520793 research-article2014

APY0010.1177/1039856214520793Australasian PsychiatryCorrespondence

AP

Correspondence

Australasian Psychiatry 2014, Vol 22(2) 202­–206 © The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav apy.sagepub.com

Correspondence with general practitioners

public psychiatric health services.3

Dear Sir,

In light of the advantages of collaboration and suspicions of inadequate communication with GPs from our own service, our team initiated the following review. The primary goal was to investigate attitudes towards correspondence between the clinic’s medical team and local GPs known to treat case-managed patients. From this information, we aimed to identify barriers to effective communication, in addition to specific areas for improvement. Ultimately, we hoped that these findings could help contribute to the design and implementation of strategies to improve communication between our service and GPs.

The case management model of community psychiatric care incorporates a partnership with general practitioners (GPs). There are multiple incentives for making this an integrated and collaborative relationship. Perhaps most obvious amongst these is the prompt identification and management of medical issues. This is particularly pertinent given the known increased prevalence of medical comorbidities amongst patients with severe mental illnesses.1 Close ties between clinic and primary health care providers can also foster improved collaboration between services, facilitating minimisation of errors and more consistent planning and prescribing. Likewise, such relationships could allow better management of crises. Furthermore, strong bonds between services align with the increasing movement towards consumer-centred care and integration between key partners.2 As members of the Continuing Care Team in a large inner urban clinic, we had become increasingly aware of the shortcomings of our own communication with the GPs of our case-managed patients. Anecdotal accounts focused on dissatisfaction with our standards of written communication as a service. In particular, this pertained to doctors working in the clinic. While the value of strong ties with primary health care providers were certainly recognised by medical staff, no formal protocols existed for medical communication. More broadly, we were also aware of a historical precedent for poor communication between 202

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The initial stage of the review was a survey that was sent out to GPs known to care for patients case managed by our clinic. This survey aimed to elicit opinions held by these GPs about written communication with clinic doctors. Approximately 90 GPs were contacted over several months in early 2012, with 27 completing and returning the survey. Of these respondents, 62% felt that our current level of written communication was at least adequate, with delays or frank absence of written information cited as major factors in negative appraisals. Of concern, over half (52%) of all respondents were able to recall a situation in which poor communication from our clinic had had a negative impact on a patient’s care. Following this initial survey, we devised a standardised single page template letter for GPs. This consisted of five headings: Diagnosis, Current Issues Raised, Management Plan, Current Medications, and Follow-up Required. It was decided

that the medical officer or registrar would complete this letter by hand for each patient discussed at the weekly clinical team review. In addition to patients with active management issues, a letter was also completed for those patients whose progress was reviewed on a rostered basis as a part of the clinic’s practice protocol. Each of these letters was then posted to the nominated GP. This initiative was trialled between November 2012 and June 2013. In that time, a total of 175 standardised letters were sent out. After this initial trial period, a survey similar to the one described previously was distributed to linked GPs. The purpose of this follow-up survey was to assess GP opinions on the handwritten letter trial. There were 23 respondents. Responses were generally somewhat more positive than those received prior to the standardised letter initiative. Approximately 68% felt that the overall standard of communication was at least adequate, with 83% considering the usefulness of communication to be at least adequate. Of ongoing concern were the 45.5% of respondents who could recall an episode of suboptimal patient care attributed to inadequate communication. Significantly, 91% of responding GPs gave preference for typed correspondence, with legibility of handwriting being a further concern on qualitative questioning. Our series of investigations appear to have validated initial concerns that the medical correspondence between our service and connected GPs is, at best, problematic. In particular, the pre-existing level of such communication appeared unreliable, with the potential to impact upon patient care. The standardised

Correspondence

letter initiative improved this situation to an extent, although concerns remained around the quality and format of this communication. As a result of our review, we have devised several recommendations. A standardised system of letter writing should be instigated to ensure reliable communication between clinic doctors and linked GPs. This should ideally incorporate both relevant information from clinic reviews and periodic summaries of patient progress. Formatting preferences of receiving GPs should be taken into account, given their time constraints and need for succinct information. In line with professional expectations, this correspondence should be typed. Currently, no streamlined system exists in our clinic to expedite typed letters. As a matter of priority, investment is required in appropriate technology and administrative support to facilitate this last recommendation. References 1. Lambert T, Velakoulis D and Pantelis C. Medical comorbidity in schizophrenia. Med J Aust 2003; 178: 67–70. 2. Victorian Department of Health. 2011. Framework for recovery-oriented practice. Available at: http://docs. health.vic.gov.au/docs/doc/0D4B06DF135B90E0CA2 578E900256566/$FILE/framework-recovery-orientedpractice.pdf 3. Horner D and Asher K. General practitioners and mental health staff sharing patient care: working model. Australas Psychiatry 2005; 13: 176–180.

Dr David Syfret, Dr Beatrice Huang Psychiatry Registrar, Department of Psychiatry, Royal Melbourne Hospital, Parkville, VIC DOI: 10.1177/1039856214520793

Comment on Newman L, Proctor N and Dudley M. Seeking asylum in Australia: immigration detention, human rights and mental health care. (Australasian Psychiatry 21(4) Aug 2013; 315-320) Dear Sir, We are psychiatrists working in Australian Immigration Detention Centres (IDCs), and in Regional

Processing Centres in Papua New Guinea and Nauru. We recognize the valuable contribution by Newman et al. in this different area of psychiatric practice and for their thoughtprovoking recent article ‘Seeking asylum in Australia: immigration detention, human rights and mental health care’.1 As senior and experienced Psychiatrists and Fellows of the RANZCP currently involved in the direct provision of care in these settings we wish to offer the following comments and observations.

The authors state that ‘…the capacity to treat psychiatric conditions within the immigration detention setting is limited.’ Yes, of course; however, we disagree that it follows that treatment, including anger management and standard medication prescribing practices, has ‘questionable value and utility’. This statement also seems at odds with our College’s Position Statement 46, and with the Australian Medical Association’s 2011 Position Statement on the Health Care of Asylum Seekers and Refugees.2

The authors’ overview provides a concise historical perspective of mental health issues in immigration detention, which is timely in the current context of policy flux. It is notable that the cases of SB and CR occurred many years ago, and that engagement by the profession with the system, notably by these authors themselves, has led to greater recognition of the mental health needs of people in detention and to significant policy change; conditions which have enabled improvements in service provision including the establishment of multidisciplinary mental health teams in immigration detention facilities with oversight by psychiatrists.

As clinicians dealing with these issues on a daily basis we know firsthand of the potential harm done by prolonged immigration detention, and we share the authors’ concerns over the effects of detention on vulnerable people, especially children. We believe that asylum seekers and refugees deserve quality mental health treatment, regardless of whether they are in IDCs or the community, and regardless of the challenges that such treatment poses. We practice within the recommended College Guidelines and Position Statements. We are mindful of the “contentious” nature of this work,3 and of our ethical responsibilities. We maintain these with due care and diligence, and consider that we provide humanitarian clinical care to people who are surely some of the most disenfranchised, marginalized and needy.

The authors’ points on the complexity of the ethical dilemmas faced by psychiatrists working within immigration detention facilities are valid. We believe, however, that these challenges are not dissimilar to those encountered by many clinicians working in other institutional settings, such as prisons, where dual client relationships apply. Also, with regard to observations of lack of understanding of meanings and motivations of self-harming and suicidal behaviour, this is not unique to immigration detention and is, for example, commonly encountered in liaison psychiatry. We assert that psychiatrists working within the system are best placed to support patients and other mental health staff in navigating these complex issues. Psychiatrists can, and do, provide education to other stakeholders, and with advice and health advocacy promote the interests of best patient care.

It is unfortunate that negative commentaries related to the ethical challenges of working within the immigration detention system have created some stigma associated with this area of practice. It would be preferable if our Colleagues and associates support this valuable work, and encourage the recognition of the skills and expertise provided. Disclosure The authors are employees of International Health and Medical Services, the health service provider to the Department of Immigration and Citizenship. The views and opinions expressed in this letter are those of the authors and do not necessarily reflect the official policy or position of International Health and Medical Services.

References 1. Newman L, Proctor N and Dudley M. Seeking asylum in Australia: immigration detention, human rights and mental health care. Australas Psychiatry 2013; 21: 315–320.

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