The consultation found that though the Better Access Initiative has been successful in encouraging private psychiatrists to see more new patients, the view of most stakeholder groups was that access remained limited due to workforce shortages and the general availability of psychiatrists.
Overall, most psychiatrists nominated by the RANZCP reported that the Better Access initiative had increased access to psychiatrists and the specialist skills provided by psychiatrists. These psychiatrists welcomed the new MBS item numbers for initial consultations, Assessment and Treatment Plans and to review Treatment Plans. They saw the new MBS item numbers as an effective means to encourage psychiatrists to accept new referrals. This positive support for the Better Access initiative is mirrored in the growth in the Better Access initiative services provided by psychiatrists (see Figure 1). As such, it is likely that the opinion of this group of psychiatrists, in respect of the improved access to services, is more reflective of the profession as a whole.
Psychiatrists supported the Better Access initiative for the following reasons:
- The remuneration for the new MBS items was perceived to be more reflective of the time required to assess a client and prepare a report.
- The focus on assessment and review, with the Treatment Plan to be carried out by the referring GP, meant that there was not an expectation that the psychiatrist would have ongoing management of the patient. It was reported that psychiatrists with a full caseload would previously have been reluctant to accept a new referral for assessment where they would also have to assume ongoing patient care.
- Due to the level of remuneration and ongoing patient management by the GP, psychiatrists were able to set aside dedicated slots within their appointment schedule to assess and/or review new patients.
- The tertiary assessment and referral focus of the new MBS items was professionally rewarding and an appropriate and cost effective use of the specialist skills of psychiatrists.
- Providing a mechanism to assess and review more patients increased access to psychiatrists and went some way in addressing the high level of unmet demand in the community. One psychiatrist noted that they, and a number of their colleagues, now allocated appointment slots for initial assessments, Treatment Plans and Treatment Plan reviews, and that waiting times for new assessments had reduced from up to six months to within six weeks.
Psychiatrists working within the public mental health system or private hospital system were less able, or were unable, to comment on whether there had been changes in the level of access to psychiatrists.
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From the perspective of most public mental health providers, NGO providers, consumers, carers or allied health providers, there was little if any discernible improvement in access to psychiatrists as a result of the Better Access initiative. The over-riding issue raised by nearly all groups was the ongoing difficulty in accessing psychiatrists due to workforce shortages. The shortage of psychiatrists was most marked in rural and regional areas.
It was noted by one GP that many psychiatrists worked in small, private practices and did not utilise online Medicare billing. This meant that patients receiving a management Treatment Plan (MBS Item 291) may be required to pay between $355.50 (85 per cent of the scheduled fee – bulk billed patients) to more than $418.20 (scheduled fee) before receiving the Medicare Rebate. This out of pocket expense was seen as a major deterrent to patients seeing a psychiatrist. Interestingly, one consumer from a small, rural community indicated that access to psychiatrists was easier than access to allied health providers because of a lower gap payment. Several consumers and carers reported the high, up-front fee being an unaffordable barrier in access to psychiatrists.
A further concern raised by some GPs was that the frequency of a Treatment Plan review by a consulting psychiatrist (once in a 12-month period) is insufficient for more complex patients and as such did not improve access for this group of individuals12.
It is of note that one psychiatrist interviewed indicated that psychiatrists within the region in which they worked had decided not to utilise the new item numbers as they did not feel that single assessments provided appropriate quality care.
There was no indication that the Better Access initiative had increased the number of psychiatrists practising in the community. A small number of interviewees noted that the increased competition from AHPs for the provision of focussed psychological therapies may result in some psychiatrists reducing their number of psychotherapy patients to provide more psychiatrist specific specialist care and/or increase the turnover of patients through their practices. One principal public health psychiatrist reported that the Better Access initiative had resulted in two psychiatrists returning to part-time, public sector practice because of increased competition from AHPs. This was reported as a positive outcome of the Better Access initiative.
12 Issues relating to access by individuals with more complex problems was raised across stakeholder groups and is reflected in this report. It should be noted that the primary intent of the Better Access initiative was to improve access to mental health services by individuals with high prevalence disorders as outlined in section 1.3.1.