One thing is clear: primary mental health care must be at the heart of the next stage of national mental health reform.
The future of primary mental health care will be a major challenge for the new federal government. Community demand for mental health care is far from being met.
The Better Access program began in November 2006, following the landmark Better Outcomes program (initially funded in 2002), aimed at increasing the number of Australians using primary mental health care services for mild to moderate, where short-term evidence-based interventions are most likely to be helpful.
Medicare spending on mental health services under the program provided by general practitioners, psychologists and psychiatrists was more than $25 million per week in 2020-21. Given the magnitude of this public investment, it is important to monitor its evolution.
Program architect Professor Harvey Whiteford and colleagues were able to find evidence in 2013 that the program has increased the rate of access to mental health care in Australia as a whole. More recently, the federal government increased the number of Better Access program sessions per person from 10 to 20 per year until at least the end of 2022. The only formal government evaluation of the program took place in 2010. This evaluation has revealed strong consumer support for the Program, although respondents were recruited by their treating healthcare professional rather than an independent sample.
What happened to Better Access?
Since the introduction of the Better Access program (first full year 2007-2008), there has been a continuous increase in the provision of services by clinical and registered psychologists as well as general practitioners (Figure 1). In contrast, there was a much smaller increase in services provided by psychiatrists. Our analysis of Medicare data (available online) shows that a total of 125.5 million services were provided at a cost of $13.5 billion over the period 2007-2008 to 2020-21.
Figure 1 shows a significant interruption in this upward trend in face-to-face Medicare mental health services in 2019-20, during the first phase of the COVID-19 pandemic, which kept people from visiting to in-person services.
Figure 1 – Better Access in-person services from 2007-2008 to 2020-2021
As telehealth services have become more widely available under Medicare to compensate for this, the number of such services provided in 2020-21 more than doubled from the previous year, from 1.2 million to nearly 3 million (Table 1).
Table 1 – Telehealth services 2019-2020 and 2020-2021
|GP mental health treatment plan (telehealth service)||21,635||35,353|
|GP Mental Health Treatment Plan (telephone service)||280 314||723,945|
|Consulting psychiatrist telehealth services||103,597||294 270|
|Consulting Psychiatrist Telephone Services||159,870||413,651|
|COVID-19 Clinical Psychologist Psychological Therapies Telehealth Services||231,611||495,978|
|COVID-19 Clinical Psychologist Psychological Therapies Telephone Services||112,817||205,388|
|COVID-19 Registered Psychologist Focused on Psychological Strategies Telehealth Services||194 213||478,323|
|COVID-19 Licensed Psychologist Focused on Psychological Strategies Telephone Services||138,704||274 190|
Source: Medicare Group Statistical Reports, online database.
Given these increases in telehealth services, the overall upward trend in Medicare mental health service delivery, although now split between face-to-face care and telehealth, remains clear.
While the number of services may increase, the number of clients receiving care is less clear. The Government Services Productivity Commission report shows that the proportion of clients who were new to the Better Access program was 36.6% in 2012-2013, but only 29.2% in 2020-2021. The majority of service users are therefore repeat offenders seeking ongoing support.
This trend raises questions not only about the impact of the program, but also about the overall design of the program. Specifically, these data raise the possibility that enhanced access program services are not provided for “short-term” interventions as originally intended, but increasingly for users with more complex and longer term. In the absence of definitive outcome data, questions have been raised about the effectiveness of the program.
The most recent changes in program operations introduced during the COVID-19 pandemic in response to increased demand have placed more emphasis on providing long-term care rather than facilitating mental health care-seeking for more Australians. It should also be noted that GPs wrote over 1.2 million mental health plans for Australians in 2020-21, but of these only just over a third (36.8%) were reviewed, meaning that patients’ progress was largely unmonitored by their GPs. Without monitoring, it is not possible to discern whether a person’s mental health is improving or deteriorating and to plan next steps appropriately. It also removes an important element of systemic accountability.
Constraints and challenges
There are manpower constraints with limits on working hours and total number of professionals. Paradoxically, this could mean that recent federal government funding that has increased the number of sessions available per person may actually reduce the total number of people who can access the program, which has the effect of worsening public access for some. , not to improve it. This situation is more acute for psychiatric services, where growth under the Better Access program has been significantly slower than among other occupational groups.
We know that the out-of-pocket expense associated with the fee-for-service model under which the program operates deters people from seeking care. Simply making more sessions available does nothing to alleviate this burden.
This analysis and commentary on the Improved Access Program should be seen in the context of recent recommendations for its reform and better targeting made by the Royal Commissions on Productivity and Victoria, as well as the earlier comprehensive review undertaken by the National Mental Health Commission in 2014. They all suggest that the most effective way to organize primary mental health care is on a region-by-region basis, creating opportunities for state and federal agencies to work more together, to pool funding and to conduct joint planning.
Participants at the recent Sydney Mental Health Policy Forum expressed strong support for structural mental health reform, including multidisciplinary approaches that combine clinical and psychosocial care in new ways, particularly to meet the needs of people with more complex mental health issues. For these people, repeatedly seeing the same clinician working alone may not be enough to meet their multiple needs. For example, someone with an eating disorder can benefit from a coordinated team consisting of a general practitioner, psychiatrist, psychologist, nurse, dietician and other paramedical services as well as peers.
What destination now?
New “bilateral” agreements are in place between the federal government and all states and territories. Publicly available information on these agreements does not suggest that they involve a significant shift towards greater regional control of funding and planning, nor better targeting of the Better Access program as part of broader care reform. primary mental health. Both the Victorian and federal governments are working to establish new community mental health clinics, but how these relate to each other and to the task of primary mental health reform is not clear. clear.
A second federal government review of the improved access program is underway and was expected to be completed in June, with results expected any day. It represents an important opportunity to recalibrate the program around its original mission of increasing public access to primary mental health care and to examine related issues such as quality and value for money, as well as to s ensure that other services are available for people requiring more than acute care. long-term mental health interventions. This work must be at the heart of structural and strategic mental health reform, as a priority for the new Labor government.
There are four obvious focal points for this recalibration.
First, consideration needs to be given to how to increase access to specialist assessment and short-term interventions, in line with the directions initially envisioned for the program.
Second, there is a need to develop practice incentives that support the provision of services under the program to disadvantaged and other currently absent groups. This would include economic, social, geographic and cultural groups.
Third, there is clearly a need for new incentives to support active review of patient plans. This is essential to program accountability.
Finally, there is a need to develop and promote the use of new technologies to support more effective triage, assessment and review of patient progress.
The federal government is clearly thinking about the future of telehealth right now. One thing is clear: primary mental health care must be at the heart of the next stage of national mental health reform.
Dr Sebastian Rosenberg is a Senior Lecturer at the Brain and Mind Center at the University of Sydney.
Professor Ian Hickie is co-director of the Brain and Mind Center at the University of Sydney. He is a member of the clinical advisory group for the evaluation of the Better Access Initiative.
Statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of WADA, the MJA Where Preview+ unless otherwise stated.
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