Referral issues

Apart from screening and diagnosis challenges, there were also challenges for both the women and the HCPs within the referral process. Five common themes

regarding referral issues emerged from interview data. These issues included perceived lack of action, non-clinical support service use, timely referrals, personal and professional views of PND, and cost impacts on referral patterns and choices. These issues were common between both the HCPs and the women.

4.6.2.1 Perception of lack of action

Despite all of the women being screened by their CHN using the EPDS, only two women were referred on to other services. Both women were referred to their local parenting centre for assistance. One woman was referred to her parenting centre for assistance with sleeping and settling her baby. She reported that the assistance provided was not very helpful.

They didn’t call it controlled crying but it was basically controlled crying. They wanted me to put my baby down and just let her cry. I couldn’t handle listening to her cry. It just made things worse for me and my baby didn’t sleep any better. (Woman 10)

The other woman was referred to her parenting centre for help with breastfeeding. She reported that she felt “too much pressure to continue breastfeeding even though it wasn’t going very well.” (Woman 9)

While these two women had been referred for further support, no further screening was undertaken after visiting the parenting centres and they were not referred on to their GP for further screening or diagnosis. The data analysis indicates that none of the women were referred by their CHN to their GP for further screening and diagnosis. In each case, the women saw their GP without being referred. However, many went to visit their GP due to the urging of their partner or other family

members. For most women, the GP referred on to other services such as a psychologist or psychiatrist, or prescribed medication. One woman revealed that her visit to the GP was not helpful. She stated:

My GP was useless. When I went in he just said, “What do you want from me?” It would have been better if he had said “This is what I think and these are your options” or “Let’s try this and see how it goes.” But maybe, he just doesn’t have enough knowledge about PND or maybe he just doesn’t have the time? (Woman 10)

Beyond the challenges encountered by each of the women, four were highlighted among HCPs and a number of women. These challenges included generic services, timely referrals, personal and professional views of PND, and cost.

4.6.2.2 Non-clinical support services

There were government and non-government services, both clinical and non-clinical support services that were available to support women and their families. If women were screened, often what happened next was determined by information gained throughout the screening process, including the EPDS and interview. If it was determined that a woman was in the high risk range they were typically referred on to other services. However, it was felt that women were referred to agencies that were not mental health services or clinicians who could provide appropriate care. For example, it was highlighted that women were often referred to services such as Anglicare or City Mission, who provide physical and social support, but may not have the requisite staff or clinical skills to meet the needs of women with PND. In addition, it was highlighted that there was often a lag in time before a service or clinician recognised that further assessment was required and then linking women to the appropriate services. This difference in time may have led to further or continued poor mental health. It was observed that some services were good at this timeliness. However, there were other services which did not routinely screen, which had a large impact on the outcomes for women. One HCP stated:

There are some really good services that actually engage the women who need support and link them together with services… If the [PND] risk factors

are routinely screened for, then the support services would flow naturally. (HCP 2)

This process was further complicated by the lack of specialist services in various areas of Tasmania, which may cause delays in women being seen by the appropriate professionals or supported through the appropriate services.

4.6.2.3 Timely referrals

One of the biggest challenges reported by HCPs was the ability to get women into the appropriate services in a timely manner. For example, two HCPs stated:

You can’t get them in to see somebody today or tomorrow; it’s impossible. Even if they go to a GP… it can be four weeks to three months before they receive [psychologist or psychiatric] care. There is a lack of timeliness, which leaves us waiting… for far too long without therapeutic interventions. (HCP 3)

We have trouble getting an appointment straight away with the GP [and] the Mental Health Helpline… [is] very unhelpful and really quite rude at times. (HCP 5)

In order to assist with this challenge, perinatal mental health co-ordinators were employed at the parenting centres in Launceston and Burnie to assist CHNs to organise the appropriate care for women and their children. This may include clinical or nonclinical care. However, these positions were not permanent, but fixed term, funded by the National Perinatal Depression Initiative.

4.6.2.4 Personal and professional views of PND

In addition to timely referrals, there was the challenge of referring to health professionals who are appropriate for the women. Some HCPs expressed concerns about the attitudes of some GPs who were providing care to women who could have PND. This was specifically highlighted when one HCP stated:

I have one GP who just doesn’t believe in it [PND]. “It’s a load of rubbish; they are just mums who need to get over it…. You are just wasting my time.”

How could a woman talk to him? It’s really hard when you know they are a client of his but there is nothing you can do about it. (HCP 8)

On the other hand, some GPs were identified as being ‘PND friendly’. If there was a situation where a woman did not feel comfortable speaking to her GP, the HCPs could contact one of these ‘PND friendly’ GPs. Many of these ‘PND friendly’ GPs were women, which often made it easier for the woman to speak of her

experiences. However, as one HCP acknowledged:

This could be a good thing to do but that is also crossing some borders of ethics to tell someone to go to another doctor because they don’t get the answer they want from the doctor they’ve got. (HCP 8)

Overall, it was agreed that some GPs were excellent and refer to other services or specialists; some worked together very well with other HCPs; while others took the woman into their care. However, it was recognised that the personal and

professional views of a GP influenced which GPs women were referred to by other services; and impacted if and where a woman received further care after seeing a GP.

4.6.2.5 Cost impacting referral patterns and choices

Factors such as location, transportation, low cost health care such as ‘bulk billing’ and practices not receiving new patients due to ‘closed books’, also impacted the referrals women received to appropriate care. These factors play a large role in women’s ability to access timely and appropriate care.

Paying for services was highlighted as one of the key inhibiting factors among all patients, both those with limited and high incomes. The cost of accessing potential long term care from a GP, psychologist or psychiatrist was observed to be quite impossible for many, and inhibited the care being accessed. For example, one HCP outlined:

I think for the lower socioeconomic people, people struggling with money, it is much harder both because of the stressors of financial problems, social isolation and their access…it is more difficult….It comes down to if people

have the money to afford to see a psychologist or to afford their medications or to be able to afford to get some support like child care. (HCP 10)

In addition, a HCP specifically outlined the issues of cost and their frustration concerning the bureaucracy that patients encountered when attempting to access ‘free’ health care:

[A woman had] been offered… a certain number of free visits with a psychologist or psychiatrist. However, when she rang to make the actual appointment she was told that she would have to pay $130 upfront and then claim it back… I don’t know whether the GP just isn’t doing the correct paperwork or whether it’s the psychologist putting their own slant on things but it’s very frustrating. (HCP 5)