33 years, and stories like this are getting more and more common.

Psychiatrists – like all medical professions – strive to provide the best possible care for their patients. I can’t speak for individual clinicians or services, but recognizing the limits of expertise, capacity, availability and making appropriate referrals are an important part of this in various clinical circumstances.

However, you’ve touched on something important. When we talk about the ‘system’, it’s not a system. We’re talking about people’s experience navigating a myriad of disconnected threads. People’s journey seeking and receiving care.

When the ‘system’ is broken, it’s the individual patients who feel this most acutely as it gets harder to get help.

The private outpatient system has evolved in a way that lacks coherence and direction.

People do good work, but inefficiency plagues the sector and there is no system to prioritise care to those who most need it. There is a maldistribution of resources across the MBS, and the system lacks capacity for incentivisation or prioritisation.

The complexity and pressure on the system should not be our patients’ burden to bear. But it often is.

You speak to GPs, psychiatrists, psychologists, and mental health nurses and while we’re diverse in our professions, we’re all saying the same thing: the system is broken.

Decades of patchwork funding, fiscal neglect and policy stagnation is fracturing people’s trust in the mental health care system.

Multidisciplinary care and access to the right help at the right time is the cornerstone of good patient outcomes. It shouldn’t be this hard to refer a patient. It shouldn’t be this hard to get a patient help.

Research tells us that prevention and early intervention are the cheapest and most effective forms of mental health treatment at a population level. On an individual level, it’s getting enough of the right help, early enough, regardless of the issue. But when you don’t have enough practitioners, or the system is too fragmented, it impacts the ability to deliver that.

Yes, we need immediate solutions. Yes, people need help now. But the reality is we need to immediately and sustainably invest in the foundations of the mental health system – its workforce.

From a psychiatry perspective, workforce projections undertaken by the Department of Health predict a significant national shortfall of 125 psychiatrists by 2030. If we don’t invest now – today – in our future workforce, we’re going to be having this same conversation every year, asking how we can address the mental health crisis immediately.

I don’t want to get 10 years down the road, with thousands of Australians unable to get the help they need because we didn’t make the necessary investment. The time is now.

We also need to invest in restructuring the way mental health is funded and delivered, incentivising, prioritising, allowing multidisciplinary care options, allowing psychiatrists to do the work they’re best trained to do: assessing and treating those with the most severe mental disorders.

In your letter, you said you’re not trying to complain. This is the only point where we disagree. I think you should complain. I think you have the right to be frustrated. I think our patients deserve more than what the system can currently provide.

The next letter we write shouldn’t be to each other. It’s to the state, territory and federal governments who have been given a lot of the solutions and have the power to fix it."

Dr Angelo Virgona is Chair of the NSW Branch of the Royal Australian and New Zealand College of Psychiatrists.


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