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By Associate Professor Warrick Brewer MAPS, ORYGEN Research Centre and Department of Psychiatry, University of Melbourne, Dr Priscilla Yardley MAPS, Senior Psychologist, Peninsula Health, Gail Bradley MAPS, Senior Psychology Advisor, NorthWest Mental Health, a program of Melbourne Health and Associate Professor John Gleeson MAPS, Department of Psychology, University of Melbourne and NorthWest Mental Health.

The impact of the introduction of Medicare benefits for psychology services presents significant challenges for the provision of evidence-based psychological interventions within public mental health services. In particular, there are significant risks to the retention of well trained, experienced clinical psychologists and neuropsychologists delivering these services. Moreover, many public sector psychologists are concerned that Medicare developments could result in psychology services for consumers of mental health services being contracted out to private providers, resulting in a disconnection between psychological and other mental health treatments provided. The dilution of a psychological contribution to treatment planning and multidisciplinary service functioning is a likely outcome. Consequently, many public sector psychologists are of the firm view that any developments of private/public partnerships should be targeted to consumers presenting with ‘sub-threshold' presentations that are not likely to meet formal inclusion criteria for treatment in the public system, or for consumers on discharge from the service.

Overall, the challenge of the impact of the Medicare initiative upon the profession provides a rare and timely opportunity for psychologists, along with their industrial and professional representatives, to co-ordinate their efforts from a position of increased status and to meet these new challenges in a fully informed manner. To this end, a forum was held in Melbourne in 2007 for psychologists working in public health which included representatives of industrial and professional bodies. One of the aims of the forum was to examine the strengths and weaknesses of working models of mixed public-private employment for consideration by psychology department heads and administrators, as well as exploring various options that would maximise benefits for individual psychologists who were considering transfer of some or all of their time to private practice.

This article briefly outlines examples of emerging private/ public models, highlighting the strengths and weaknesses of those proposed at the forum. In addition, the boxed information outlines key principles to guide both public organisations as well as individual psychologists in exploring these arrangements.

Models of public-private practice

Model I: Refer relevant clients to private psychologists

One proposed model is to refer consumers of public mental health services to private psychologists for specific psychological treatment for psychotic disorders, mood disorders, anxiety disorders, eating disorders, etc. Variations of this model include private psychologists co-located with GPs, private psychiatrists, or other psychologists. The benefits of this model include a clear referral pathway into the community for many consumers, resulting in shared care options or direct discharge to private providers.

A difficulty of the new Medicare initiative is that referrals to psychologists may be conducted on the basis of geographical region or the availability of bulk-billing arrangements, rather than on the level of a treating psychologist's individual competence or confidence in dealing with a particular client group. Thus, the public mental health services may receive an increasing number of crisis calls from private psychologists who may not have the resources to respond to high levels of clinical risk.

One response to this dilemma is to release expressions of interest to individual private psychologists who have relevant experience and expertise in dealing with more serious psychological issues, and who are prepared to work in a more systematic manner with the public health services in a shared-care arrangement. Shared-care arrangements would afford private psychologists the opportunity to contact a particular clinician from the service for a secondary consultation or to organise a case conference if required.

Model II: Private psychologists conduct sessional private work at the public health service

Peninsula Health Psychiatric Service has recently established a GP clinic at the service to provide medical care to consumers who are unable to be linked with a GP in the community. The GPs record notes in a separate part of the medical file, liaise with the clinicians in the service, bulk-bill the clients, and pay a room-booking fee. They do not attend clinic meetings.

In a similar arrangement, private psychologists who have the relevant expertise and a desire to co-locate in a public health service may be invited to work within the service for one or more sessions per week of bulk-billed private work. Just as with the GP clinic, this model would necessitate pre-agreed arrangements with the psychologists to address issues such as confidentiality, case notes, payment, etc. Managed effectively, this model could result in additional services to consumers. A number of services have already developed on-site private consulting suites accessible by employees of the public mental health service (e.g., Harvester and Glencairn clinics in Melbourne's west).

Such shared care models could also provide psychologists currently working in the public service who are contemplating reducing their hours to develop private practice with an opportunity to provide a private service to sub-threshold or discharged consumers. A number of psychologists are currently commencing negotiations within their services regarding private practice rights, administrative support, room access, etc.

One risk of focusing these arrangements upon existing consumers of public services is that psychologists may experience pressure to reduce their psychology-specific work within their public role, which could reduce availability of psychological input across the service. Further, co-location of private psychologists at a public service may reinforce the idea that psychological input is the province of the private sector, thus undermining efforts to recruit and retain psychologists in public health.

Other models: The ‘niche' approach

ORYGEN Research Centre in collaboration with several bodies including the APS and the Australian General Practice Network more recently developed the ‘headspace' platform, designed to address unmet need of 12-25 year old youth who currently do not meet the inclusion criteria for acceptance into a public youth mental health service. A main component is direct service delivery operating through the Medicare system. It utilises a multidisciplinary approach including general practice, psychology, psychiatry, mental health nurses, social work and occupational therapy. This involves an ‘episode of care model' as opposed to a case management model. Some key principles have been established from existing partnerships that act as a roadmap both for service delivery organisations and for individual psychologists working within these services.

Conclusion

We look forward to a follow-up of the lively discussions that commenced at the Melbourne forum in 2007. We are optimistic that the issues outlined here can be creatively addressed and that a variety of mixed public-private service models will emerge over the coming months, although of course the change in the Federal Government in 2007 highlights the need for planning processes to allow for future changes in government policy. We believe that the next step is for public sector psychologists to actively engage in dialogue via their professional bodies and across State jurisdictions to share the best ideas for the benefit of consumers.

The principal author can be contacted on warrick.brewer@mh.org.au.

Important key principles for mixed publicprivate practice models 
  • Models need to work towards establishing reliable retention and recruitment pathways for the profession
  • Lessons should be learned from evaluating existing models
  • Guidelines for shared-care should be developed
  • Co-ordinated advocacy between senior psychologists, the APS, Registration Boards and State industrial bodies is required to reflect and reinforce workforce models to service providers
  • Advocacy role by membership and registration bodies to hospital executive and government is needed regarding optimal workforce planning
  • Models should clearly address the clinical needs of the targetpopulation 

 

Individual psychologists contemplating mixed public-private models - issues for consideration 
  • Possible effects on shift in consumer characteristics within the public setting
  • Effects on representation of psychologists within the service
  • Status of psychologists within proposed partnerships between services and individual psychologists (e.g., within Memorandums of Understanding)
  • Availability of administrative support for private psychological practice (e.g., reception, billing services, maintenance of tests, forms, record keeping, etc.)
  • Clarity around responsibility for the fidelity to treatment models, quality assurance, and clinical standards
  • Availability of access to supervision and support for case conferences
  • Availability of professional development and support to maintain minimum required professional development points
  • Availability of support for professional indemnity insurance
  • Sharing of responsibilities for practice viability/liability
  • Caseload balance in relation to mix of diagnoses
  • Risk management/shared clinical care arrangements, including clarification of responsibilities in the event of litigation
  • Management of maintenance of privacy and confidentiality including access to, and maintenance of clinical records

 

Individual psychologists contemplating mixed public-private models - issues for negotiation with public health employer

  • Private practice rights while working in the public service
  • Work-based incentives to remain in public health such as professional development support, supervision, research opportunities
  • Involvement in service strategic development
  • Alternatives to working within generic models in public service
  • Additional resources to maintain the provision of student placements
  • Strategies and resources to ensure the maintenance of access to discipline-specific supervision