General overview

Description of specialtyPsychiatry is the branch of medicine that deals with the diagnosis, treatment, and prevention of mental and emotional disorders, and abnormal behaviour. Psychiatrists can further specialise in areas such as child and adolescent psychiatry, forensic psychiatry (legal and criminal matters), psychoanalysis, psychotherapy, psychiatry of old age, addiction psychiatry and psychiatry of learning disability. Psychiatrists also act as consultants in drug and alcohol programs and to community services. Within hospitals they are commonly involved in liaison with other areas of medicine and surgery, for example as consultants to pain clinics.
NumberThere are ~2460 registered psychiatrists in Australia.30
Gender mix33% female, 67% male.

Psychiatrists and eHealth

Examples of relevant eHealth applications

Some example uses of eHealth that psychiatrists currently and could possibly benefit from include:
  • Psychiatrists are likely to be particularly interested in eHealth solutions that allow them to enhance their long-term patient relationships
  • There are some niche applications of eHealth in psychiatry that have attracted enthusiasts and which have developed a strong evidence-base around cost-effectiveness and improved access to mental health services. The iCBT program developed by the Clinical Research Unit for Anxiety and Depression at St Vincent’s Public Hospital is one such program that allows carefully selected patients to undertake cognitive behavioural therapy online with minimal clinician involvement, as an alternative to medication and face-to-face counselling.

Current eHealth ‘position’

  • Psychiatrists tend to favour eHealth for event summaries at a greater rate than other specialties, in part due to the potential for time savings when creating and distributing large amounts of patient information
  • Some psychiatrists are particularly interested in telepsychiatry as a way of providing increased access to patients in rural and remote areas. They noted that their patients responded surprisingly well to consultations via videoconference
  • In general, the specialty perceives little value from eHealth, although practitioners see some benefit in increased patient engagement from eHealth, which is particularly important given the typically long-term nature of psychiatrists’ relationships with their patients
  • There are no strong drivers for greater adoption of eHealth among psychiatrists, as they feel no pressure to do so from patients, their professional network or professional associations.

Key insights from eHealth readiness survey

  • Psychiatrists are below-average eHealth users as compared with medical specialists in general. Relative to other specialists, they are especially less likely to use computers for the following applications:
    • Viewing diagnostic imaging (20 percent) and pathology results (38 percent) and ordering diagnostic imaging (5 percent) and pathology tests (11 percent). 37 percent of psychiatrists reported that they don’t use and don’t need computers to order diagnostic imaging, largely because they rarely if ever order imaging in their specialty
    • Sending or receiving referrals (11 percent use computers)
    • Viewing or recording information during consultations (24 percent currently use computers, 45 percent stated that they don’t use and don’t need computers)
  • Psychiatrists are approximately average in their use of telehealth (12 percent currently use versus 9 percent of all specialists). Among the 42 percent that will definitely or probably use telehealth within the next three years, 70 percent are interested in training, 59 percent are interested in remote consultations with other providers, and 44 percent are interested in remote consultations with patients
  • During interviews, psychiatrists expressed strong concerns that using computers during consultations would interfere with patient relationships. They commented that patients often complained about GPs using computers during consultations, which they did not like. The psychiatrists that maintained computerised records typically completed computerised entries of their notes after each consultation
  • Psychiatrists were one of the least interested segments in using computers to share information with their patients (60% stated that they don’t use and don’t need a computer to share information with patients). Some psychiatrists mentioned that they provide their patients with information to share with their families, but this is usually in the form of a pamphlet or website suggestion rather than specific health details
  • Psychiatrists are also less likely to express interest in sharing health records with other practitioners (41 percent don’t use and don’t need a computer). Their health records tend to be shared among fewer practitioners due to the nature of their work and the level of confidentiality required
  • Psychiatrists are beginning to transition to computerised notes, but only 4 percent reported that they are paperless. A further 53 percent use a combination of paper-based and computerised records
  • Not surprisingly, psychiatrists are much less likely to agree that most practitioners in their network use computers (33 percent strongly agree) and that computer use is expected in their specialty (32 percent strongly agree). They are also less likely to agree that computer use reduces error in their specialty (22 percent strongly agree) and less likely to consider themselves early adopters of new computer systems (just 17 percent strongly agree). During interviews, psychiatrists commented that the specialty tends to be more conservative and less interested in adopting the newest technology, in part because computers and technology are not a required part of the job
  • Psychiatrists have fairly average perceptions of eHealth benefits, with one exception. They are less likely to agree that eHealth will improve quality of care (23 percent strongly agree versus 33 percent of all specialists). The greatest perceived benefit is improved collaboration (40 percent strongly agree)
  • Perceptions of adoption barriers are much higher for psychiatrists as compared with other specialists. Relative to specialists overall, psychiatrists are especially concerned about system malfunctions or downtime (47 percent strongly agree this is a barrier), privacy breaches (41 percent strongly agree), and drops in productivity during the transition to a new system (29 percent strongly agree). They are also waiting for the technology to mature (34 percent strongly agree that they prefer to wait until systems are proven before adopting) and that not enough people are using the systems for them to provide a benefit (27 percent strongly agree)
  • Agreement on adoption drivers is relatively weak, but the two strongest influences for psychiatrists are financial incentives (19 percent strongly agree and 32 percent somewhat agree) and professional bodies (17 percent strongly agree and 42 percent somewhat agree)

Characteristics and practice attributes

General workforce trends

There are several factors likely to put pressure on psychiatry workforce levels in the near term:
  • The workforce is ageing. The majority of psychiatrists (56 percent) are aged between 35–54 years but a significant proportion (40 percent) is older than 55 years. The impact of ageing of the workforce may be more immediate for psychiatry than other specialties (70 percent of psychiatrists are older than 45, compared to 62 percent for all medical specialties)
  • Psychiatrists are working fewer hours. Average weekly hours are falling from 45.0 in 1995 to 40.9 in 2004 and 38.3 in 2008, will put further pressure on workforce requirements
  • Although two thirds of practising specialists are male, there is an increasing feminisation of the workforce (in 2004, females made up 56 percent of psychiatrists in training) and women tend, on average, to work fewer hours31.
  • There are currently difficulties in filling psychiatry training positions, and the College is working with Federal, State and Territory Governments on making psychiatry training a more attractive option for junior doctors.

Private practice is the most common setting for psychiatrists: 41 percent of psychiatrists work exclusively in private settings, 23 percent exclusively in public settings and 36 percent in both sectors.32 Although the ratio of psychiatrists to population in Australia is higher than the World Health Organisation recommendation, they are unevenly distributed and (like most medical specialists) concentrated in capital cities.33

A high-level practice profile of survey respondents suggests:
  • High patient volumes. Nearly three-quarters of respondents see 6-15 patients daily
  • Few practice locations. Nearly 70 percent of respondents practice in one or two locations, which is consistent with consultations in rooms
  • Consistent source of income. Respondents appear to practice overwhelmingly in either the public or private sector (earning at least 75 percent of their income from a single sector), rather than mixing their settings. This may reflect the very different patient mix encountered in each sector.

EXHIBIT 36
(D)

Education, registration and accreditation

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) trains and accredits doctors throughout Australia and New Zealand to be psychiatrists, through initial qualification, registration and continuing professional development.

The Royal Australian and New Zealand College of Psychiatrists
254 - 260 Albert Street, East Melbourne VIC 3002
T: +61 3 9640 0646
F: +61 3 9642 5652
http://www.ranzcp.org

The College’s program for post graduate training in psychiatry takes a minimum of five years and is based around rotations in adult general psychiatry, child/adolescent psychiatry, and consultant liaison, together with training experiences in rural psychiatry and indigenous mental health, psychiatry of old age, addiction, ECT and psychotherapy.

Sources of financial reimbursement/role in the healthcare ecosystem

The great majority of psychiatric services are performed as outpatient services, as changes in practice and improvements in medication mean that increasingly only the most severely ill patients require admission to hospital, for example patients with psychosis, suicidal patients and those with life-threatening eating disorders.

In the private sector Medicare rebates for psychiatry consultations are payable once a referral has been made to a consultant psychiatrist from the General Practitioner or another specialist. In most cases an initial assessment involves a diagnosis and a care (treatment and management) plan being constructed which contains the outcomes of the assessment, the patient's diagnosis or diagnoses, opinion on risk assessment, treatment options and decisions, appropriate care pathways and appropriate medication recommendations where necessary. Copies of the treatment and management plan must be provided to the referring practitioner and, where appropriate, relevant allied health providers. Medicare benefits for psychiatric consultations are generally reduced after 50 attendances in a calendar year.

For certain very severe conditions specified in the Medicare Benefits Schedule (MBS), like serious eating disorders, the psychiatrist may use Medicare items, which permit much more frequent visits to a consultant psychiatrist than a standard mental healthcare plan; however these items are monitored very closely by Medicare to ensure appropriate use. Referral from a GP is required to access Medicare benefits for psychiatry services.

As with other Medicare attendance items in the private sector, psychiatry consultations attract a rebate of 85 percent of the scheduled fee which varies according to the duration and complexity of the assessment. Very few psychiatrists bulk-bill due to increased demand, workforce shortages and psychiatrists generally working fewer hours. Bulk-billing rates were about 29 percent in 2009. 34

Medicare rebates for telepsychiatry consultations were introduced in 2002. Since the introduction of telepsychiatry item numbers, uptake has been very low. Barriers identified by the RANZCP include: lack of funding for GP or clinician time to facilitate patient consultations in rural areas; lack of patient awareness; lack of facilities; and insufficient incentives and information for psychiatrists.35 In qualitative interviews, individual psychiatrists suggested that barriers to uptake have been; a culture in psychiatry that over emphasises the necessity of the patient being physically present, low cultural acceptance in some remote communities – particularly amongst Aboriginal and Torres Strait Islander patients and psychiatry patient loads currently being too high to permit the additional burden of telemedicine services.

30AIHW Medical Labour Force Survey 2008, published in 2010.
31 Trend across all medical specialties.
32Mental Health Workforce Advisory Committee, ‘Mental Health Workforce: Supply of Psychiatrists’, February 2008.
33IBID.
34Department of Health and Ageing website – Medicare statistics.
35 Royal Australian and New Zealand College of Psychiatrists ‘Connecting Health Services with the Future: Modernising Medicare by Providing Rebates for Online Consultations’ Submission to the Australian Government Department of Health and Ageing, January 2011.