984242 ANP ANZJP ArticlesPaton et al.

Research

Australian & New Zealand Journal of Psychiatry

Clinicians’ perceptions of the 2021, Vol. 55(5) 494­–505

https://doi.org/10.1177/0004867420984242
DOI: 10.1177/0004867420984242

Australian Paediatric Mental © The Royal Australian and

New Zealand College of Psychiatrists 2021

Health Service System: Problems Article reuse guidelines:

sagepub.com/journals-permissions
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and solutions

Kate Paton1 , Lynn Gillam2,3, Hayley Warren1,

Melissa Mulraney1,4 , David Coghill5,6, Daryl Efron1,4,
Michael Sawyer7,8 and Harriet Hiscock1,4,9

Abstract
Objectives: Despite substantial investment by governments, the prevalence of mental health disorders in developed
countries remains unchanged over the past 20 years. As 50% of mental health conditions present before 14 years of age,
access to high-quality mental health care for children is crucial. Barriers to access identified by parents include high costs
and long wait times, difficulty navigating the health system, and a lack of recognition of the existence and/or severity of
the child’s mental health disorder. Often neglected, but equally important, are clinician views about the barriers to and
enablers of access to high-quality mental health care. We aimed to determine perspectives of Australian clinicians includ-
ing child and adolescent psychiatrists, paediatricians, psychologists and general practitioners, on barriers and enablers
within the current system and components of an optimal system.
Methods: A total of 143 clinicians (approximately 35 each of child and adolescent psychiatrists, paediatricians, child
psychologists and general practitioners) from Victoria and South Australia participated in semi-structured phone
interviews between March 2018 and February 2019. Inductive content analysis was applied to address the broad study
aims.
Findings: Clinician-identified barriers included multi-dimensional family factors, service fragmentation, long wait
times and inadequate training for paediatricians and general practitioners. Rural and regional locations provided addi-
tional challenges but a greater sense of collaboration resulting from the proximity of clinicians in rural areas, creating
an opportunity to develop support networks. Suggestions for an optimal system included novel ways to improve
access to child psychiatry expertise, training for paediatricians and general practitioners, and co-located multidisci-
plinary services.

1
 entre for Community Child Health, Murdoch Children’s Research Institute and The Royal Children’s Hospital Melbourne, Melbourne, VIC,
C
Australia
2
Melbourne School of Population and Global Health, The University of Melbourne, VIC, Australia
3
Children’s Bioethics Centre, The Royal Children’s Hospital, Melbourne, VIC, Australia
4
Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
5
Mental Health, The Royal Children’s Hospital, Melbourne, VIC, Australia
6
Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
7
School of Psychology, University of Adelaide, Adelaide, SA, Australia
8
Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
9
Health Services Research Unit, The Royal Children’s Hospital, Melbourne, VIC, Australia

Corresponding author:
Harriet Hiscock, Centre for Community Child Health, Murdoch Children’s Research Institute and The Royal Children’s Hospital Melbourne,
Flemington Road, Parkville, Melbourne, VIC 3052, Australia.
Email: harriet.hiscock@rch.org.au

Australian & New Zealand Journal of Psychiatry, 55(5)

Paton et al. 495

Conclusion: Within the current mental health system for children, structural, training and workforce barriers prevent
optimal access to care. Clinicians identified many practical and systemic ideas to improve the system. Implementation
and evaluation of effectiveness and cost effectiveness of these ideas is the next challenge for Australia’s children’s mental
health.

Keywords
Health service use, children, mental health, qualitative

Introduction psychologists, paediatricians and psychiatrists (Johnson

Mental health disorders are a leading contributor to the
global burden of disease (Vos et al., 2020). Despite increased
recognition and investment by governments in treatment,
the prevalence of mental health disorders in developed
countries remains unchanged over the past 20 years (Jorm
et al., 2017). Fifty percent of mental health disorders begin
before the age of 14 years (Kessler et al., 2005). Left
untreated, they can have lifelong personal and societal
impacts (Bor and Bor, 2001; Bosquet and Egeland, 2006).
Thus, it is crucial to ensure that children with mental health
problems can readily access high-quality mental health care.
The second Australian national Child and Adolescent
Survey of Mental Health and Wellbeing (known as Young
Minds Matter [YMM]) reported that approximately 14% of
Australian children aged 4–17 years experienced a mental
health disorder within a 12-month period (Lawrence et al.,
2016). The most common diagnoses were attention-deficit
hyperactivity disorder (ADHD, affecting 7.8%), followed
by anxiety (6.9%). Only 50% of those with a mental health
disorder had received services in the previous 12 months
(Johnson et al., 2016). However, among these children, few
receive a sufficient dose of care that would be likely to
improve their symptoms (Mulraney et al., 2020; Sawyer
et al., 2019).
A nuanced understanding of barriers and enablers to ser-
vice access is needed to inform the development of policies
and practices that will increase access and ensure that chil-
dren who do attend services receive the right treatment at
the right dose. Several studies have identified barriers to
care consistently reported by parents. The most commonly
reported barriers include high costs and long wait times, dif-
ficulty navigating the health system, a concern with being
blamed for their child’s problems, and a lack of recognition
of the existence and/or severity of the child’s mental health
disorder (Lawrence et al., 2016; Reardon et al., 2017;
Sawyer et al., 2000). Often neglected, but equally important,
is understanding clinician views about the barriers to and
enablers of access to high-quality care. We could find only
one study (conducted by our group, Paton and Hiscock,
2019) of Australian clinician perspectives, but this study
focused on autism and ADHD and did not include the views
of general practitioners (GPs). In Australia, the majority of
child and adolescent mental health care is provided by GPs,
et al., 2016). As such we aimed to expand previous research
by investigating the perspectives of Australian GPs, psy-
chologists, paediatricians and psychiatrists on:
1. The barriers to access and optimal care within the
current health system for children and adolescents
with ADHD and anxiety;
2. Components of an optimal system.
We chose to focus on mild to moderate mental health
problems (the ‘missing middle’; Rosenberg, 2015; Victorian
Government, 2019) as these are more common than severe
problems and lack of timely care may lead to deterioration
in the problem.
Methods
This qualitative study was nested within a larger study
‘Towards an equitable mental health system for children in
Australia’ (NHMRC grant 1129957), which investigated
current use of mental health care by Australian children and
adolescents and how best to improve care. The qualitative
methodology for this project was based on interpretative
description which aims to generate an understanding of
complex clinical phenomena which can lead to applied out-
comes in real-world circumstances (Thorne, 2016; Thorne
et al., 1997).
Approval was received from Human Research Ethics
Committee at The Royal Children’s Hospital, Melbourne,
Victoria, Australia, (HREC37105) prior to commencement
of the project. Prior to interviews, participants were
informed that their participation was voluntary and unpaid.
Verbal informed consent was sought.
Recruitment
A purposive sampling strategy was used to recruit clini-
cians in two states of Australia (Victoria and South
Australia) spanning clinicians across low and high socio-
economic settings (based on socioeconomic index for
advantage [SEIFA] of clinician practice postcode), major
city and regional areas and public and private work
settings.

Australian & New Zealand Journal of Psychiatry, 55(5)

496 ANZJP Articles

Table 1. Clinician characteristics by Victoria (VIC) and South Australia (SA).

Locationa Socioeconomic status Health setting

Regional/ Major Low Medium High Private Public Public and
remote (N) city (N) (N) (N) (N) only (N) only (N) private (N)
Psychiatrist 3 SA 9 SA 9 SA 7 SA 6 SA 0 SA 3 SA 6 SA
11 VIC 19 VIC 23 VIC 23 VIC 21 VIC 7 VIC 7 VIC 12 VIC
Psychologist 4 SA 7 SA 9 SA 9 SA 8 SA 9 SA 1 SA 1 SA
9 VIC 19 VIC 14 VIC VIC 22 21 VIC 22 VIC 0 VIC 4 VIC
Paediatrician 1 SA 6 SA 6 SA 5 SA 4 SA 1 SA 2 SA 3 SA
VIC 11 VIC 22 27 VIC 27 VIC VIC 21 4 VIC 8 VIC 17 VIC
General practitioner 3 SA 4 SA 6 SA 6 SA 2 SA 4 SA 0 SA 4 SA
7 VIC 24 VIC 21 VIC 23 VIC 19 VIC 12 VIC 2 VIC 14 VIC
a
Several clinicians practice in both regional/remote settings and major city settings.

Participants were sourced via three key strategies: web-
sites linked to professional organisations, e.g., find a
Psychiatrist (The Royal Australian and New Zealand
College of Psychiatrists, 2020); key informants (Marshall,
1996) from within professional networks of the clinicians;
and Internet searches of the first five pages on Google.
Where recruitment strategies generated lists larger than
20 clinicians for each group, a statistician not associated
with the project assigned a random number to each clini-
cian and the clinicians were contacted in order of the
numerical number assigned.
Procedures
A total of 143 (of 270 specialists and 165 GPs contacted)
semi-structured phone interviews were conducted with cli-
nicians (35 child and adolescent psychiatrists, 37 child psy-
chologists, 35 paediatricians and 36 GPs) from Victoria and
South Australia between March 2018 and February 2019.
Participants were provided with one of two alternately
allocated vignettes: either a child experiencing symptoms
of ADHD or a child with symptoms of anxiety (see
Supplemental Material) prior to the interview, to orientate
them to the population of interest. Interviews lasted approx-
imately 45 minutes. A semi-structured interview guide was
used to ensure the key questions were covered, but also
allowed participants to discuss what was important to them.
Detailed field notes were kept of all interviews.
Reflexivity was maintained by ongoing discussions
between researchers and a reflexivity journal. Interviews
were audio recorded and transcribed verbatim. Transcripts
were validated, de-identified and participants assigned
pseudonyms. Transcripts were then coded for analysis
using NVIVO 12.0 (NVivo, 2017) software.
Analyses
The study research aims provided the broad focus for anal-
ysis but following coding more ‘interpretive’ constructs
were developed using an inductive approach (Elo and
Kyngäs, 2008).
Three researchers (K.P., H.W. and S.R.) developed the
initial coding schema which was reviewed by senior
researchers (L.G. and H.H.) and applied to all transcripts.
Categories were developed in line with the primary
research questions and themes were identified using the
processes of content analysis. Regular discussion between
members of the research team ensured a rigorous process
of qualitative coding to identify similarities and differ-
ences, enabled iterative development and validation of
emergent themes. The lead analyst was a female Master of
Public Health (K.P.) with no clinical training. K.P. com-
pleted analysis until data saturation was achieved in rela-
tion to the research question. A further eight transcripts
were then reviewed for each clinician type. Findings are
reported in line with the COnsolidated criteria for
REporting Qualitative research (COREQ) (Tong et al.,
2007) checklist.
Results
Demographics
Characteristics of participating clinicians are shown in
Table 1. There was a spread of clinician types across prac-
tice and socioeconomic settings. More respondents prac-
tised in metropolitan than rural/remote areas and more
psychologists practised in private than public settings,
likely reflecting workforce distributions.
Findings
Analysis of the interview transcripts from a broad range of
participants revealed important themes which are presented
using verbatim quotes.
Some quotes have been truncated for space reasons
without changing the meaning. This is represented by an
ellipsis (...).

Australian & New Zealand Journal of Psychiatry, 55(5)

Paton et al.
The overall study identified five overarching key
themes. In this paper, we provide a summary of findings
from one key theme: health sector challenges and compo-
nents of an optimal system for child and adolescent mental
health care. Other key themes included health system fund-
ing models (with some overlap of the findings in this
paper); an evidence-based role for the education sector;
role of emotion and perceptions about mental health; and
supporting parents to support their child.
Clinician reports describing system barriers
to access and optimal care
All clinician groups raised issues about access to services.
Access to services is restricted by degree of severity and
complexity of the condition, age ranges for specific ser-
vices, fragmentation of services with no roadmap to navi-
gate, out-of-pocket costs and lengthy waiting times.
Clinicians identified multi-dimensional interrelated
individual and family factors which influence access to ser-
vices, including severity and complexity of the condition,
geographic location of services, age of the child/adolescent,
parental factors (e.g. health literacy, mental health, capacity
to pay) and individual personal circumstances such as
employment status.
At the extreme ends, i.e., when a child had conditions
sufficiently complex and severe to have access to publicly
funded child and adolescent mental health services
(CAMHS) or when families had a high degree of health
literacy and were able to pay for services, services were
relatively easier to access.
The term the ‘missing middle’ was used to describe
those that fell outside these two extremes and described a
very large group of families, children and adolescents.
The CAMHS model was identified as positive, in terms
of many practitioners in one setting but clinicians also sug-
gested that public mental health services (and specifically
CAMHS) have strict criteria for accepting a referral through
their intake processes and their capacity covers only a small
proportion of the need.
Although long waiting times were perceived to be more
likely to occur in public settings, clinicians perceived that
private services also had long waiting lists in all profes-
sions. This was reflected as impacting both referral to other
service providers and waiting times for clinicians’ own
practices. This varied according to location and was
reported to be worse in rural and low socioeconomic areas
where provision of specialist services is limited.
Furthermore, clinicians identified that the need to travel
long distances was challenging for families.
However, a greater sense of community and collabora-
tion resulting from the proximity of clinicians in rural areas
provides an opportunity to develop support networks. This
was perceived to provide a mechanism for closer liaison
and more coordinated care than that experienced by their
497
metropolitan peers. Table 2 provides a detailed summary of
system issues and solutions.
Clinician reports describing workforce
barriers to access and solutions towards
optimal care
Limited numbers of child and adolescent psychiatrists was
identified as an issue by all clinician groups including child
and adolescent psychiatrists themselves. GPs and paediatri-
cians feel they can manage some mental health conditions
but expressed a desire for more support from child and ado-
lescent psychiatrists for more complex cases. Psychiatrists
see one of their roles as consultants and advisors to other
professions.
A more general shortage of trained professionals for
younger (<12 years) children was seen across the sample.
Publicly funded psychologists were recognised as a
particularly scarce resource by all clinician groups.
Combined with lengthy waiting lists this led to clinician
burnout, particularly in regional areas. Clinicians expressed
the view that in some cases employment contracts were
short term and this led to high turnover in staff. In addition,
the workload in regional areas also had an impact on
recruiting new staff.
Many clinicians identified that the system of care is top
heavy with a focus on specialist medical staff when some
first-line mental health care management could be under-
taken by other professions, provided they were trained in
mental health.
Variability in the quality of services provided both at the
individual clinician level and organisational level was
identified.
GPs are typically considered to be generalists. Clinicians
suggested that opportunities for GPs to specialise in mental
health services could be valuable; however, some GPs did
not have an interest in paediatrics and/or mental health and
others felt they did not have the skills to treat mental health
conditions.
Within all clinician groups, appropriate training and pro-
fessional development was identified as a challenge par-
ticularly for those in regional areas. Table 3 provides a
summary of clinician identified workforce challenges and
possible solutions.
Clinician reports describing the challenges
of working together to improve outcomes
All clinician groups expressed the view that working
together would improve care. However, the health care sys-
tem is not structured for clinicians to deliver coordinated
care.
Many clinicians across all clinician groups wanted
clearer referral pathways and better communication
between clinicians.
Australian & New Zealand Journal of Psychiatry, 55(5)
498
Table 2. Clinician reports describing system barriers to access and optimal care.
Quotes describing problems
Complex systems – multiple factors impact access to services
Representative quote
‘It’s actually appreciating why kids can’t get to appointments. It’s not
just that they can’t afford it; it’s that Mum’s having her own panic
attack and can’t drive her that day, or they didn’t get the appointment
because Mum’s phone’s been cut off because she couldn’t pay it,
or they didn’t get the appointment because they’re actually living
in their car because Dad’s come home and kicked them out’. (VIC
Paediatrician 10, public/private)
Fragmented services
Representative quote
‘I guess that we’re looking at ... especially with a lot of the complex
cases, that there is such a big overlap between their physical,
particularly neurological development, their emotional needs, their
experiences that ideally you’d want to handle the things together’.
(VIC Child and Adolescent Psychiatrist 10, public/private)
Rules and restrictions but no roadmap about how and where
to find appropriate services*
Representative quote
‘I’ve heard people talk about the missing middle and I’ve
experienced that so often and its really frustrating ... and it happened
this morning with the young person I saw who has been suicidal off
and on ... [service] didn’t feel he needed an inpatient admission, he
doesn’t fit criteria for [mental health service] and he says to me that
he tried a number of psychologists in his local area, he’s been to
[service] and it didn’t help ... and then I’m sort of left, stuck, and not
really knowing where to fit him in the system’. (VIC Paediatrician 1,
public)
*Identified as a barrier by parents (Lawrence et al., 2016: Sawyer et al.,
2000)
Restricted access to services (the missing middle)*
Representative quotes
‘It’s a huge barrier because when we turn people away from CAMHS
because they really don’t meet the complexity and what is needed
to take someone on to the extremely expensive intervention of kind
of case management and therapeutic care in CAMHS, then for a
whole lot of them, it’s kind of “well, what now?”’. (VIC Child and
Adolescent Psychiatrist 1, public/private)
‘So Child and Adolescent Mental Health are really important, but
they’re also being marginalized in a way because now they’re being
asked to only take referrals for sort of the most difficult, complex
cases and yet there’s a big gap between what they can provide and
what a private practitioner can provide with only ten sessions a year.
There’s a whole gap in the middle there’. (SA Psychologist 2, private)
*Identified as a barrier by parents (Lawrence et al., 2016;
Sawyer et al., 2000)
Out-of-pocket costs for services*
Representative quotes
‘Some of the parents clearly say, “I can’t even afford the $50 extra
gap that they charge us”’. (VIC Paediatrician 28, public/private)
‘Well, they have to wait ’cause they can’t have treatment. They
don’t have a choice. Like you know, if you’re broke you don’t
have access, that’s the reality’. (SA Psychologist 5, public/private)
*Identified as a barrier by parents (Lawrence et al, 2016; Sawyer
et al., 2000)
Australian & New Zealand Journal of Psychiatry, 55(5)
ANZJP Articles
Quotes suggesting solutions
Integrated multi-disciplinary services
Representative quote
‘I mean in some way it would be nice to see a kind of, well, a
department of paediatrics in each region, that focuses on children,
well you know, the developmental stages from nought to 18 or even
higher in terms of physical, social, emotional needs so that you know,
everything is much more integrated’. (VIC Child and Adolescent
Psychiatrist 10, public and private)
Integrated multi-disciplinary services
Representative quote
‘In the ideal world a lot of us would be co-located. ... we need more
time, we also need funding for planning time and case consult and
multi-disciplinary assessments and other services around providing
best quality care’. (VIC Psychologist 14, private)
Information about how and where to access services with assertive
follow-up
Representative quote
‘From experience, I know that parents struggle to navigate the system
and sometimes the clinicians don’t know what the pathways are ...
if there is a simpler pathway that the parents can follow and the
practitioner knows where to direct them, then that will be the easiest
thing. ... and then some mechanism of making sure that this child and
the family is followed through ... and the child is not being lost’. (SA
Child and Adolescent Psychiatrist 4, public/private)
Access to specialist services
Representative quotes
‘I think would be really helpful if we had ... better access to clinical
questions, so one thing you can do in the UK is send a fax with a
clinical question, so essentially you’d send a referral letter and they
send what their advice would be back, so it’s a same day advice
service’. (VIC GP 2, private)
‘... we’re thinking about at least three monthly forums for GPs, where
every three months, we invite the GPs to an education session
from CAMHS, and then keep this as an ongoing thing where it’s
also spreading the awareness, and also kind of helping the GPs to
understand how mental health works, what is a triage for mental
health? What to expect when they’re referred?, when to refer? ...
and when CAMHS is saying we want to send down this client to
the community, and they can be managed by the GPs, what are the
expectations? All that is what we’re trying to kind of plan’. (VIC Child
and Adolescent 6, public/private)
Increased rebates for bulk billed services
Representative quote
‘... they currently can come and not have to be out of pocket but it
relies on the clinician bulk billing the service, and the bulk bill rates
haven’t changed since about 2010. So the burden then is put back
onto the clinicians. So if that was gone, if the clinicians could still be
paid properly and the patient wasn’t out of pocket, that would be
great’. (VIC Psychologist 6, private)
(Continued)
Paton et al.
Table 2. (Continued)
Quotes describing problems
Waiting times for accessing services*
Representative quote
‘... long waiting lists for psychologists up here, sometimes six months.
And similarly for paediatric reviews ... nine to twelve months is what
I’ve heard of up here’. (VIC Child and Adolescent Psychiatrist 18,
public)
*Identified as a barrier by parents (Lawrence et al., 2016; Sawyer
et al., 2000)
Impacts of geographic location*
Representative quote
‘When I was in [country town] which is a remote, rural area, there
was a huge non-compliance rate because the patients there were
isolated in many, many situations. I certainly found that having an
outreach clinic improved the situation ... but after hours, on the
weekends was a bit difficult getting the psychiatry input’. (VIC
Paediatrician 18, public)
*Identified as a barrier by parents (Sawyer et al., 2000)
Funding system
Representative quotes
‘On one hand, the public sector wants more things to be shifted
to us. On the other hand, we have noticed that it’s becoming very,
financially hard, to be honest to you. If you want to do a proper
mental health plan, looking at everything physical and mental side,
you need at least half an hour, but how you going to run a medical
centre if you do that?’ (VIC GP 6, bulk billing/private)
‘You’ve got some GP practices that would see without any
exaggeration, they would see eighty cases a day. Eight zero. Well,
there obviously not the sort of practice that is well suited to this
sort of coordinating and case discussion’. (SA Child and Adolescent
Psychiatrist 5, public /private)
Medicare items numbers
Representative quote
‘One of the biggest obstacles I find is that ... there’s no facility under
Medicare system to see the parent without the child, at least in the
practice. And that can be problematic because a lot of the work
most of the time needs to be done with the parents. (VIC
Psychologist 6, private)
‘My ideal world is I don’t have a limit on sessions ... And I don’t have
to always be thinking how am I going to make best use of this client’s
10 sessions? Do I use four now and save six for the end of the year
when I know that she, historically, will have more issues as they get
tired throughout the year?’ (VIC Psychologist 6, private)
Effective communication between practitioners was
considered an enabler for optimal care. In the absence of
a systematic way of communicating, clinicians identified
ad hoc arrangements they had developed which were
effective in supporting children and families to receive
improved care.
Some ad hoc arrangements develop from connections
with colleagues.
However, others developed their own support networks
without a personal relationship. Co-location was a possible
enabler of improved communication. Table 4 provides a
499
Quotes suggesting solutions
Grassroots mental health services*
Representative quote
‘Ideally, it would be more publicly funded services, but also putting the
services at a grassroots level; having it more accessible to families’.
(VIC Paediatrician 10, public/private)
Collaboration provides support
Representative quote
‘In the rural region, it’s very collaborative. You usually make some
sort of connection and professional with the person on the other end
of the phone. ... And you know, sort of get to know how the other
works, and you’ll know their thresholds and their needs’. (VIC Child
and Adolescent Psychiatrist 31, public)
Robust primary care system
Representative quote
‘Primary care is not valued and that’s really obvious from the way the
funding system works in the health system where you’ve got this very
heavily funded tertiary system, which gobbles up all the money and
primary care gets the crumbs. In lots of ways, it should be the other
way around. If you had a really robust primary health care system
where people could get, not just the mental health support that they
needed for minimal cost to themselves, so it was very well funded, ...
If you had that, and across the board, not just in mental health but in
all aspects, then we wouldn’t need such a big tertiary system. There’d
be a lot of stuff that would get sorted out at the primary care level,
at the community level where it should get sorted out’. (SA GP 3,
private)
Changes to Medicare funding
Representative quote
‘... lift the restriction that you have to have the client present so
that you could freely have sessions with just the parents on some
occasions so that you could have that whole hour to talk with the
parents and workshop with them’. (SA Psychologist 2, private)
‘We can’t charge for phone calls, but I think you know if you could
speak to a client over on the phone and that could be billed under
Medicare, that could be really helpful as well, ’cause I’ve had clients
who can’t come in, you say can you call me for a therapy session, and
it’s not covered by Medicare and they can’t pay, so I end up doing it
pro bono. So stuff covered by Medicare, phone, Skype’s covered now,
you know email maybe, that could be helpful’. (VIC Psychologist 5,
private)
summary of clinicians’ views of the challenges in commu-
nication and how to address them.
Discussion
This is the first study reporting clinicians’ perceptions of
the major barriers faced by Australian young people and
their parents when seeking help for common child and ado-
lescent mental health conditions.
Clinicians identified barriers at three levels: (1) parent
– poor mental health literacy, competing life stressors;
Australian & New Zealand Journal of Psychiatry, 55(5)
500
Table 3. Clinician reports describing workforce barriers to access and solutions towards optimal care.
Quotes describing problems
Lack of training for GPs
Representative quote
‘Some are very proactive and are willing to work with young people
who have mental health issues. ... but unfortunately I could say that
a third or a quarter of GPs are very anti-mental health and I think
that’s partly is because of the degree of anxiety that they feel as
individual clinicians themselves, their lack of training ...’ (SA Child and
Adolescent Psychiatrist 8, public/private)
Lack of training for paediatricians
Representative quote
‘As paediatricians, we tend to end up having to see these children
and manage these children because of the stress on the mental health
system and the lack of availability of you know, child psychiatrists in
our public mental health system ... So I think that you know improved
training, improved support around that for pediatricians, is really,
really important’. (SA Paediatrician 1, public)
Lack of Psychiatry availability
Representative quote
‘Yeah, I had a GP in my rooms the other day very upset cause my
books were closed, and was really angry about it actually, sort of
yelling at my receptionist. . ...and then I called them back, and they
were kind of making a few comments like, “what a luxury to be able
to close your books, I should’ve been a child psychiatrist”’. (VIC Child
and Adolescent Psychiatrist 1, public/private)
Appropriate utilisation of workforce
Representative quote
‘I think we’ve got a system at the moment which to me is a little bit
like expecting the cardiologist to see everyone with chest pain ... and
we certainly don’t have enough cardiologists to do that ...’ (SA Child
and Adolescent Psychiatrist 5, public/private)
System reliant on specialist services
Representative quote
‘What I find as a general paediatrician in the community is that I end
up being everything. I’m the social worker and the speech pathologist
and the nurse, and they end up getting someone who’s quite
expensive but very well-trained holding a lot of stuff that could be
done by a case manager ...’ (VIC Paediatrician 10, public/private)
Challenges of staffing in regional locations
Representative quotes
‘After I’m up in [regional towns] l often you have to carry very hard
difficult caseloads. Often days when you’re the only ones there, and
not having a colleague to talk and speak with is really hard, and we
have a problem recruiting staff to the more regional clinics because
there’s just not the staff in those towns’. (VIC Child and Adolescent
Psychiatrist 31, public)
‘So obviously, training tends to occur in the capital cities, and so
it’s difficult to organize that and particularly when you’re a bit thin
staffing-wise’. (VIC Child and Adolescent Psychiatrist 18, public/
private)
Australian & New Zealand Journal of Psychiatry, 55(5)
ANZJP Articles
Quotes suggesting solutions
Improved training for GPs
Representative quote
‘GP trainees to be able to do more rotations, so long, extended
rotations within a CAHMS service, I think would be very helpful’.
(VIC Child and Adolescent Psychiatrist 4, public/private)
Improved PD and training opportunities
Representative quote
‘There should be more training in paediatrics about mental health
disorders for children, and there should be more training in psychiatry
about paediatrics. That’s another practical thing, I think. But I don’t
think it’s our job as paediatricians to take over what psychologists do’.
(VIC Paediatrician 6, public/private)
Novel ways to access psychiatry services
Representative quotes
‘I think would be really helpful if we had ... better access to clinical
questions, so one thing you can do in the UK is send a fax with a
clinical questions, so essentially you’d send a referral letter and they
send what their advice would be back, so it’s a same day advice
service’. (VIC GP 2, private)
‘It’s really, it is kind of like a secondary consult service. I think that
would be brilliant. We’re trying to build that into the Doctors in
Schools program. Trying to get that to be like a peer support, and also
secondary consult’. (VIC GP 31, bulk billing)
Psychiatrists as consultants
Representative quote
‘In my ideal world, I might have a more consultative educational role
in discussing the more high-end complex cases, and holding systems,
and all the anxieties that that provokes. Rather, than just coming in
as specialists and writing a letter with a diagnosis on it’. (SA Child and
Adolescent Psychiatrist 7, public)
Use of other workforces, e.g., Mental health nurses, for first line of
mental health response
Representative quote
‘... mental health nurses or mental health OTs can manage it. You
know, there a place for that stepped up care approach so that
there’s a mental health nurse in every GP practice ..., skills training
or parenting training or sleep training or behaviour training ...’ (SA
Psychologist 3, private)
More funding
Representative quote
‘a big grant of funding ... or at least potentially Commonwealth
funding to support more visiting allied health type workers, you
know, working in the country would be a great help’. (SA Child and
Adolescent Psychiatrist 3, public/private)
(Continued)
Paton et al.
Table 3. (Continued)
Quotes describing problems
Lack of interest in mental health
Representative quote
‘I see my role as, I often compare this to say, heart disease. I see a
patient, I diagnose. I can work-up, I can do the blood test and I can
come up with what I think is the diagnosis and then I refer to the
specialist. And then the specialist takes over and treats them. And I
think that’s how mental health should be. Because as GPs we don’t
have the skills to carry out counselling and advice and all those
things’. (SA GP 10, bulk billing/private)
Variability in the quality of services provided
Representative quotes
‘GPs who are perhaps less inclined towards managing mental health
on their own, and there are GPs who just flatly refuse to. They tell
patients, and we know who those ones are because, you know, when
they refer to a psychiatrist it’s just a one-liner, “Please take over the
care”’. (SA Child and Adolescent Psychiatrist 2, public/private)
‘Well if we start with at the GP level, so I feel relatively confident
and happy seeing adolescents for mental health issues, but not all
GPs would feel the same. And that may be because, they simply don’t
see many adolescents, or they don’t see a lot of mental health. So I
think there’s a large variation between GP’s in terms of experience,
knowledge, skills, and I guess general comfort in managing these
issues. That’s potentially a barrier there, that they may not be getting
the treatment they need from the GP’. (VIC GP 15, bulk billing/
private)
Lack of services for children under 12 years
Representative quote
‘I’m getting clients re-referred back to me because they’re not seeing
kids that young. So they’re calling themselves a child psychologist but
they’re not actually seeing children under the age of eight ... there’s
just not enough trained professionals’. (SA Psychologist 3, private)
(2) service – long wait times, restrictive entry criteria,
large out-of-pocket costs, fragmentation of services; and
(3) workforce – need for better training, need for better
access to specialist support for GPs. These clinician-
identified barriers are strikingly similar to those reported
by parents in the two Australian child and adolescent
national mental health surveys (Lawrence et al., 2015;
Sawyer et al., 2000). For example, parents in both sur-
veys also reported that not knowing where to get help,
long waiting lists, high costs and geographical distance
were major barriers to getting effective help for children
and adolescents with mental health problems. The
501
Quotes suggesting solutions
Opportunities for GPs to specialise in (child) mental health services
Representative quote
‘I think GPs are really important, but again, if you think the skillset
of paediatricians is varied, the skillset of GPs is very varied. I think
that GPs who are interested in child and adolescent health should be
supported and they should be educated on child physical and mental
health’. (VIC Paediatrician 6, public/private)
Medicare item numbers for mental health trained GPs
Representative quote
‘In an ideal world I’d like to do what the government did a few years
ago, and chucked a whole lot of money at training GPs in mental
health in adults, and released MBS item numbers so that they could
be remunerated for doing this kind of work, as part of improving
mental health in adults, but doing this in kids and so that GPs will
have a module to do, and once they’ve done that module in three or
four conditions, then this module will allow them to manage these
conditions in a way that’s clearly evidence based, and also allow those
GPs that have done this module- there will be a period of assessment-
and then they should be allowed to prescribe the stimulant
treatment’. (VIC GP 1, bulk billing/private)
Specialist services for children under 12 years
Representative quotes
‘... children’s centres, and they are funded by the Department for
Education. They’re sort of places where there are often childcare,
possibly kindy. They often do have a speech pathologist and OT
onsite, and they may have a social worker, they currently provide
services up until five years, and sometimes up until eight years. So I
think that sort of service, if expanded, and if able to provide more
assessments. So, at the moment they don’t do a lot of assessments,
it’s mostly sort of, general support stuff. But if they were able to
provide more developmental assessments, if they were able to
provide more social work support, more parenting support to
families, and perhaps expand the age up until sort of 12. I think the
potential there for, you know, really a lot more support for families, I
think that would be really useful’. (SA Paediatrician 1, public)
‘But they only start from twelve as well. So there’s kind of that
missing for children. Like a [service] equivalent for children where
it’s not government, which is a very complex, low SES, high risk one.
Not privately where they’re paying up to a hundred dollar gap but
that, yeah [service] equivalent for children’. (SA Psychologist 5, public/
private)
barriers are also similar to those reported in our smaller
(n = 30) study of clinician perspectives about the care of chil-
dren with complex mental health conditions using ADHD
and Autism as exemplars (Paton and Hiscock, 2019). The
consistency of results across these different groups suggests
that these barriers should be given the highest priority in
future planning for services designed to help children and
adolescents with mental health problems in Australia.
This study extends previous work by including GPs as
respondents. Results from GPs highlight the extent to
which these clinicians want better access to secondary con-
sultation with mental health specialists and also better
Australian & New Zealand Journal of Psychiatry, 55(5)
502
Table 4. Clinician reports describing the challenges of working together to improve outcomes.
Quotes describing problems
Lack of structures within the health system to support communication
Representative quotes
‘I don’t think private psychiatrists or GPs have very much time to
liaise with each other, and I think I write these lengthy letters every
now and again and I wonder who reads them ... when I do have
conversation with GPs, even really short ones, I think we both come
out of it better off’. (VIC Child and Adolescent Psychiatrist 1, public/
private)
‘There’s probably not a lot of communication between psychiatrists
and paediatricians around management of children with mental health
disorders. There’s no real forum for that to occur. ... So I can actually
say to you, that with regards to children that I look after, it’s very
unusual for me to get on the phone and even speak to a psychiatrist.
Maybe there needs to be some sort of you know ability for that to
happen’. (SA Paediatrician 9, public)
Difficulty accessing resources
Representative quote
‘And I’m sure there are resources and central points of information
available but then I don’t know about them. And so trying to sort of
keep on top of what’s available, where, and when, it’s quite difficult’.
(VIC GP 19, private)
Insufficient time for case management
Representative quote
‘All of that stuff that would make it great quality care. You don’t get
given time for report writing that would mean that you could get a
really succinct letter out to a teacher that could change a lot of things
at home. You don’t have the time allocated necessarily into your diary
to do that because you have to see x number of clients in a week to
get statistics’. (VIC Psychologist 16, public/private)
Process duplication
Representative quote
‘I think there’s a lot of duplication. So I’ve done my thorough
assessment, but so too has the paediatrician and so too has the
psychologist and we all kind of applaud each other for getting the
same history but really from the child and family point of view that’s
the same history that’s been delivered three times over’. (SA Child
and Adolescent Psychiatrist 5, public/private)
Australian & New Zealand Journal of Psychiatry, 55(5)
ANZJP Articles
Quotes suggesting solutions
Formalise communication mechanisms between clinicians
Representative quotes
‘I guess I have built up a big enough, sort of, referral base that I can
actually pick up the phone and ring, and say, “Look, I’ve got this
family, what can we do?” And usually, if you’ve got a relatively good
relationship with the other providers, they’ll, you know, they’ll fit
them in ... Yeah and that’s taken me years to establish. You know, 20
or more years’. (VIC GP 19, private)
‘... One good discussion often shores up their [GP’s] understanding
and in a sense, they can get on with the work. But a lot of it comes
down to having my own personal connections with paediatricians,
GPs, allied health professionals, that I know, and that know me.’ (VIC
Child and Adolescent Psychiatrist 31, public/private)
‘So I’ve sort of made friends with the psychiatrist and I’ve text and emailed
her. I have never seen her ... She’s been kind enough to reply. And I’ve sent
a few referrals on to her but, again, she’s very expensive and she’s private
so not all my patients can see her’. (SA Paediatrician 4, private)
Centralised system
Representative quote
‘I would like central source of information, whether it’s like a website
for example that is easy to access and navigate that gives me a list
of people in my area in terms of whether psychologists or social
workers or psychiatrists or whatever, who for example, see kids
and adolescents. Or what they do, their approximate waiting times
if they can tell that, fees, and then the best way to contact, whether
email or phone or whatever. So that I can go to that and find that
information quickly. There is for example the find a psychologist or
find a psychiatrist with the Australian Psychological Society, but they
don’t have much information, and you still have to ring around to
find out if they are actually taking new patients and what are their
fees, for example, so something that’s kind of regularly updated and
comprehensive would be, I think quite a simple but very useful thing
to do’. (SA GP 1, private)
Upskilling as a means of case management
Representative quote
‘the structure that we have developed for CAMHS in the region
here, is pretty robust, I would say, and has been kind of reviewed
as well, by quite a few. So having that front end and having this
core case management upskilling of the second tier services, regular
stakeholder meetings that we have planned ... I think that structure is
... at this stage, is near to ideal. It’s just the lack of resourcing for that
structure’. (VIC Child and Adolescent Psychiatrist 6, public/private)
One stop shop
Representative quotes
‘We already know that co-location of services, one stop shop, it’s
good for everything. There is a lot more that I can chat about over
a cup of coffee while in the kitchen when the kettle is boiling, than
I can do writing on a letter head, which is going to take time and
effort and everything. Paperwork is important ... but the nonverbal
communication that goes with having a chat with the therapist is
of utmost important. Paperwork is there. You need to just do the
paperwork, but the strength that you can use in verbal communication
overrides any of the paper communication’. (VIC Paediatrician 28,
public/private)
‘What would be really good is if you had it all in the one setting,
where they would just go to the one place where they could see
the variety of people, instead of having to go to, say, a private
paediatrician there, the private psychologist over there, you know the
school over there, then the GP here and it’s all sort of very scattered.
Not easy access for the families too, because often the families have
got other kids as well, they’re competing interests. After school,
they’ve got to be taken here, there and everywhere and it becomes
very tricky for some parents’. (VIC GP 19, private)
Paton et al.
training, particularly in relation to the management of acute
child and adolescent mental health problems.
This study focused more specifically on mental health
care than previous studies (as opposed to education and
social care), purposively sampling clinicians working
across diverse socioeconomic areas and including ADHD
and anxiety as the two most common child mental health
disorders. We could find no other study reporting on clini-
cian views of how to improve the mental health system for
children. Although the study is limited to clinicians work-
ing in one of two States in Australia, we believe results are
readily generalisable to all Australian States and Territories
(Paton and Hiscock, 2019).
Our findings suggest several avenues for improving the
current system for children and are especially pertinent
given the potential increase in mental health problems with
the Covid-19 pandemic. These avenues include increasing
the availability of specialist mental health support to non-
specialists such as GPs and paediatricians via email, tele-
phone or telehealth, as per successful US models (Sarvet
et al., 2010). With the Covid-19 pandemic, most clinicians
have pivoted to telehealth. Anecdotally, this seems to suit
many families and clinicians, but rigorous evaluations are
yet to be published and telehealth may not deliver effective
care for children and adolescents with complex mental
health problems.
Clinicians also called for a centralised service that pro-
vides information on services and pathways in a staged
manner, responding to the child’s needs. While some major
mental health initiatives provide this type of support for
adolescents and adults (e.g. Beyond Blue, 2020), they do
not provide information relevant to children under 12 years
of age. Furthermore, many websites suggest patients should
seek help from GPs in the first instance, but our study sug-
gests that GPs want more effective specialised support
when assessing and treating child and adolescent mental
health problems.
Many clinicians in this study called for increased train-
ing in child mental health, including practical experience
working in public specialist mental health services. For
GPs, this would require significant changes to their current
vocational training requirements for paediatrics which
largely focus on medical and not mental health or behav-
ioural problems (The Royal Australian College of General
Practitioners (RACGP), 2020). Telementoring is one
approach that might allow for GPs to upskill in child mental
health. Project ECHO is a telementoring model which uses
proven adult learning techniques and interactive video
technology to connect groups of community providers with
specialists at centres of excellence in regular real-time col-
laborative sessions (Zhou et al., 2016). Queensland
Children’s Health has been using the Project ECHO model
(Queensland Children’s Health, 2020) for ADHD and
behavioural concerns, with positive feedback from clini-
cians involved (Dr Newcomb, Medical Director Integrated
503
Care, Queensland Children’s Health, personal communica-
tion). More intensive approaches include the REsource for
Advancing Children’s Health (REACH) project in the
United States (The Reach Institute, 2020) which provides
interactive skills building followed by a 6-month case-
based distance-learning programme or the United
Kingdom’s general practitioner with special interest (GPSI)
model where GPSIs take referrals from other GPs and work
within integrated consultant-led clinical teams in addition
to specialists (Yellamaty et al., 2019). This model has been
associated with superior patient satisfaction and compara-
ble outcomes to specialists but requires appropriate train-
ing, mentoring and ongoing professional development for
GPs and employers adopting this role.
Co-location of ‘private’ and ‘public’ services that provide
help for the emotional, physical and social needs of children,
parents and families has the potential to overcome several
current service barriers identified by clinicians and parents.
For example, co-location of such services has the potential to
reduce current service fragmentation and to make it easier
for parents to know where to get help for problems in these
areas. The latter is an important issue because comorbid
problems at the child, parent and family levels are common
among children and adolescents with mental health prob-
lems. Co-location of services would allow children and par-
ents to more easily access services that could address a range
of such comorbid problems. The closer proximity of services
would also encourage better co-ordination and information
flow between staff in co-located services.
The current Medicare emphasis on funding based on the
‘fee for service’ concept limits opportunities for even co-
located staff and services to work together in a coordinated
and cooperative manner. This is a significant problem for
the effective assessment and management of children with
mental health problems, many of whose mental health
problems are entwined with family, education and social
issues – all of which may need addressing before a child’s
mental health will improve. As recommended in the
recently released Productivity Commission into Mental
Health (recommendation 10.3) (Productivity Commission,
2020), funding models that encourage different clinicians
and services to work together more effectively have the
potential to help address this issue.
In summary, the provision of help for children and ado-
lescents with mental health problems in Australia has often
floundered as a result of major structural, training, resource
and workforce issues. Clinicians in this study identified a
range of barriers and potential solutions to these problems.
It is notable that the issues identified by clinicians were
strikingly similar to those identified by parents in the two
Australian national child and adolescent mental health sur-
veys. The challenge now is to get the Australian Government
along with State and Territory Governments to use the
information provided by both clinicians and parents when
developing, implementing and evaluating new systems of
Australian & New Zealand Journal of Psychiatry, 55(5)
504
care for Australian children and adolescents with mental
health problems.
Acknowledgements
We would like to thank Shea Rendall for her assistance in inter-
viewing participants. This research project was completed as part
of the ‘Towards an evidence-based and equitable mental health
system for children in Australian project’.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest
with respect to the research, authorship and/or publication of this
article: D.C. reports grants and personal fees from Shire, personal
fees from Eli Lilly, personal fees from Medice, personal fees from
Novartis, personal fees from Oxford University Press, grants from
Vifor, personal fees from Servier, all outside the submitted work.
All other authors have no financial relationships relevant to this
article to disclose.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship and/or publication of this article: The
project’s study design and conduct, data collection, management,
analysis and interpretation were funded by National Health and
Medical Research Council (NHMRC) Grant No. 1129957. H.H. is
supported by NHMRC Practitioner Fellowship Award 1136222.
The Murdoch Children’s Research Institute administered the grants
and provided infrastructural support to its staff but played no role in
the conduct or analysis of the research. D.F.’s position is funded by
a Clinician Scientist Fellowship from MCRI. The Victorian
Government’s Operational Infrastructure Support Program support
research at the Murdoch Children’s Research Institute.
ORCID iDs
Kate Paton https://orcid.org/0000-0002-2210-8667
Melissa Mulraney https://orcid.org/0000-0003-1953-6481
Harriet Hiscock https://orcid.org/0000-0003-3017-2770
Supplemental Material
Supplemental material for this article is available online.
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