Aspects of Component C can inform the analysis of whether the Better Access initiative is improving the workforce's capabilities and capacity to provide primary care for people with a mental disorder. Five workforce objectives were associated with Better Access:
- Encourage more GPs to participate in early intervention, assessment and management of patients with mental disorders
- Streamline access to appropriate psychological interventions in primary care
- Encourage private psychiatrists to see more patients and expand their role as specialists in backing up the primary health care sector
- Provide referral pathways for appropriate treatment of patients with mental disorders
- Support GPs and primary care service providers with education and training to better diagnose and treat mental illness
5.4.1 Increase GP participation in mental health care
5.4.2 Streamline access to appropriate psychological interventions
5.4.3 Encourage private psychiatrists to see more patients
5.4.4 Provide referral pathways
5.4.5 Education and training for GPs and primary care service providers
5.4.1 Increase GP participation in mental health careA high proportion of GPs provided Better Access services. Of the 24,953 GPs registered with Medicare in 2008, 87% provided mental health care plans and services associated with Better Access. Despite the widespread provision of Better Access services, the data suggest that GPs have a relatively low level of usage per provider: the average use per provider was 1.2 services per week (64 consults per year) in 2008. This totalled approximately 47 minutes of GP billing time. Although this was a slight increase of 6 minutes from the previous year, only future analysis of data from subsequent years will provide an indication of whether there is a trend toward increasing GP participation at the service provider (individual) level.
The reasons for this low level of usage per provider cannot be determined from the research undertaken for Component C. It may be that this reflected the level of demand for these services from GPs. It is also likely that there will be geographical differences in the levels of use given that 85-90% of Better Access services in remote centres and other remote areas are provided by GPs.Top of page
5.4.2 Streamline access to appropriate psychological interventionsTo fully assess whether Better Access has contributed to meeting this objective an analysis of client data would need to be undertaken to examine treatment pathways. This was out of scope for Component C. From the analysis of MBS and Medicare Provider data, one issue was identified that may influence whether Better Access is meeting this objective.
As indicated in the report, by 2008, 1181 clinical psychologists were providing both Psychological Therapy Services and Focussed Psychological Strategies. This suggests that the triaging of clients to ensure that they are being treated by health professionals with the most appropriate skills may have the capacity for improvement.
Triaging takes place within Better Access when a GP (or other Better Access referral provider) develops a care plan, makes an assessment of client needs and then either treats the client themselves, or refers them to an allied mental health professional. The referral process depends on the GP diagnosis, the level of psychological intervention required, and the availability of different allied mental health professionals within the GPs' professional networks. While GPs are referring to allied mental health professionals, it is difficult to determine whether referrals are made to the most appropriate allied mental health professional for the required psychological intervention. This may be better addressed in other Components of the evaluation. From the data and literature analysed in Component C, we are suggesting that it is possible that the streamlining may not be as efficient as it could be, given that clinical psychologists are using Focussed Psychological Strategies.31
There are workforce implications if triaging is not working efficiently. In effect, it means that there is a mismatch between the skills and capacities of clinical psychologists and their utilisation by Better Access. Clinical psychologists have the capacity to deal with the more severe or complicated psychological disorders. If they are providing services to clients with relatively straightforward psychological disorders, then they cannot use that time to provide services to clients with more complex needs.
5.4.3 Encourage private psychiatrists to see more patientsAn estimated 51% of psychiatrists used Better Access Items in 2008. The most used MBS Item by psychiatrists was 296 (initial consult with a new patient, in rooms), which accounted for 77% (78,008) of services provided. Items 297 and 299, also for consults with new patients, accounted for a further 10.4% (10,559) of services provided. There is evidence then, that psychiatrists are using Better Access Items when consulting new patients. Items 296, 297 and 29932 alone indicate that psychiatrists have seen 183,825 new patients over the life of Better Access.
While these figures appear to indicate that Better Access is meeting this objective, it is difficult to know how many of these new patients would have been seen by psychiatrists had the Better Access initiative not been implemented. That is, the extent to which psychiatrists are seeing more new patients because of Better Access is unknown. To evaluate this objective, data is required that can compare the number of new patients seen by psychiatrists who do use Better Access with those who do not to see if there is a difference in the rates in consultations with new patients.
5.4.4 Provide referral pathwaysThe development of formal referral pathways between GPs and allied mental health professionals, especially psychologists, began in 2004 with the Better Outcomes initiative's ATAPS program. Better Access expanded this by providing selected allied mental health occupations with access to MBS Items based on the implementation of referrals from medical mental health professionals.
Better Access provides referral pathways for the delivery of mental health services in which referrals are made by GPs, psychiatrists or paediatricians to clinical psychologists for Psychological Therapy Services; or to registered psychologists, social workers and occupational therapists for Focussed Psychological Strategies. As referral data was out of scope for the analysis undertaken in Component C, the extent to which we can inform discussion of this objective is limited.
From the implementation of Better Access until Dec 20008, GPs developed 1,093,891 mental health care plans, many of which would have had referrals to allied mental health professionals. The data suggests that the number of referrals each year is likely to be increasing. For example, the number of mental health care plans developed by GPs increased by 18% between 2007 and 2008, the first two complete years of the Better Access initiative.
As part of Component C we were asked to investigate concerns that mental health care plans were not being utilised effectively. This issue was explored in the consultations where the perception was that the quality of the plans varied greatly between individual GPs and issues were exacerbated by:
- The incorrect use of referral pathways which resulted in the lack of time during initial consultations to fully ascertain client needs
- Clients skipping steps in the referral process
- The forms lacking the flexibility to capture the nuances and detail required for effective communication between health professionals
- The lack of evidence regarding whether/how the quality of a care plan affects the outcome
- The need for benchmarks in good practice
Consultations with representatives of groups from each of the allied mental health professions also indicated that GPs may require clearer information about the role of each profession within the patient pathway. As outlined in Chapter 1, clinical psychologists, registered psychologists, social workers and occupational therapists each have a different approach and field of expertise within mental health care. There are indications that referral pathways between GPs and psychologists are improving due to the development of a shared literacy forming a stronger basis for communicating across disciplinary / professional boundaries. This does not appear to have occurred to the same extent between GPs and social workers and OTs. The AASW, in particular, indicated that one of the reasons that social workers are under-utilised within Better Access is that the lack of understanding about their role in mental health care impacts on their likelihood of receiving referrals.Top of page
5.4.5 Education and training for GPs and primary care service providersFrom the available data, it was difficult to determine the extent to which Better Access has supported GPs and primary care service providers with education and training to better diagnose and treat mental illness. There is evidence however, that Better Access has stimulated interest in mental health training by social workers and, to a lesser extent, occupational therapists and psychologists, by providing pathways for allied mental health workers to develop a more financially viable practice in mental health.
Data from a small survey conducted for Component D of the evaluation (comprised of 264 psychologists, 153 social workers and one OT) indicated that 32.5% thought that Better Access had improved their access to training. For social workers this is evident from the increase in the number of accredited mental health social workers: from 150 in 2006 to 839 in 2008 (by 2009, this had further increased to 1054). Although a proportion of these social workers would have attained their mental health accreditation based on experience and training prior to the implementation of Better Access, the sustained rate of increase suggests that Better Access is encouraging mental health training by social workers. In contrast, Better Access appears to have had a marginal impact on mental health training by OTs (consultations).
For psychologists, Better Access was viewed as exacerbating existing issues relating to the lack of availability of supervisors in the public sector workforce. Alternative options for clinical training, such as virtual training and simulations were being implemented in some areas; however, there was some concern about the ability to achieve the same quality of training as had previously been available through face-to-face supervision.
Since July 2009, GPs have been financially rewarded through access to higher schedule fees for acquiring accredited mental health training. GPs without the training can provide Better Access services but will only be able to access the lower schedule fee (Department of Health and Ageing, 2009c). In a survey conducted for Component D of the evaluation, approximately half of the medical mental health workforce indicated that Better Access had affected their access to training, with over 90% of these respondents indicating that it had improved their access.
Some gaps in mental health education and training were identified. In a recent survey of OTs using Better Access, respondents identified three areas in which additional resources are required to support them to provide Better Access services: clinical practice, business skills, and an organised peer support system (OT Australia, 2008). In the consultations GP organisations identified the need for training and resources in the use of care plans and the development of benchmarks, and in the area of multi-disciplinary communication and working.
31 There is no indication that clients were receiving inappropriate psychological interventions; or that the MBS Items were being used inappropriately. The issue is whether the appropriate service provider is being utilised.
32 Psychiatrists can also claim for Items 291 and 293 (consults with referred patients). As these Items were available prior to the implementation of Better Access, they are not included in this discussion. In 2008, these two Items accounted for 12.6% of services provided by psychiatrists.