GP Link Lunches – Dr Angelo Virgona

Dr Kenneth McCroary, Chair of Sydney South West GP Link, hosts a series of meetings with clinical/political/regional individuals or organisations to discuss issues and solutions for GPs working in South Western Sydney.

Ken McCroary – Hello and welcome to another edition of GP link lunches with Dr Ken McCroary.  As you may know, I chair the amalgamated divisions of general practice of South West Sydney known as GP Link and unfortunately as we are all under strict lockdown orders I am holding this interview virtually. With me is Dr Angelo Virgona, current chair of the NSW branch of the Royal Australian and New Zealand College of Psychiatrists and medical superintendent at Macarthur Clinic in Campbelltown.

He is interested in mental health policy generally and deplores the current state of mental health funding and service delivery. He is interested in exploring innovative models to improve same including better coordination of the private/public interface, with particular interest in improving access to psychotherapy services for severely personality disordered and traumatised individuals. I am pleased to welcome Dr Angelo Virgona, Psychiatrist at Northside Macarthur, here to talk to us about a crisis advice service for GPs, particularly during the Covid-19 pandemic.

Ken McCroary – Hi Angelo are you able to tell us a bit about who you are and what organisation you are working for and who they are please?

Angelo Virgona – Hi Ken I am Angelo Virgona I am a Psychiatrist at General Psychiatric Practice Northside Macarthur Clinic in Dumaresq Street. This is a unit run by Ramsay, a 48-bed adult general private psychiatric unit and we deliver general psychiatric care to privately insured people but we also have a contract with the public sector and we take referrals from the Local Health District.

We mainly look after people with mood disorders, personality disorders, disorders related to trauma and the more severe end of anxiety disorders. We don’t tend to look after too many people as inpatients with psychotic disorders although we do have them occasionally of course. We are a private unit so we are not converted and we can’t keep involuntary patients although we are having some discussions around that for the future as to whether we would have that capacity.  We also provide day patient services so we have extensive day patient services programs run by our psychologists and clinical psychologist, particularly DBT, designed for people with borderline personality disorder or traits and so they are very popular those groups and quite effective with good outcomes. 

We have a range of other outpatient day programs for people with anxiety and depressive disorders. We also have ECT that we provide. We have quite a big list of ECT and we do more ECT than the public sector does and we provide that to the inpatients but also to people for only ECT. So there are some people that only respond to ECT. They have a course of ECT which might be anything from 8 to 12 sessions while they are an inpatient and they go home on antidepressants or mood stabilising medication they may then relax and if they continue to relax after courses of ECT we offer them maintenance ECT where they will have ECT on a weekly basis to begin with as an outpatient and then we stretch it out to fortnightly etc. so it is quite a big list of patients having ECT.

Ken McCroary – Obviously in this time it is really keeping you busy. We would also like to enquire about you and the organisation’s mission and objectives for the South Western Sydney region? 

Angelo Virgona – Well the objective of a private health organisation is to make money so that is primarily their objective, but Ramsay is an organisation that’s been committed to mental health for more than 50 years. In fact, Ramsay is the fourth largest private hospital group in the world, certainly the largest in Australia. It began when Paul Ramsay opened a small private psychiatric clinic in Cremorne in the early 1960s. So basically it provided psychiatric type clinics and expanded through to the 70s and 80s and then it sort of branched out to general medical and surgical and become this massive and successful company, so it has always had a strong commitment to mental health. From the perspective of the psychiatrists on the ground, there are 11 of us now and we are about to get a 12th psychiatrist to join our group. None of us are full time in private practice, we all have appointments elsewhere and most of the group have appointments at the Local Health District as VMOs or staff specialists. So there is a broad commitment from the psychiatric group to mental health in the south west. As you know I have been working in the south west since 1996 when I started as a VMO at Waratah House and Brown Street Community Health Centre, so I have been around for a long time myself and had various iterations to my career in the south west and ended up the area director for south west for about five years in the late 2000s then moved into the private sector. 

I tried to, I suppose we as a group, but I as an individual, tried to see in what ways we could come up with some innovative ways of delivering private sector services. It is very difficult within the constraints of the MBS. We have a difficulty where we have just got item numbers for face-to-face or telehealth consultations and there is not much else we can do. There is certainly very little innovation that occurs within the MBS structure but the arrival of the division of GPs and then the PHN there is some opportunities I think to deliver some psychiatric services in different models and Dokatela has been doing that through their service during the last few years.

We tendered as a group for that contract but we were unsuccessful, and we also tendered for the headspace psychiatry input contract last year or the year before but we were unsuccessful again so I think there is something wrong with our tender process. But I think that gives an indication we are keen to try to do something different, something extra, and provide a better range of services because we know that what we do. And we get the frustration from patients and GPs on a regular basis, trying to get access to our clinic and our clinicians, because five o’clock in psychiatry you fill your books in pretty quickly. With capacity to be able to offer more and more becoming limited over time, you get to the stage where people like me, where I close my books, which I have done for some time now, because I have a group of severely unwell or difficult patients that take up my time. I don’t have the time or resources to be able to provide anything extra.

What we try to do is bring new young psychiatrists in and they are enthusiastic, and they have plenty of space in their diary but over time the same thing will happen to them and that’s because, as we were discussing earlier Ken, of the problem with the MBS not really funding multidisciplinary care that allows a psychiatrist to work more of a consultant capacity rather than as a face-to-face treater and sometimes a bit of a case manager as well for their patients.

Ken McCroary – Yes, we do have had that problem with mental health funding throughout primary care as well, there is no doubt we need to encourage that cooperation. Now GP Link, as you know being a local organisation, we are wondering if you are aware of any issues and challenges facing GPs working in the south west of Sydney?

Angelo Virgona – Specifically I think you are dealing with, I mean the specific demographics of the population that is out there, that is particularly unique and we are talking about south west Sydney being Bankstown to Bowral – I mean that is quite a diverse range of communities and demographics. I think there are certainly some areas where it is extraordinarily difficult when dealing with populations which are very high in terms of non-English speaking. We are dealing with populations with significant social and economic disadvantage and then we have the poorest LGAs, the lowest income LGAs in the country here in South West Sydney, and we also have people that have come from traumatic backgrounds from various locations around the globe. So there are some really challenging groups GPs are dealing with and it means that trying to deliver care to those people is much more complex than delivering care to someone who comes from a relatively stable and financially secure position.

So there are those sorts of global issues that are affecting GPs of the south west, then there is also, I think, the issue of the number of psychiatrists amongst the population in the south west is lower than elsewhere in Sydney. We tend to find that outer metropolitan areas of the major cities like Sydney and Melbourne look much more like rural areas in terms of the numbers of psychiatrists per head of population, so that means there is a major struggle, as we were talking about earlier, it is really hard to get in to see people like me. I could put on another 20 psychiatrists in my place and I am sure I would have their books filled within a matter of months, so I think there are those challenges trying to get access.

One of the things we are trying to do during this crisis is provide GPs with the opportunity, if they want to, get some timely advice from a psychiatrist. We can do that if we are not particularly good at giving you an urgent appointment, at least we might be able to give you timely advice. So we came up with the proposal to provide a roster over seven days, of psychiatrists who will provide advice back to GPs. All you have to do is to send a text message – the GP to send a text message probably from the GPs mobile phone, that is what I would prefer because I prefer direct contact, and to be honest with you, the mobile phone that they are going to be texting to is going to be mine and so they have got to text me on my mobile phone if it is not my day I will just be forwarding the message onto Dr Cross, Dr Bharadwaj or one of the other members of the group who are on the roster and then they will get back to you. They will call you back and give you advice about the clinical issue you need to discuss, whether it’s a medication issue you want clarification on, what would be the next steps if there is an appointment coming up that you can’t get in and see the psychiatrist for a month or two and you have some concerns about the medication regime, that’s the advice we can give you in the meantime.

We can also give you advice around pathways care because we have got a good idea of how to negotiate the systems as well as links with good clinical psychologists that we refer regularly to. I’m sure that a lot of your GP members have those sorts of relationships already but for some other GPs that don’t do this on a frequent basis that sort of advice can be quite useful.

Ken McCroary – Yes absolutely and I think you have just segued into my last question. Which was what you think you can do to help support general practice and general practices in south west Sydney? And I think that this idea of yours to provide a rapid turn-around timely advice line through the text message is a superb way of assisting us dealing with, not just the acutely unwell mental health conditions we face, but also exacerbations and ongoing issues with the chronically mentally unwell also. With the world we are living in at the moment, with the mass exacerbations of tension for all of us. Just to some up, that advice line are you able to share with us the number you would like us to text?

Angelo Virgona – Yes, it is 0407 466 687 and all we want you to say is that it is Dr McCroary wanting some advice please call back. What we will do is either call back that day or that evening.  We will try and get everything done that day or that evening so we don’t have anything blowing into the next day. That is the way we are planning on doing it. We will see how that goes over the next couple of weeks and see if we need to fine tune the system a bit. We have got some advice that will go out from Ramsay because we told Ramsay about it and they have got their own database of GPs in the area so they will also be putting it out there. They want to actually put their little logo on it even though it wasn’t their idea, but you know anyway they are going to put it out there and also the PHN is also going to be distributing this. I think they were going to put it in the newsletter last week so hopefully the message gets out there and if GPs are worried about themselves too, we are not a doctor’s advisory line however if you are struggling and you need to connect with someone, let us know about that as well and we can give you some help in that direction through us, or the advisory service we are aware of.

Ken McCroary – That is a great point Angelo I really appreciate that offer the local GP practices have been struggling with the pandemic and vaccination and the whole mental health stressors that go along with that so having that knowledge that you guys are out there and approachable will be really helpful.

Once again, thank you so much again for your time today I really appreciate it.

And once again to remind everyone the text message number for Dr Virgona’s psychiatric service is:  0407 466 687.