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How GPs and PHNs can work together to provide care

The GP must remain central to the patient’s care. It is the PHN’s remit to commission or provide stepped care services to their populations, but PHNs can also help GPs navigate non–PHN funded mental health care services. Individual PHNs will have different eligibility criteria and ways to navigate care – for example, some PHNs require a GP referral and GPMHTP, while others accept self-referral with the aim of linking the patient back to their GP early in their care.

Initiatives such as HealthPathways or the government’s Head to Health website can help GPs find these services within their PHN region, or GPs can explore their local PHN’s website for more information on what is available.

Direct communication between GPs and PHNs is vital to ensure that GPs fully understand the services offered through the PHN and how the PHN intends to work with the GP to make sure that the patient is not ‘lost’ between services, especially when care is being transitioned from one step to another.

It should be highlighted that there are 31 PHNs and there will be different services across districts. It should also be acknowledged that PHN services only account for a small part of the total mental health system, and services delivered by other providers may suit the treatment need.

The following are examples of how stepped care services can work based on the different tier levels of care; these in no way provide a full picture of services available.

Low intensity

  • A patient presents to their GP with mild symptoms. The patient works full time but is keen to explore online options. The GP creates a GPMHTP, and uses HealthPathways (or similar resource) to provide the patient with e-therapy information. The GP arranges follow-up with the patient in four weeks’ time.
  • A patient has had six face-to-face psychology sessions with a mental health professional and their symptoms have improved considerably. They do not want  to continue any further sessions, but are at risk of relapse based on past history.  The GP discusses online e-therapy options, or refers to PHN-commissioned  low-acuity telephone-based care.

Moderate intensity

  • A patient has moderate symptoms and is keen to consider face-to-face psychological treatment. Their GP creates a GPMHTP and refers the patient to a private psychologist or a PHN-commissioned face-to-face psychological service for no-fee access.
  • The patient describes moderate symptoms, but has not previously engaged well with face-to-face psychological care, falling into a vulnerable demographic group. The GP creates a GPMHTP and refers the patient to a PHN-commissioned stepped care service for initial assessment to determine appropriate treatment and eligibility criteria. Appropriate treatment may include support from a range of service providers such as credentialed mental health clinicians, care coordinators or peer workers.
  • The patient describes moderate symptoms and requires disability support to  aid recovery. The GP accesses disability and social support available through  PHN-commissioned services.

Care coordination

  • A child has learning disabilities and attention deficit hyperactivity disorder (ADHD) causing significant impact on schooling and family life. The child attends a public paediatrician, a children and youth mental health service, and an NDIS service.  The child’s family is somewhat chaotic and the child continues to miss appointments. The child’s GP refers to PHN-commissioned stepped care services for care coordination.
  • An Aboriginal man with depression presents to his GP. The GP creates a GPMHTP and suggests psychological treatment but is unsure of local culturally appropriate services. The GP refers to PHN-commissioned stepped care services for care coordination.

There are 31 PHNs across Australia with vastly different populations, which means each PHN can have a different array of services. For example, some PHNs accept self-referrals direct from patients, others require referrals from a GP or other health professional. Some PHNs conduct their own intake and assessment processes, others use a service offered by another provider.

Contact your PHN and ask to speak to the GP liaison staff member. The following are some questions GPs could ask their PHN to find out more about the processes and available services offered.


Working with the Stepped Care Model