Victoria’s program to put GPs in high schools may provide a lesson in the value of early intervention
How many promising kids become underachievers during their teenage years because of impaired health, substance abuse or depression? The suspicion is, a lot.
The Victorian government is embarking on a potential game-changer, installing GPs in schools on a bet that giving teenagers easier, confidential access to healthcare during a crucial stage of their development will help stall cycles of ill health and disadvantage.
The state’s six Primary Health Networks are now finalising arrangements to establish bulk-billing GP clinics in 20 schools during the current school term. They are the first of 100 schools lined up for the Doctors in Secondary Schools program being implemented over the next year.
Dr Lena Sanci, a GP and Melbourne University academic who has advised the government on the roll-out, says the $43.8 million pilot program is in step with global thinking and could break new ground in adolescent healthcare.
“Adolescent health researchers around the world are looking at school-based health services as a way of reducing unmet healthcare needs in young people, because they are the lowest users of healthcare, particularly primary healthcare,” she said.
“Here we have a population starting to manifest mental health risks and behaviours that can set them on a certain trajectory through life, at a time of life when they are not seeing doctors.”
In no small part, the Victorian program – to put GPs in schools for up to one day per week in rural and low-socioeconomic areas – owes its existence to the success of a school-based clinic in the southwestern Melbourne suburb of Mulgrave.
Victorian Premier Daniel Andrews, the MP for Mulgrave, was an enthusiastic supporter of the scheme at Wellington Secondary College before he won government in 2014.
Hugh Blaikie, the principal of Wellington, said the community had happily accepted the scheme whereby the school’s 1800 students were free to make appointments at the clinic via a school-employed coordinator after their parents had given consent.
The clinic, operating since 2013, is served once a week by GP registrars attached to the nearby McKinley Medical Centre, who have proven a hit with the students. “We have these highly kid-oriented, dynamic, multicultural young doctors coming through for six to eight weeks at a time,” Mr Blaikie said.
Far from having misgivings over consent and confidentiality issues, parents in this heavily Asian-immigrant school community are avid supporters of the service.
“There has not been a single piece of push-back that I have heard of,” Mr Blaikie said. “It takes the pressure off the families. Where dad is doing shiftwork and mum is working, they don’t have time to take the kid to the doctor, and the kid does not have to take time off school to go.”
After his predecessor set things in motion with her vow to make the school a community hub for wellbeing, Mr Blaikie was honour-bound to follow through. Armed with a substantial government grant, he spent $80,000 on a second-hand structure comprised of two rooms with an office in the middle. The clinic is also used by psychologists seeing students on a pro-bono basis.
Students with a chronic illness would be regular visitors; others might never attend the clinic during their whole school career and would barely be aware it existed. But when a health issue arose, “there is never a reason not to go”, Mr Blaikie said. “It is one of the things of which I am most proud.”
While school-based primary care to address disadvantage has a 40-year history in a number of US states, a small group of school-based clinics in Australia, the UK, New Zealand and a few European countries has been developed in an ad-hoc manner.
In Australia, an evidence review turned up only seven examples, mostly in Victoria. From their experience, it was evident that mental health stood out as the issue that young people wanted help with most of all and was a key factor impeding their learning, Dr Sanci said.
“That’s fascinating because in routine general practice only about 8% present with mental-health issues, so there are clearly barriers being overcome in the school-based services.”
She also noted that schools with GP services reported teachers carried less of a load in terms of time and stress trying take care of students’ health needs.
As well as providing easy access to bulk-billed medical care, the Victorian program aims to “demystify” the consultation process and raise students’ health literacy.
“For this age group, barriers to healthcare begin with the ability to identify a health concern and knowing where to go. We see this process as preparing them to be able to seek health care anywhere,” Dr Sanci said.
In northwest Tasmania, Dr Jane Cooper has been operating a clinic at a senior high school for 16- to 18-year-olds since 2013. She has come to think society overestimates the ability of teenagers to negotiate the transition to taking responsibility for their health.
For this age group, barriers to healthcare begin with the ability to identify a health concern and knowing where to go.
“This process has allowed me to look at young people’s learning and their capacity to learn, the expectations that we have and the expectations they set for themselves. Sometimes those expectations are set way too high for their capacity to achieve. That can influence your management plan,” she said.
Dr Cooper is passionate in her belief that general practice is the specialty best placed to address main concerns of adolescent healthcare – preventive health, the development of healthy habits and the surmounting of social determinants. GPs should not underestimate the huge influence they could have on young people’s education and prospects in life, she said.
“It’s about taking the time to listen, taking their issues seriously and being actively engaged in doing something about those issues with that person,” she said.
“When kids are struggling in school or behaving badly, nine times out of 10 it’s because of a profound anxiety that they can’t quite work out how to manage. For some, we need to look at other avenues, part-time school or e-schooling, or consider medication to tone down their symptoms so they can stay in a classroom and learn.
“It’s rewarding, because it is such a crucial time in their lives.”
Dr Cooper became something of an accidental pioneer in the field, setting up shop in an empty room at Don College in Devonport, after the school’s social worker noted her evident rapport with young patients and the increasing numbers of youth referrals sent her way at a mainstream practice.
“It was a big step into the unknown, but it felt right at the time,” said Dr Cooper, who was named the RACGP’s General Practitioner of the Year in 2016 for her commitment to helping young people and her holistic approach to medicine.
“Adolescent health is a really interesting part of medicine that is really not been taught well in the medical curriculum,” she told The Medical Republic. “A lot of us are coming out with a big chunk of our medicine missing.”
On a clinical level, her school-based case load has ranged from serious mental health issues resembling psychosis and post-traumatic stress disorder to drug and alcohol issues, sexual health, STI screening and young people “just wanting a check-up to see what’s normal and what’s abnormal”.
She has been surprised, however, by the prevalence of complex conditions, such as young people presenting with anxiety, an eating disorder and complications from the eating disorder. More young patients were also showing up with chronic disease such as rheumatoid arthritis and asthma, and some with signs of impaired glycaemia linked to obesity.
Dr Cooper has opened the on-campus clinic to outsiders aged 12 to 24 to compensate for the paucity of youth services in Devonport. It’s an area where, she says, education has not been highly valued, literacy levels are low and too many children “have not been supported as little people”, but early intervention can make a difference.
“Financially, it’s a challenge, but the rewards are great,” said the GP, who also operates a three-doctor practice in Devonport’s CBD.
When kids are struggling in school or behaving badly, nine times out of 10 it’s because of a profound anxiety that they can’t quite work out how to manage.
“It’s fascinating because you can intervene and teach strategies early. I will be very interested to see what happens to some of these young people over the next 10 years, who will continue to see me after they finish college, and how they cope with the bigger challenges in life. You can head things off, before hysteria becomes a way to manage.”
In interviews conducted by University of Tasmania medical students, most of the school pupils said they wanted to talk about mental health, substance use and sexual health with their regular GP, even if they presented for another reason. The second-most important issues to discuss were contraception, STIs and pregnancy.
GPs have responded warmly to the Victorian initiative.
Dr Anita Munoz, a GP working with Northwest Melbourne PHN, which has three schools in the first round of 20, said the organisation had received “quite a number of expressions of interest” for each school and was now in the process of choosing the most suitable applications and finalising contracts.
“I think it could be enormously successful,” Dr Munoz said. “What we know is that this population under-utilises care. They have concerns about privacy and confidentiality and there are barriers to accessing care such as transport and cost. (The scheme) has the potential to do a great amount of good for the health of young people, and it makes a lot of sense.”
High-prevalence disorders such as depression and anxiety, if left unrecognised in young people, could affect their school attendance, their ability to complete assignments and their ability to complete school, she said.
Dr Ewa Piejko, a GP and medical adviser for the Murray PHN, which takes in a large rural area as well as regional centres such as Bendigo and Mildura, said doctors putting up their hand for the program had a keen interest in early intervention, preventive care and mental health.
“Another important aspect is that the GP will work closely with the school, to see if there are programs of information they can provide so students can improve their own healthcare. It will be more than just seeing people one on one.”
The state government’s $43.8 million outlay includes $25.8 million for operating costs and staff, including practice nurses, and $18 million to build consultation rooms at schools.
The first 20 schools in the Victorian program will start offering GP services during the current term, followed by 40 more in the third term this year and another 40 in the first term of 2018. Altogether, the program will provide GP access to some 70,000 students.