GP perspectives on a psychiatry phone line in Western Australia’s Great Southern region: implications for addressing rural GP workload

When asked to comment on the most beneficial aspects of the GPPPL, interview participants typically spoke about having immediate access to ‘consultant-level’ advice. This was contrast with ‘the old ways’, when GPs were either unable to get expert advice or had to wait for a delayed call back. Immediate access, that is, the call being answered and advice provided during the consultation, enhanced GPs ability to manage their patients, especially given the limitations of short consultations; this was highly valued by all GPPPL users interviewed:

You can get clinical information quickly, but also when you have the patient sitting right in front of you, you can deliver better patient-centred care if you can find the answer to things straight away and – rather than putting in referrals and then waiting for weeks and then having appointments that – there’s just lots of delays with the old ways that we had before. (I06, GP Fellow)

Similarly, another GP commented on the importance of getting advice ‘in real time’:

So the most beneficial thing is getting support and advice in real time such that you can make decisions with a patient sitting in a consult with you, sitting in the consult room with you at the same time. So, that’s extremely beneficial in managing mental health patients, especially high-risk patients, because it’s very anxiety-provoking, and it’s not exactly safe to let a patient go whilst you’re awaiting feedback or advice from a psychiatrist who might not be available until later on in the day. So, I feel like that’s probably the most beneficial thing. (I10, GP Registrar)

All GPs who had used the service agreed that accessing the GPPPL was quick and straightforward, with most calls answered straight away and no ‘administrative hurdles’. One GP explained:

You can just ring them anytime, and they – I’ve probably only rung up a few times, but every time, they’ve answered it pretty much straight away. And if they can’t talk, then they call you back really quickly. (I13, GP Fellow)

A single dedicated mobile number that can be easily stored in their own mobile phone was perceived as facilitating access to the service, compared with online logging systems. Overall, ease of access was highly valued among GPs and was perceived as one of the facilitators of access to the GPPPL, as this quote reflects:

I don’t think you need to fill out 10 forms and wait in queue and whatnot. I think it’s just a simple matter of phoning a number and speaking to someone. (I07, GP Fellow)

When asked to reflect on the impact of accessing the GPPPL on perceived levels of knowledge and skills, the level of agreement was somewhat lesser than that achieved around perceived impact on confidence (this is consistent with survey data). Only a few GP participants explicitly admitted to having knowledge gaps on mental health; however, increased knowledge and skills were broadly regarded as being intrinsically linked to increased confidence in managing mental health issues. Reflecting on the impact of the GPPPL, one GP explained the knock-on effect of increased knowledge and skills on referrals:

It’s had a good impact, because I know that if I’ve got that tricky patient I don’t need to send them for a tertiary – into a psych review, I can call up and get the information I need straightaway and then I can just continue to manage the patient, and so it avoids physically for my patients to having to travel to Albany for something, and then it makes me more confident, and next time I have something similar I’m like, ‘Okay, that’s the advice I got last time, let’s just do that this time’. (I11, GP Fellow)

The positive impact on knowledge and skills tended to be discussed in the context of the clinical complexity associated with the medical management of patients with multimorbidity, multiple psychiatric problems, polysubstance use or polyprescription use issues (see visualisation of the two domains of patient complexity in Fig. 3). GP Registrars tended to emphasise this knowledge-building aspect more readily compared with GP Fellows; they especially valued this educational aspect, as they did not always have a senior GP available within the practice. One GP Registrar explained:

I guess a good example is, I‘ve got a gentleman with bipolar who’s on lithium and he was getting more anxiety-type symptoms, and I just had a chat to someone on the GP psychiatry line and they recommended that I start [medication name] and it had yeah, really positive effects and so I’ve been able to then use that again in a similar patient, whereas before, because they had bipolar and it was complex and I wouldn’t have felt that confident mixing medication, crossing over medications with lithium, I might not have started that – I wouldn’t have started that myself and it would have been a referral I guess to mental health that could have been avoided. (I12, GP Registrar)

Fig. 3.

Domains of complexity (clinical and psychosocial) with areas of most coding in bold.

The GPPPL provided reassurance to GPs that they were handling ‘difficult decisions’ safely. Some GPs expressed feelings of worry, as they spoke about ‘anxiety-provoking’ patients and decisions that ‘keep them up at night’ or they are ‘in a bind’ about:

It’s just the help down the phone when you’ve got a situation that you feel uncomfortable with, or something needs to be done – instead of sending them up to ED, or putting in the referral, and that you don’t know when that’s going to be actioned, or going home and fretting about, “Have I done the right thing?” you’ve got an instant answer over the phone, or instant advice over the phone. It’s very reassuring to have that over the phone. (I01, GP Fellow).

Participants’ accounts suggested that most ‘difficult decisions’ were linked to patients’ psychosocial circumstances rather than clinical complexity per se. Thus, they tended to highlight the reassurance provided by the GPPPL about specific patient cohorts, including youth – especially youth at risk of suicide, patients with AOD and prescription medication use problems, and patients lacking social support. One GP spoke about an ‘influx’ of new patients with multiple medication and psychiatric issues that some colleagues were ‘terrified of taking on’. Another described the reason for one of their calls to the GPPPL:

… it was something about – some kind of complex social support situation where I wasn’t really sure what the correct ethical thing to do was in the context of the patient and the mental health problem, and sorting it out. (I06, GP Fellow)

Having a trusted sounding board when making difficult decisions was especially valued, given the isolation experienced in the rural setting:

… you sometimes do feel isolated, you may have colleagues in the same practice, but mostly you’re always by yourself, and you feel very responsible and very much on the front line, but it gives you the confidence that you can – that someone’s got your back that there is support and a safety net there. (I05, GP Fellow)

The reassurance of knowing the GPPPL is there, even if not accessed, was also noted:

There’s a confidence that comes from knowing that there’s someone there who can help you, even if you don’t necessarily take advantage of it. So, just knowing that there is someone who’s accessible and available and knowledgeable who can give advice if we need it. And I’ve seen my colleagues using the support as well, and I know what it was like before we had that. And I think that we feel more confident and we’re probably giving better care as well, because we’re having that much more support to do it properly. (I06, GP Fellow)

The GPPPL psychiatrists were widely regarded as being experts in their field. GPs valued the ability of GPPPL psychiatrists to provide ‘top-level’, appropriate advice on the spot with confidence and clarity. Reflecting on the impact on the GPPPL, one GP said:

I know that there’s essentially an expert down the phone that I can call at a moment’s notice to give me the appropriate advice. (I01, GP Fellow)

GPs sometimes spoke of their high regard for the expertise of GPPPL psychiatrists by contrasting their experience of accessing the GPPPL with that of accessing other helplines or specialist teams. A previous negative experience with other telephone services was seen as a potential barrier to accessing the GPPPL, as this GP explained:

I think that, unfortunately, a lot of GPs have the experience of contacting specialty teams in tertiary hospitals and speaking to a registrar, and it’s not always – the advice you get can be very variable. So, I think maybe that puts some people off, and people don’t realise that with the psychiatry line, it’s specific people who are answering, I suppose. (I08, GP Fellow)

The quote suggests a certain degree of scepticism that is consistent with the rest of this GP’s account which, in contrast with that of the rest of the sample of GPs who had accessed the GPPPL, demonstrated a more nuanced attitude towards the service, perhaps influenced by a reported preference for email over telephone consultations. During the interview, this GP expressed their trust in one particular psychiatrist, but was unsure about the area and level of expertise of the rest of the GPPPL team, adding that ‘you’re not 100% sure if they’re going to be the best person to give me advice’; later, he explained:

So, I think something that would potentially be helpful would be – I think we’ve been sent out before a list of people who answer the phone, but their little profile might be helpful. So, like, you’ll either get this person, who is a consultant psychiatrist and has experience with these subspecialty areas, or this person, who has this. And so you kind of know who you’re talking to. I think that would help. I think that would be useful.

Most GPs reported having an ongoing professional relationship with GPPPL psychiatrists prior to the commencement of the service. When asked about how they would access appropriate advice prior to the GPPPL, GPs typically reported asking their supervisor (in the case of GP Registrars) and their colleagues or reaching out to their professional networks through what one GP called ‘an informal mates system’. For those with established professional relationships with local psychiatrists, the GPPPL was seen as formalising something that was already occurring. One GP said:

It’s really nice to have an official way that you can do that, if that makes sense, because you’re not relying on somebody’s goodwill and you’re not relying on being friends with someone to have that kind of access to specialists. I think it’s a really good thing for people who are new to the region who don’t necessarily have those contacts yet. (I13, GP Fellow)

Building and strengthening contacts within the region was noted as an additional benefit of the GPPPL. Both GP Registrars and GP Fellows spoke about the educational aspect of the GPPPL and how it benefited more junior GPs. One GP with 10 years’ experience in the region commented:

I think that the other effect of these kinds of initiatives is that it improves trust between the GPs and the mental health unit, and improves relationships and knowing one another. (I06, GP Fellow).