Down with generalist ‘gatekeepers’

7 minute read

Prominent psychiatrist Professor Ian Hickie drew heat for saying GPs don’t do enough mental health. Now he questions the need to have GPs at all.

Professor Ian Hickie – researcher, psychiatrist and architect of the Better Access scheme – has something to say.

Over the last couple of weeks, the University of Sydney Brain and Mind Centre co-director has been the subject of heated debate on social media after refusing to backtrack comments in which he suggested that GPs don’t do enough mental health follow-up consults.

What arguably drew the most outrage, though, was his suggestion that GPs who have moved to private or mixed billing are unfairly disadvantaging vulnerable low-income patients and locking them out of the healthcare space.

Professor Hickie denies that he is solely attacking GPs and said he has taken up the issue with psychiatrists and psychologists as well.

He does, however, believe that GPs shouldn’t exist. At least, not in the traditional (i.e. current) sense.

“In the primary care mental health space and many other spaces, we need people not to have to go to the GP as gatekeeper to the system,” Professor Hickie told The Medical Republic.

“They need to be able to get much of the care without going anywhere near a GP.”

For better or for worse, Professor Hickie believes that medicine will be “uberised”; essentially, the private sector will develop digital platforms to supply healthcare which meets consumer demand.

Much of the primary care around the world, the psychiatrist said, is not provided by doctors.

“Mostly it’s done by nurses, other allied health professionals and increasingly by smart systems,” he said.

“People are directly accessing the care they need for many of those things – we’ve seen it now for prescriptions, for vaccines.”

The 2021 vaccination rollout, Professor Hickie argued, would not have been possible with just GPs.

The most important aspect of his uberisation concept is the idea that consumers, particularly young people, want accessibility above all else.

“Young people love [mental health telehealth solutions] – it was like, ‘finally, you come to me instead of me having to line up in your clinic’,” said Professor Hickie.

“There was over $2 billion of investment last year in mental health start-ups in the United States alone in these [telehealth mental health] technologies.”

Professor Hickie said he imagined that general practice would improve in quality quick smart if patients were able to fill in publicly visible star ratings as they left, like they might do for Uber or AirBnB.

TMR pointed out that people liking a certain model of care and finding it accessible was not necessarily the same as a model of care being high quality or fit for purpose.

“I don’t agree with that at all,” he said.

“In fact, the more informed people are, the more they can challenge the system.”

 To illustrate his point, he brought up diabetes care.

“I was talking to a young person with diabetes today, and she said ‘I know twice as much, three times as much about my diabetes as my GP does, and I discussed with my specialist about where it’s really at with continuous glucose monitoring and what needs to be done,’” Professor Hickie said.

“People are highly informed because of the democratisation of information.”

If it sounds like the system of care Professor Hickie is promoting is American-style managed care, that’s because it is.

The problem with US managed care, according to the one-time Beyond Blue CEO, is the inequity in the system, not managed care itself.

“Generalism is dead,” he said. “Spending 20 minutes with everyone, 40 minutes with everybody and arguing for [time-based] service items – that’s dead. Who wants to pay for that?

“If you go [to a doctor], you want the problem you have sorted out.

“If it’s complex care, you want it to be coordinated.

“There are many very good managed care systems in the United States where all that work is done by nurses, allied health people and smart systems.

“You see the doctor you need to see with the right level of skill, when you need to see that doctor.”

This is a particularly contentious position.

“Even among burnt-out GPs, there are very few of us who don’t talk about the joy of being a generalist,” Sydney GP Associate Professor Charlotte Hespe told TMR.

“I know I bring so much value to my patients and to their care through being a true generalist, care that a partialist specialist will never ever be able to bring.

“On top of that, we’re so much more efficient.”

She also emphasised the importance of GPs as gatekeepers, saying that their role ensured the right people were going to the right places.

“We know why this is such a good thing, because the American states that don’t have a gatekeeper system or don’t have general practice, have a really expensive healthcare system,” Professor Hespe said.

“That’s because a patient decides where they go and what they do, and they see all the wrong people.”

Associate Professor Louise Stone, a GP with special interest in mental health, was critical of Professor Hickie’s assertion that mental healthcare could be uberised.

“If you want to take all the mild-to-moderate people with mild-to-moderate depression and nothing else, and optimise their outcomes using some sort of AI-developed thing, that’s fine,” she told TMR.

“But what you need to know is that’s the cheap end of healthcare.

“The expensive end is the bespoke things you’ve got to do to manage multimorbidities.”

Also, most of the time it is not that easy for patients to determine what exactly is wrong with them. That is, after all, what doctors are for.

“I just had a young bloke who got diagnosed with depression – I did it, I thought he had depression – but he’s actually got a metabolic muscle condition,” Professor Stone said.

“Patients don’t present with a diagnosis, they present with a problem.”

Further to that, she said, the problem is usually something vague, like fatigue.

“The most common confusion is when there’s some combination of two or more of something neurological, something psychiatric, some sort of trauma, some sort of drug and alcohol addiction, or some sort of neurodiversity,” said Professor Stone.

What GPs need is more support to sift through those conditions.

Mackay GP Dr Nicole Higgins and Tamworth GP Dr Ian Kamerman independently challenged Professor Hickie to spend a day in their rural practices and see first-hand how many mental health consults they do.

Both Dr Kamerman and Dr Higgins were firm on the fact that rural patients couldn’t just rely on telehealth.

“The professor is welcome to spend a day in my practice and see exactly what an average mental health load is in general practice,” Dr Kamerman told TMR.  

“General practice is the only specialty that provides, as part of its specialty, continuity of care. Of course we review our patients.”

Dr Higgins echoed this sentiment, and said her patients often had to fly down to Brisbane or Townsville to see a psychiatrist, adding to their already-substantial out of pocket costs.

“We may not do specific mental health in isolation, but we build it into whole patient care and I think that’s what Professor Hickie doesn’t understand,” she told TMR.

“What he’s done is he’s made the profession very angry at a time when we’re already feeling devalued,” Dr Higgins said.

“He’s brought the GP voice together and I would really like to see him take the time to understand general practice – come and meet with us, come and talk with us, come and sit in general practice and see what it’s like.”

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