Approximately 0.9% of Australians live with severe and persistent mental illness,1 by definition experiencing severe symptoms or severe difficulty in social, occupational or school functioning together with treatment for mental illness for two years or more.2 This group tends to also experience substantial physical morbidity (particularly from under-treated metabolic syndrome, cardiovascular disease and respiratory conditions) in addition to high psychosocial morbidity and premature mortality.3
Strong therapeutic relationships with general practitioners (GPs) and a local general practice have an important role in the lives of some people with severe and persistent mental illness.4 Such relationships may empower patients to care for their physical health5,6 and facilitate the management of their mental illness, including ‘normalising treatment’ for patients on compulsory treatment authorities.4 Patients are more likely to engage strongly when they believe that they are important to a primary care doctor who is credible, capable and works with them.7
Some other studies, however, cast doubt on the effectiveness of general practice care for this group,8–10 and concerns have been expressed that GP training in this area is inadequate.11,12 An Australian study reported that some patients with severe and persistent mental illness found it difficult to communicate their physical health concerns to their GPs.8 Patients have also reported difficulties organising, attending and waiting for appointments when they are unwell,6,9 a fear of attending alone6 and socioeconomic barriers to attending GPs such as cost and availability of timely appointments and transport.6
Many Australians living with mental illness are linked to public mental health services, including community mental health clinics (attended by approximately 80% of people with psychotic illness).13 Closer collaboration between community mental health clinics and general practice may improve the quality of whole-person care,12 assist with the integration and coordination of services across hospital and community settings14 and help to bridge the somewhat different conceptual and practical approaches of GPs and psychiatrists.15,16
There is surprisingly little known about the nature and extent of current GP involvement in the lives of people with severe and persistent mental illness who attend community mental health clinics, especially those on community treatment authorities, and more research has been called for.4 In this study, the researchers sought to understand patient engagement and satisfaction with general practice care and whether previously described barriers to medical appointment attendance were currently relevant to the Australian general practice context.
Methods
A survey instrument was developed on the basis of previously reported barriers and enablers to attendance at general practice care for patients with severe, persistent mental illness,5,6,9 and factors that influenced satisfaction with care.5,7,9 The survey included demographic items (including self-reported physical and mental health conditions and involuntary treatment status) and items measuring satisfaction and engagement with general practice care. Two free-text sections were included to allow patients to respond to the questions, ‘Is there anything else you would like to tell us about your experiences with GPs?’ and, ‘Do you think that your experience with GPs has ever been affected by personal characteristics such as your gender, your ethnicity, your sexual orientation or anything else?’ The survey was piloted with two patients, which led to minor modifications. The full instrument as administered is available on request from the corresponding author. Table 1 presents the Likert scale items measuring satisfaction with general practice care, including the GPs’ focus on mental health and physical health, and the items measuring the importance of previously reported enablers and challenges in accessing general practice care.
| Table 1. Likert scale items for self-reported general practice care satisfaction, access enablers and attendance challenges |
| Item response instructions: For the following statements, could you circle SA (Strongly agree), A (Agree), D (Disagree), SD (Strongly disagree) or N/A (Not applicable) as best applies to you: |
| Satisfaction items |
| I’m generally satisfied with the care I get from general practitioners (GPs). |
| The GPs I see care about me.5,7 |
| The GPs I see understand what I go through.5,7 |
| The GPs I see focus enough on my mental health.5 |
| The GPs I see focus enough on my physical health.9 |
| Access enablers items |
| It is important to me that my GP bulk bills. |
| It is important to me that my GP works close by.6,9 |
| It is important to me that my GP has extended hours. |
| It is important to me that I can get an appointment with my GP within three days.5,6 |
| Attendance challenges items |
| When I’m sick it’s hard for me to make an appointment to see a GP.6,9 |
| When I’m sick it’s hard for me to keep appointments to see a GP.6 |
| When I’m sick it’s hard for me to wait in a GP’s waiting room.6 |
| When I’m sick I am frightened to see a GP on my own.9 |
| When I’m sick I find it hard to explain to a GP what is going on.9 |
The survey was administered at community mental health outpatient clinics in South Brisbane between August and October 2017. Clinic receptionists drew the attention of patients attending an appointment to a flyer about the study, and patients who expressed interest were approached by the second author (RW) and invited to complete the survey while waiting for their appointment. Assistance to complete items was provided by RW as requested. No record was kept of patients who declined to participate, and no inducement or compensation was used.
Survey responses were analysed using descriptive statistics. Sample proportions were used to describe participant responses; group and variable relationships were analysed using Pearson correlations, chi-square tests and Student’s t tests. Exploratory factor analysis was used to determine the dimensionality of the Likert scale items measuring satisfaction, access enablers and attendance challenges. The expected three-factor structure was found, supporting the construct validity of the composite variables created by summing the satisfaction, access enablers and attendance challenges items, respectively. Internal consistency reliability was strong for the attendance challenges and satisfaction composites (α = 0.80, 0.89 respectively) but poor for the access enablers composite (α = 0.69).
A multivariate linear regression was conducted using each mental health condition, gender and age as the independent variables and each composite variable as a dependent variable. Statistical significance was evaluated at α = 0.05. Statistical analyses were performed using SPSS version 24 (IBM, 2017). All free-text comments were read and discussed by three of the authors, and a descriptive content analysis was reached by consensus.
Full project ethics approval was obtained from the Metro South Health Service and University of Queensland Human Research Ethics Committees (2017001049/HREC/17/ QPAH/340).
Results
Eighty-two participants completed surveys. Participant ages ranged from 18 to 65 years (mean = 36 years, standard deviation = 11 years). Forty-nine per cent of respondents who indicated gender identified as male. Participants reported living with mental illness for between zero and 55 years (mean = 14 years, standard deviation = 11 years), and 23 respondents (28%) indicated that they were currently under an involuntary mental health authority. Other self-reported participant demographics are shown in Table 2. Self-reported physical and mental health problems are shown in Table 3.
| Table 2. Selected participant characteristics |
| Characteristic |
n (%) |
| Country of birth |
|
| Australia |
56 (68.3) |
| Outside Australia |
26 (31.7) |
| Language spoken at home |
|
| English |
63 (84) |
| English and other |
12 (16) |
| Accommodation |
|
| Stable |
70 (85.4) |
| Unstable |
12 (14.6) |
| Living situation |
|
| Alone |
31 (38.3) |
| With others |
50 (61.7) |
| Income source |
|
| Full-time work |
9 (11.4) |
| Part-time work |
5 (6.3) |
| Other |
65 (82.3) |
| Highest level of education |
|
| Primary or secondary school |
36 (43.9) |
| Higher education |
46 (56.1) |
| Table 3. General and mental health problems reported |
| Reported problems |
n (%) |
| General health problems |
|
| Overweight |
35 (42.7) |
| Asthma |
15 (18.3) |
| Dental problems |
14 (17.1) |
| High cholesterol |
10 (12.2) |
| Physical injuries |
8 (9.8) |
| Liver disease |
6 (7.3) |
| Diabetes |
6 (7.3) |
| Smoking |
30 (36.6) |
| Mental health conditions |
|
| Depression and anxiety |
45 (57.7) |
| Psychotic illness |
34 (43.6) |
| Bipolar affective disorder |
22 (28.2) |
| Borderline personality disorder |
18 (23.1) |
| Post-traumatic stress disorder |
11 (14.1) |
Engagement with general practice care
Seventy participants (85.4%) reported having a regular GP. Frequency of consultations with any GP in the past 12 months was divided into four groups: no visits (n = 1), one to three visits (n = 27, 32.9%), four to nine visits (n = 27, 32.9%) and >10 visits (n = 27, 32.9%). The frequency of attendance was not significantly correlated with involuntary treatment status or any mental health problem except borderline personality disorder (correlated with more frequent attendance, P = 0.04).
Satisfaction with general practice care
Seventy-two participants (88%) agreed or strongly agreed that they were satisfied with the care they received from their GPs. Participants were more likely to be satisfied if they had a regular GP (P = 0.002). The four indicators of satisfaction (agreeing that their GPs cared about them, understood them, and focused enough on their physical health and their mental health) were strongly correlated with being satisfied with their GPs’ care (P <0.001), and with each other (Pearson’s r = 0.48–0.76). Of the self-reported mental health problems, only anxiety was associated with (decreased) patient satisfaction, in both univariate analyses (t = 3.52, P = 0.001) and multivariate analyses (t = 2.94, P = 0.005). Involuntary patient status was not associated with satisfaction.
Ninety-five per cent of respondents agreed (n = 46, 59%) or strongly agreed (n = 28, 36%) that their GPs focus enough on their physical health. In contrast, 24% of respondents (n = 18) disagreed or strongly disagreed that their GPs focus enough on their mental health. This difference between physical and mental health focus was significant (χ2[6] = 30.03, P <0.001).
Access enablers and attendance challenges for general practice appointments
Respondents were more likely to disagree than agree that they experienced difficulty with any of the five previously reported attendance challenges. The most commonly reported attendance challenges were waiting in a GP’s waiting room and explaining what was happening. No self-reported mental health problems were associated with attendance challenges or access enablers in either the univariate or multivariate regression analyses. Involuntary patient status was not associated with either of these composite items.
Respondents were more likely to agree than disagree that three of the four previously reported access enablers were important (bulk billing, proximity of general practice and timeliness of appointment).
Free-text comments
Thirty-two participants entered free-text comments in the section inviting them to provide information about their experiences with GPs, 16 of which were unequivocally positive.
Eight respondents expressed appreciation of their current GPs; six of these contrasted their current GPs with previous experiences of other GPs. Seven responses emphasised the importance of finding a GP with whom they felt comfortable. Negative comments included GPs with apparently inadequate understanding of mental health (four participants) or avoiding patients’ mental health concerns (three participants). Table 4 provides illustrative comments.
| Table 4. Illustrative written comments in free-text sections |
| Experiences |
Free-text response |
| Positive experiences |
|
| Appreciation of current GP |
I am incredibly impressed and indebted to my GP. |
| My doctor is good at listening and checks everything regular[ly]. |
| I’ve recently found a really good GP … she listens, is helping me work towards a solution and understands mental health. |
| Importance of being comfortable with GP |
Some GPs don’t get me at all and some do and if I’m lucky I get a GP that I really respect and love to see. |
| Negative experiences |
|
| Inadequate knowledge of mental health |
GP needs more understanding of mental health.
Most GPs seem quite professional. Some may struggle to help with mental health though. |
| Avoidance of mental health issues |
GPs refuse to treat me while I am under treatment of [the] community health team.
GPs I have come across are quick to say they can’t help and I need to see a ‘psych’. |
| GP, general practitioner |
Fifty participants entered free-text responses about whether their experiences with GPs had ever been affected by personal characteristics. Of the 10 participants who responded affirmatively, four respondents mentioned their sexual orientation. Overweight, piercings, previous drug use, youth, female gender and poor dentition were each mentioned once.
Discussion
The principal findings of this study were relatively high rates of engagement of respondents with a regular GP, and relatively high frequency of attendance (≥4 times per year for 66% of respondents, compared with 29–49% of Australians overall between the ages of 15 and 64 years).17 High levels of satisfaction were reported overall, including with their GPs’ focus on their physical health, although they were significantly less satisfied with the focus on their mental health. Key access enablers were bulk billing, proximity and timely appointments. Most participants did not report previously documented attendance challenges. Participants emphasised the importance of finding a GP with whom they felt comfortable.
The relatively small sample size and the use of a convenience sampling recruitment strategy, also used in a previous survey study with this patient group,18 are limitations of this study. The study did not use a validated measure of satisfaction, although the composite measure demonstrated construct validity and high reliability. Mental or physical health were not defined, and health issues were self-reported. The researchers did not explore whether general practice care has an impact on the substantial economic cost to the community of severe and persistent mental illness.1 The respondents may be more positively disposed to general practice than the wider population attending community mental health clinics, or more reluctant to report negative experiences with their current GPs. The sample demographics for gender and age (49% male, mean age 36 years, range 18–65 years) appear to be consistent with clinic database demographics for attendees in 2018 (56% male, mean age 42 years, range 18–70 years), although females may be over-represented. Other clinic database demographics are unavailable for comparison. Forty-four per cent of the sample self-reported problems with psychosis, which is reasonably consistent with the 54% of Queenslanders with severe and persistent mental illness who are estimated to meet the criteria for schizophrenia,1 allowing for differences between self-report and formal diagnosis. Twenty-eight per cent of respondents self-reported involuntary treatment status, compared with national estimates that 13.8% of community mental health service contacts are provided to people with an involuntary status,19 indicating that this group was well represented in the current sample.
Probably the most striking difference from some previous studies was the high satisfaction with physical healthcare provided by patients’ regular GPs. Although this does not indicate that the previously described under-treatment of physical morbidities and behavioural risk factors has been fully addressed (indeed, the self-reported smoking and overweight rates suggest otherwise), it may suggest that GPs are addressing patients’ physical health concerns with a patient-centred approach. Further research would be needed to investigate how GPs address physical morbidities and risk factors in this patient group, and how effective these strategies are.
Patient satisfaction with their GPs’ focus on their mental health was significantly lower, which is a new finding. A fear of ‘opening up’ complex mental health concerns in the limited time constraints of general practice consultations has been previously described by Canadian GPs20 and may be shared by their Australian colleagues. GPs may also be uncertain about their own role relative to that of the patient’s other mental health clinicians, including Medicare-funded psychologists,21 and fear giving mixed messages to the patient. Models of closer collaboration between mental health clinicians and GPs such as video conferencing, joint medical records and/or the embedding of GPs within mental health clinics may be useful, although the latter would need to ensure that existing patient relationships with their local general practices were not disrupted.
Implications for general practice
- Patients with severe and persistent mental illness who attend community mental health clinics have high rates of engagement with general practice care and report relatively low rates of attendance challenges.
- Bulk billing, practice proximity and timely appointments are important access enablers for patients.
- High rates of satisfaction were reported with general practice care, including GPs’ focus on physical health concerns.
- Patients may prefer GPs to focus more on their mental health concerns.
- Further qualitative research is indicated to explore these findings.