A qualitative exploration of the perceived barriers and enablers of providing mental health care in rural Australian general practice

Limited access to services and specialist support

All participants consistently emphasised the significant challenges with accessing mental health services in rural areas. They highlighted a scarcity of local resources, including a shortage of mental health-trained staff such as psychologists and psychiatrists, as well as specialised mental health teams and GPs trained in mental health. There was recognition of the value of visiting mental health specialists to address mental health service gaps, but visits tended to be infrequent (e.g., once a month or week), and participants highlighted difficulties in accommodating emergency cases due to scheduling constraints. This meant that patients had to wait to receive local care, required telehealth services, or were required to travel long distances (i.e., into cities) to access care, making these services untenable for those needing urgent care.

The main gaps, in my experience is just access to psychological services, essentially. The waiting time always seems to be quite an issue... So, the patients come in [and] had to have a GP mental health plan, referred to a local psychologist or mental health facility, and then there’s, you know, quite a lengthy delay for an appointment… [It’s an issue because] quite often, you know, a lot of presentations to the GP are usually when they’re in quite a, not critical, but very vulnerable state, and they need that access to care quite urgently. (S05: Practice Manager)

Beneficial practice location and set-up

The proximity of the three study sites to the town centre was seen as advantageous, enabling easy access for patients who could walk to the facility, considering the limited public transport options in a country town. Most participants noted the practice setup and available resources as important enablers of mental health care delivery. The ability to provide private spaces, such as having a back entrance or access to a veranda or garden, was seen to be especially beneficial for people dealing with anxiety or seeking anonymity. Several staff also spoke about the value of having separate consultation rooms available to be used by mental health specialists to provide care, as private waiting rooms, or as space for urgent use if a patient needed to speak with a staff member.

We have quite a few rooms here as well. So, I know we've got one patient, she suffers from anxiety quite a lot… she gets very overwhelmed in the waiting room. So, we offer her to sit in another room, and she really appreciates that. (S13: Receptionist)

Challenges with information transmission

Referral and communication processes within mental health care were frequently cited as challenging. Participants expressed frustration about poor communication from third-party providers, such as delays in receiving information about a patient or only receiving generic information. This was noted to be especially concerning where GP practices might not receive information about a patient’s emergency presentation for weeks, which was seen to undermine the continuity of care for both patients and staff.

We don’t actually find out patient information from a lot of third parties… you send the referral, and often you don’t even get anything back to say, ‘we’ve received the referral there is this much of a waitlist’. Or sometimes we just get generic information from the third parties to say, ‘we’re accepting new patients, but it’ll be a six month wait’. (S01: Practice Manager)

One participant noted the positive experience of their practice’s referral relationship with local schools, which prioritise early intervention for mental health concerns, highlighting a valuable aspect of the community connection.

Relational insights and the associated challenges

Participants spoke about the advantages and drawbacks of providing care to patients in a small community. This was primarily viewed positively, emphasising the benefits of familiarity that come with seeing patients in the community, which can contribute to building strong rapport between health care staff and patients. This familiarity can also provide staff with observational insights, such as noticing subtle signs of patient distress. The close-knit community dynamics were also seen to enable a form of monitoring, where the pharmacist or police would be able to flag concerns for early intervention. At the same time, this intimate connection can pose challenges, as the emotional strain of knowing patients well and wanting the best for them can lead to burnout and fatigue among staff, particularly GPs seeing numerous cases daily.

In the country, we know our patients, we know their families, we see them in the streets, I see them at supermarkets, you know, you do community activities with a bunch of them half the time, you know, you genuinely care, you genuinely want the best for them… And there's a whole other emotional burden to that, you know, because you do know them so well, you do see them so much, and so when they go downhill, it affects you. (S10: GP)

Having people living in close proximity to each other can also be seen as a hindrance, as noted by one practice nurse: “I live 40 km away – I would not like to work in my hometown, so patients probably feel the same” (S07).

Time constraints and balancing care needs

Time constraints in the context of mental health service provision was a recurring theme discussed by participants, especially GPs and receptionists. There was recognition of the time needed to listen effectively to patients and understand their mental health issues, and GPs highlighted the difficulty of achieving this in an environment where appointments of an appropriate length may not be available in the short-term.

They … tell you all about these things in their life and how stressed they are, and it cannot be sorted out in the 15-minute appointment… [but] if the patients don't feel like you’re listening then they feel their doctor doesn't care… I find it very difficult to balance this. Normally, if they come in with mental health… I listen [to] them, because, you know, if I don't listen, I might lose the opportunity for them to come back and talk to me again. So, I'd rather spend the time [with them and then]… apologise to the next patient [and say] “I'm sorry I'm running late”. (S03: GP)

Some GPs spoke about attempting to address the mental health concern within the 15-minute time slot, with the trade-off being that the patient might feel that the doctor is rushing them or does not care, which can critically undermine the doctor-patient relationship. Receptionists additionally spoke about prioritising quick responses to phone calls and ensuring patients feel that their needs were a priority for staff members, whether that be over the phone or in person at the clinic. However, these staff also acknowledged the struggle of finding time to adequately achieve this in general practice.

Difficulties in attracting and retaining a local workforce

The challenge of attracting and retaining specialised mental health professionals, such as social workers, psychologists and psychiatrists, was a recurring concern. This was, in part, attributed to the less appealing rural lifestyle compared to urban settings, with participants specifically highlighting limited resources and entertainment options in rural areas as preventing health care staff settling in rural and remote settings. Several participants pointed to the need for a long-standing GP presence to enable continuity and the effective delivery of primary mental health services, which patients often preferred over “a revolving door of junior doctors” (S06: GP). One GP described how not having this continuity could potentially cause a patient to discontinue care: “the person has to tell their story again … and again and again and again, like- this might be the jumping off point” (S03).

However, this also means that senior doctors who remain in the community will have assumed significant responsibility for mental health patients to maintain continuity of care. While these GPs welcomed this responsibility, it meant that patients requiring urgent care might not always see their primary GP, as they could be fully booked months in advance.

I think the hard thing is and is probably the way it works in the country, at least up here, is there's probably a couple of GPs in each practice that are booked out. I think I'm booked out for four months and so is another colleague, and then we’ve got other doctors that you could see next week, it’s not because they are not good doctors, it's just they're newer to the area. So, everyone's sort of, well, if this doctor stays, I'm going to see them… they tend to want to see someone that they know is going to stay. (S06: GP)

Societal stigma and individual hesitancy

Many participants highlighted mental health being seen as a ‘taboo’ subject in small communities, increasing vulnerability and, ultimately, affecting patient engagement. One participant noted that residing in a close-knit community may exacerbate a fear of being recognised, particularly due to the stigma associated with mental health. Yet, despite potential concerns, practice managers and nurses found that most patients were comfortable disclosing their mental health appointments, with one receptionist noting a perceived shift towards greater openness within the community towards mental health in recent years.

Like, people are quite happy to tell you that they need to see him for mental health … I’ve noticed a huge difference, like probably in the last five years, … where prior to that they would never say to you “I need the appointment for mental health.” Or even speak to you about it at the desk … I think it’s what with society now it’s way more accepted and out there in the general public. (S14: Receptionist)

It was also noted that some patients may avoid seeking help due to perceived fears around involuntary hospitalisation and psychiatric treatment. Participants highlighted that older patients tended to be reluctant to seek mental health care, relating this to perceived stigma of mental health and potentially not even recognising their own struggles. Farmers and men were highlighted as specific groups reluctant to seek mental health support, which was commonly attributed to being “…stubborn and … ashamed” (S13: Receptionist).

Lack of awareness and understanding

Study participants also noted a lack of awareness, understanding, and education within rural communities around accessing mental health care. A significant issue that was highlighted was perceived confusion and misunderstanding around appointment times, with patients booking standard appointment slots for discussing their mental health concerns, creating challenges for GPs as discussed above.

People do not understand the difference between a 15-minute appointment and a mental health appointment that might take an hour. (S02: Practice Nurse)

Additionally, interviewed staff cited uncertainty among the public about the pathways to accessing mental health care, including limited awareness of additional support beyond GP appointments. GPs emphasised the importance of educating the public in how to navigate the health care system, and how critical mental health plans are in improving access to mental health care.

Travel, technology and cost concerns

There was discussion of how travel, technology, and costs influenced patients to seek support. It was noted that many patients strongly preferred local services and were less willing to journey outside their area. While telehealth was seen to be an option, reluctance of patients to engage, technological barriers, and costs were cited as common barriers to access. However, as explained by one participant, even patients willing to travel to the city may struggle to find someone “who doesn’t have their books closed” (S06: GP).

People don’t really want to travel but also don’t really want to do telehealth, which makes it all very hard… the telehealth services may be really good, but… often the actual telehealth is a barrier, either from a user's point of view and not being a tech savvy or just not wanting to do it. (S06: GP)

Costs associated with travel, along with service costs were frequently cited as additional barriers. While GP appointments are usually completely or at least partially covered by public health insurance, specialist services often incur out-of-pocket costs, although (some) patients may be happy to pay the fee to get the help they need.