Poorer access to mental health services for people living in rural and remote communities was the most common area of inequity identified by all stakeholder groups. For mental health professionals, this was recognised as reflective of broader rural workforce challenges and as not being specific to the Better Access initiative.
While stakeholders believed that the Better Access initiative was a successful model for the urban context, there were concerns about its application in rural areas. The main issue facing clients seeking mental health services in rural and remote areas was the limited availability of psychologists and other allied health professionals, a factor also confirmed in the literature. 21 22 23 24 The Australian Institute of Health and Welfare (AIHW) also reports poor access to allied mental health services provided by psychologists, social workers and occupational therapists in outer regional and remote areas (25 and 22 services per 1,000 population, respectively) compared to access in major cities and inner regional areas (33 and 34 services per 1,000 population, respectively).25
Results from a recent workforce survey administered by the APS were somewhat more optimistic, showing that around 26 per cent of psychologists currently providing Medicare funded services are outside a metropolitan area. However, the survey also identified a diminishing workforce with increasing remoteness and strongly recommended assessment of the nature of the rural and remote psychology workforce and the factors that might contribute to future growth.26
AHPs reported that as a consequence of the lower numbers of AHPs outside cities there are longer waiting lists for Medicare approved mental health practitioners in rural and regional areas, especially when compared to their urban counterparts. Psychologists reported that relative to other professional groups, the waiting lists for clinical psychologists were the longest. Public provider and GP participants in one small area consultation and two participants consumer participants in teleconference offered anecdotal reports of psychologists moving away from rural and remote areas and relocating to the city in order to capitalise on the new business opportunities available following the introduction of the Medicare rebate, with subsequent further strain on the limited resources available in these areas.
Where instances of services being developed in rural areas were identified in the consultations, these appear to be to more lifestyle friendly locations, for example popular regional locations.
A range of options were proposed by AHPs to improve access for rural communities. These included:
- Introducing items for secondary consultation to allow AHPs to support local workers (NGOs, Aboriginal Medical Services, local mental health workers) to provide services in these communities, including specialised supervision to work with individuals with complex care needs.
- One psychology practice group advocated the provision of online therapy using telephone and/or VOIP27 and webcam. They were already providing this service to some clients and noted that this model of care was operating in other areas of health service delivery and broader education and community service provision.
Countering the argument for expanding the scope of approved providers was a much stronger response from public providers and the Divisions of General Practice suggesting that private practice sessional-based services were not an effective means of providing services to these populations. They recommended:
- maintaining and expanding the Division of General Practice budget holding to provide services on a contract or block grant basis, a view expressed by most Divisions of General Practice and many GPs;
- enhanced funding to public mental health services to provide population based mental health services, a view expressed by most public providers; and
- enhanced funding to NGOs to provide population based mental health services, a less commonly expressed view of some NGOs.
Northern Territory (NT) stakeholders described particular challenges faced in delivering mental health services to their population. In the NT, general practitioners largely operate out of Territory-funded facilities and therefore their use of MBS item numbers is low. Given that the Better Access initiative is linked to the MBS system, the NT population are subsequently much less likely to be able to access mental health services through the Better Access initiative. Similar problems were reported in remote areas of Queensland.
A number of psychiatrists in public practice suggested that, as the capacity to refer to an AHP was limited by GP availability, access would improve if they could refer directly to AHPs.
Representatives of psychotherapists and counsellors not within the provider groups eligible for a MBS provider number strongly argued for the expansion of eligibility to their members. They argued that their members were underutilised in rural and remote areas, despite significant demand for mental health services. These stakeholders claimed that there were more members likely to be located in rural and regional setting.29 They also suggested that, because of the availability of the Medicare rebate influencing individuals to choose an approved AHP, they had a greater level of availability. They argued that providing Medicare provider numbers to accredited members of the organisations would lead to an immediate increase in access to services. They indicated that, due to the rebate, individuals would join waiting lists to see approved AHPs rather than non approved counsellors, and that there had been a decrease in their waiting lists and demand for their services. Non-approved counsellors reported that the reduction in demand for their services threatened the financial viability of their services, particularly in rural and remote areas.
Three AHPs observed that there may be an increasing proportion of general psychologists, social workers and occupational therapists being recruited to ATAPS because of the lower Medicare rebate payable to these professional groupings, making service provision through ATAPS relatively more financially attractive than they are to clinical psychologists.
21 URBIS 'Environmental Scan Component of the Mental Health Professionals' Association Multidisciplinary Training Resource Program' Final Report January 2008.
22 Rural Doctors Association of Australia "New mental health items 'out of reach' for rural patients" (2006) Accessed 19 March 2009 from the RDAA website (www.rdaa.com.au).
23 Eckert, K.A., Wilkinson, D., Taylor, A.W., Stewart, S, Tucker, G.R., 2006. "A population view of mental illness in South Australia: Broader issues than just location". Rural and Remote Health, 6, 541 p11.
24 Australian General Practice Network "Mental health Medicare measures welcome, but equity at risk" (2006) Accessed 19 March 2009 from the AGPN website (www.agpn.com.au).
25 Australian Institute of Health and Welfare "Mental health services in Australia 2005–06" (Canberra 2008)
26 Dr Louise Roufeil, Anne Lipzker, "Psychology Services in Rural and Remote Australia" InPsych October 2007 Accessed 19 March 2009. Available on the Australian Psychological Society (APS) website (www.psychology.org.au)
27 Voice Over Internet Protocol.
28 Component B of the evaluation: Analysis of Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) Administrative Data will be able to examine distribution of individuals receiving services by poverty rates by postcode.
29 No evidence was received to support this assertion.