How has private psychiatry in Australia responded to the COVID-19 pandemic?

. . . Some of them regard private enterprise as a predatory tiger to be shot. Others look on it as a cow they can milk. Only a handful see it for what it really is – the strong and willing horse that pulls the whole cart along . . .

–Winston Churchill

The COVID-19 pandemic has highlighted the role of private psychiatry, which responded to the crisis with expanded outpatient/telehealth practice and ongoing private hospital care, complementary to public sector care. Despite the significance of the private sector, it has been largely overlooked in recent reports from the Productivity Commission, the Royal Commission into Victorian Mental Health Services and the Fifth National Mental Health Plan. We highlight research findings that demonstrate the scope and resilience of the private sector in meeting the challenge of the pandemic, as well as previous private–public sector collaborative initiatives that could be revivified.

The profile of private psychiatry

The majority of private psychiatric care in Australia is provided in outpatient clinic settings, or in private psychiatric hospitals (excluding bulk-billing by salaried public sector psychiatrists – which is a form of state-federal cost-shifting, rather than private care). One response to the COVID-19 pandemic was the introduction of telehealth items in the Medicare Benefits Schedule (MBS). As a result, there has been a substantial and sustained increase in the number of consultations provided by private psychiatrists. During the first 6 months of the pandemic, private psychiatrists provided 14% more consultations than in the corresponding period pre-pandemic, and in the state with the longest lockdowns, Victoria, the increase in number of consultations was 19% (Looi et al., 2021). In Victoria, telehealth accounted for 73% of this increase (Looi et al., 2021). This rapid and sustained upscaling of provision of care during a period of increased mental health distress therefore illustrates the flexibility of Australia’s private psychiatric care. Further research is required on the outcomes of telehealth, using the measures collected for private psychiatric hospitals.

This expansion of outpatient care was accompanied by substantial and ongoing psychiatric inpatient care as reported by the Private Psychiatric Hospitals Data Reporting and Analysis Service (PPHDRAS) of the Australian Private Hospitals Association (APHA, 2021). In 2019–2020, results for 69 private psychiatric hospitals reveal the significant size and outcomes of the sector. There were 42,942 inpatients with 1,286,470 days of care, and a mean length of stay of 19.6 days (SD = 13.9), with a 28-day readmission rate of 13%. The casemix comprised major affective and other mood disorders (49%), and alcohol and other substance abuse disorders (21%) (APHA, 2021). Clinician-rated outcome measures, i.e. the Health of the Nation Outcome Scales (HoNOS) showed an improvement effect size of 1.64; while the patient-rated Mental Health Questionnaire - 14-Item version (MHQ-14) showed an improvement effect size of 1.18 (APHA, 2021), both of which would be considered as high to very high. Process and outcome measures are similar for previous years.

The Australian Institute of Health and Welfare provides comparative data on the private and public sectors, surveying 160 public hospitals and 66 private hospitals in 2018–2019 (AIHW, 2021). For public hospitals, there were 213,370 separations/services with a short average length of stay of 12.7 days, and 28-day readmission rate of 15% (AIHW, 2021). Based on changes in HoNOS scores from admission to discharge available from the Australian Mental Health Outcomes Collection Network (AMHOCN, 2021), the calculated effect size is also rated as high (1.05), in common with the private sector. There are, of course, differences in casemix. For instance, private hospitals account for 78% of admissions for recurrent depressive disorders and 67% of admissions for mental and behavioural disorders due to alcohol use, while 95% of admissions for schizophrenia and 65% for bipolar affective disorder occur within the public sector (AIHW, 2021). Notwithstanding these differences, the data on length of stay, readmission and effect size suggest that both private and public sectors have delivered services that are equally effective, but also complementary.

With under-resourcing of public mental health services leading to care shortfalls and emergency department access block, it is worthwhile considering initiatives for private–public sector collaboration. One example was a federally funded Partnership Project between the publicly funded St. Vincent’s Mental Health Service and private The Melbourne Clinic (Pirkis et al., 2004). This was a shared care model facilitated by a liaison unit that matched patients to local private psychiatrists with public sector multidisciplinary team (MDT) support. The liaison unit was staffed by a public sector psychiatrist, two mental health nurses and a psychiatric social worker. The case-conferencing that facilitated the MDT support led to the development of the current MBS Items for psychiatrist case-conferencing. There was also secondary consultation to general practitioners (GPs), as well as clinical training and supervision of MDT staff. Elements of this partnership project should be adapted to provide complementary enhanced capacity to public mental health services, leveraging the skills of private psychiatrists for telehealth, as well as specific supervision and training in the management of affective and other mood disorders, and alcohol and substance abuse disorders that predominate in private psychiatric hospital care.

Health economic and needs analyses are needed to determine where gaps exist between the public and private sectors, and understand the benefits and costs of public–private partnerships. These analyses need to be complemented by more comprehensive process and outcome research, especially to assess the quality of care provided. Analogous process and outcome evaluation of the role of other non-governmental-organisation mental health services and the Private Health Insurance (PHI) sector will be needed to complete mental healthcare mapping and planning.

The future of private psychiatry

During the COVID-19 pandemic and beyond, Australia’s private psychiatrists will be essential for outpatient and inpatient psychiatric care for patients with serious mental illnesses such as major affective and other mood disorders, as well as alcohol and other substance abuse disorders, complementarily to public mental health services. Given the ongoing challenges for psychiatrist staffing in public mental health services, the reconsideration of public–private shared care models is especially relevant. Increased support for private sector psychiatry training through the federal Specialist Training Program would also help. Academic and research innovation, including public–private partnerships, have been championed by the private psychiatric sector, such as The Melbourne Clinic, Albert Road and Adelaide Clinics.

However, recent reviews by the Productivity Commission Report on Mental Health, the Royal Commission into Victorian Mental Health Services and the Fifth National Mental Health Plan have failed to adequately consider the role and impact of private psychiatric services. Private psychiatry should be recognised as a major part of the solution to current mental healthcare shortfalls and needs to be included in comprehensive mental health policy and planning in Australia.

The success of the additional MBS telehealth items, as demonstrated by their uptake by both patients and practitioners, suggests that they should be made permanent. Finally, it is important to address affordability through scrutiny of PHI profits, as well as adequate indexing of MBS fees so that they keep up with ‘real world’ increases in costs to medical practitioners of delivering services.