It would appear from views expressed in the consultations and the volume of services funded through the Better Access initiative that the initiative has improved access to, and affordability of, mental health services in the community. The rapid increase in the volume of Better Access MBS items processed appears to suggest an increase in the number of individuals accessing services for mental health problems through GPs, psychologists, social workers and occupational therapists (see figure 1).
This is also self evident when we consider that a rebate is now provided for services that were previously only available to a limited number of individuals with capacity to pay the full cost of private service delivery and the relatively small number of individuals accessing services through GPs with Level Two mental health skills training2, ATAPS, psychiatrists who 'bulk billed', services provided through other funding sources (for example DVA, Workers' Compensation, Victims of Crime) and a number of NGOs providing telephone crisis counselling and/or counselling services to selected client groups (for example in the areas of early intervention services, domestic violence, sexual assault, gender issues, etc).
Not only has the Better Access initiative increased affordability and access to AHPs that were in private practice prior to the initiative, the rebate and increased utilisation has allowed AHPs to expand their practices and new practices to be established, increasing access across geographic areas and to a wider section of the population. However, improvements in access have not been equal across geographical areas and populations and though overall access has improved some locales and population groups experience poorer levels of access than others.
Better Access has also succeeded in its aim to encourage more general practitioners (GPs) to participate in the provision of mental health services. Improving access to psychiatrists has been less successful although in some sites where the uptake of the new item numbers has been facilitated it has succeeded in improving access to psychiatry services.
Figure 1 is based on Medicare Australia data and demonstrates continuing high rates of growth for services provided by GPs, psychologists and clinical psychologists. For and GPs, there was almost a 300 per cent increase in the number of MBS items processed each month between November 2006 and September 2009. This increase is artificially inflated as GPs have been the predominant provider of mental health services in the community for many years and much of the identified increase may reflect utilising the newly available specific item number for mental health services, instead of previously utilised general item numbers.
GPs also reported that the new MBS items provided a more adequate remuneration for the time spent providing mental health services and that they were now doing more mental health work than ever before. Overall, the Divisions of General Practice reported that the Better Access initiative was well established and strongly supported by GPs, particularly in relation to the capacity to refer patients to AHPs to receive focussed psychological strategies. Though most GPs were strongly supportive of Better Access, a number thought that there was scope to further improve access by continuing to enhance GP awareness of the Better Access initiative and improve their skills in mental health diagnosis and preparing Mental Health Treatment Plans.Top of page
Nearly all psychiatrists providing responses perceived the new MBS items as an effective means to encourage psychiatrists to accept new referrals and as supporting their tertiary assessment and consultation role. A number of psychiatrists reported setting aside regular appointment slots for new referrals. A number of GPs also reported a perceived improvement in access to psychiatrists as a result of the Better Access initiative. However, most GPs, AHPs and consumers also reported that it still remained difficult to access psychiatrists, particularly for patients who needed to be bulk billed or charged a reduced fee. This was perceived to be in part a result of a general shortage of psychiatrists. In some areas where the uptake of the item numbers was supported there was a greater shift in psychiatry work practices increasing the number of new patients able to benefit from psychiatric input into their care. ( UPASA in SA; GLAS in Brisbane).
There was also an increase in the number of services provided by psychologists. Prior to the Better Access initiative, Commonwealth mental health funding was limited to services provided through ATAPS and MAHS3, both of which had capped budgets administered by the local Divisions of General Practice.
Prior to the Better Access initiative, Medicare funding for mental health services was not available to social workers and occupational therapists. Stakeholders from within these groups suggested that the relatively low growth in services provided by these professions may be reflective of the relatively small number of providers in private practice.
Most AHPs interviewed (predominately psychologists), when commenting on the high rate of growth in services indicated in figure 1 thought that the level of growth was unsurprising and that it would continue as a result of high levels of unmet demand in the community, increased affordability of services, increasing awareness of service availability by GPs and consumers, increasing referrals to AHPs from GPs and increasing supply of AHPs. Through consecutive consultations the review explored with AHPs the factors contributing to increased service utilisation to develop the conceptual framework identified in figure 2.
All stakeholders and interviewees were unanimous in reporting a real increase in the number of people receiving allied health services through the Better Access initiative. Though it was noted that some of the service increase would comprise pre-existing clients of established AHPs now claiming the MBS rebate (i.e. people who were receiving or would have received services without the Better Access initiative), the effect of any shift in billing arrangements was perceived by AHPs as relatively minor and most of the growth after the first few months was perceived to be a result a real increase in the number of individuals treated.
Children were reported by GPs, AHPs and consumers as one group most benefiting from improved access to mental health services as a result of the Better Access initiative, although limitations were identified with the current items not facilitating services to parents in the absence of the child. AHPs also reported that increasing numbers of men and older people were accessing the services as awareness of mental health issues and service availability increased and stigma associated with accessing mental health services decreased. The later factor was seen by many AHPs and consumer representatives to be a result of wider mental health promotion strategies (such as awareness and prevention strategies around depression) leading to greater understanding of mental health issues in the community and local networks of knowing people who have used and found mental health services useful – 'word of mouth referrals'. AHPs also reported an increasing complexity of individuals accessing the service as referral networks with GPs strengthened.
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Although improved access to services was reported throughout the consultation process, a number of inequalities in access to services were identified. Disparities were reported to be present across a range of domains.
- Though children were a major beneficiary of the Better Access initiative because of the few services previously available, nearly all AHPs working with children expressed concern that the lack of MBS items to see parents or carers without the child present or provide family therapy meant that many children were not receiving the most appropriate care for their needs. Most AHPs and GPs also saw affordability of families to meet gap payments as a factor limiting access for children.
- Similarly, though many AHPs reported increasing utilisation by older people, many GPs and AHPs also reported that older patients faced issues of affordability of gap payments and AHPs working with older patients reported limitations on providing services to patients resident in nursing homes.
- Affordability of services for youth was also reported by GPs, NGO mental health providers, AHPS working with youth and consumers. It was also noted by AHPs that while youth had less capacity to pay a gap payment the cost of working with youth can be higher due to more time being required to engage with young adults, higher likelihood of comorbidities (such as drugs) and/or social welfare problems (e.g accommodation, income, employment) requiring engagement with other agencies and professionals and missed appointments.
- Issues of affordability were also reported for people on low incomes and those living in low socio economic communities. GPs were particularly aware of affordability of gap payments for low income patients and the challenges of finding 'no gap' AHPs. Affordability was also an issue raised in all the small area consultations and discussions with consumers. A number of GPs and the small area consultations also noted less services being located in lower income areas and patients from these areas facing difficulties in both affordability and availability of services. Most AHPs also reported the difficulty of having a no gap fee given the level of MBS rebate that was available.
- The very few GPs, and AHPs and public mental health service providers working with Aboriginal and Torres Strait Islander communities also identified the challenges that people from these communities faced in relation to affordability and model of care. It was noted by these respondents that the need to be accepted within the community and develop wider family and community solutions to problems did not fit well with a fee for service model of care. Though several psychologists reported successful interventions based on the provision of secondary consultation services to local Aboriginal Health Workers, these were not funded through the Better Access initiative. Of those commenting on access by Aboriginal and Torres Strait Islander clients, it was generally believed that services for these communities may be more appropriately funded through alternative programs such as ATAPS or Aboriginal and Torres Strait Islander health services.
- Issues of challenges of providing an affordable and culturally appropriate model of care were also identified by GPs, AHPs, public mental health and NGO service providers working with culturally and linguistically diverse communities. As with working with Aboriginal and Torres Strait Islander people, the investment of time required to develop linkages with the community and other resources within the community is not returned in a fee for service model.
- The small number of GPs and consumers from remote areas reported that access to mental health services in these communities may have decreased. The GPs suggested that this was a result of the increased financial viability of private practice in metropolitan and regional areas, driving a reduction in the number of AHPs who may have otherwise worked in rural and remote communities through ATAPS. It was noted by one GP that not only was it more difficult to recruit AHPs, the cost to the Division had doubled.
Figure 1: Number of services funded through the Better Access initiative
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Text version of Figure 1This graph shows Better Access items processed for psychiatrists, general practitioners, clinical psychologists, psychologists, social workers and occupational therapists. Figures in this description are very approximate as they have been read from the graph.
Items processed for:
- psychiatrists have risen very gradually from about 4,000 in November 2006 to about 9,000 in September 2009.
- general practitioners have risen in a fluctuating manner from about 39,000 in November 2006 to about 151,000 in September 2009.
- clinical psychologists have risen in a fluctuating manner from 0 in November 2006 to about 92,000 in September 2009.
- psychologists have risen in a fluctuating manner from about 4,000 in November 2006 to about 159,000 in September 2009.
- social workers have risen very gradually from 0 in November 2006 to about 13,000 in September 2009.
- occupational therapists have risen very gradually from 0 in November 2006 to about 3,000 in September 2009.
Figure 2: Cycle of increasing demand for services provided by AHPs
Text version of Figure 2The image shows the cycle of increasing demand for service provided by AHPs. With unmet demand and the increased affordability of AHPs, the cycle starts with more patients accessing AHPs. This increases GP awareness and GP referrals to AHPs. As private AHPs become more viable, the supply of AHPs increases. This leads to AHP services becoming more accessible and improved relationships with GPs and referral pathways. This encourages more GP referrals to AHPs and increases demand, leading to even more patients accessing AHPs (and the cycle starting again).
2 Level-2 GPs refers to GPs who have completed mental health training as described under the MBS schedule.
3 More Access to Allied Health Services Program (MAHS) is not dedicated mental health funding, although it is used by some Divisions to provide mental health services.