4.4.1 Summary of compliance with guidelinesOverall, the perception of all stakeholders was that the services were being provided in compliance with the guidelines for the Better Access initiative. However, there appeared a wide variation in interpretation of the guidelines in respect to client eligibility and services that can be provided. The perception of most GPs and AHPs was that the eligibility criteria were broad enough to include most mental health conditions. Similarly, most AHPs indicated that the choice of intervention was based on the needs of the client and that most therapies would fall within the definitions of interpersonal therapy.
A number of providers (possibly one-third) indicated that the number of sessions available through the Better Access initiative did influence the choice and planning of interventions to try and remain within the approved number of sessions. The restricted number of sessions available was a concern of most AHPs with respect to providing services to clients with longstanding and/or more complex problems.
A small number of GPs, psychiatrists and psychologists raised concerns about some individuals in situational or relationship difficulties who were not eligible for services under the Better Access initiative being referred under a loose definition of anxiety or depression. A further concern of these respondents was the lack of outcome measurement and evidence base for services being provided.
The issue of who was referred was identified as the responsibility of the GP as the 'gatekeeper' to services through the Better Access initiative. While GPs and AHPs generally reported the importance of GPs maintaining the responsibility for making referrals, there was debate as to the requirement for GPs to maintain ongoing responsibility for the patient care under the GP Mental Health Treatment Plan. Though there was the need for a comprehensive diagnosis and treatment plan prior to the commencement of therapy, a number of AHPs and a small number of GPs argued that this function could be undertaken by the AHP in instances where the AHP was assuming responsibility for the care and management of the client's mental health disorder. GPs reported, in some instances, that they were approached by an individual for a referral, where they had not been involved and were not going to become involved in the ongoing management of the patient's mental health disorder. In this situation, a GP Mental Health Treatment Plan was perceived as adding little value to the treatment process. They argued that it may be more appropriate to refer the patient to an AHP as they would refer to most other specialists.
Only a minority of respondents expressed concerns about the value and adequacy of GP Mental Health Treatment Plans. The majority (73 per cent) of respondents reported the information provided in the GP mental Health Care Plan as good or fair and notably, 72 per cent of respondents reported that they had not received inappropriate referrals. Of the stakeholders expressing concerns about GP awareness of and use of MBS items through the Better Access initiative, nearly all reported that awareness of the Better Access initiative and quality of Mental Health Treatment Plans and information provided to consumers was improving.
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4.4.2 Assessment and eligibilityThe general assessment of all stakeholder groups was that the Better Access initiative services were being provided to the intended target group. This is also reflected in the results of the online survey (Table 2), with more than 95 per cent of respondents reporting that the Better Access initiative had improved access to mental health series for people with anxiety and depression related disorders.
However, many interviewees also noted that despite the specificity of the MBS descriptors for Better Access the interpretation of the list of eligible disorders was so broad that almost any individual could be considered eligible. A number of GP and AHP providers argued strongly that it was appropriate to provide services through Better Access to individuals with more complex disorders and that many of these would come within the MBS descriptors of alcohol use disorders, drug use disorders, chronic psychotic disorders, acute psychotic disorders, bipolar disorder, depression, mixed anxiety and depression or mental disorder, not otherwise specified. Several instances at an individual provider and Division of General Practice level were identified of AHPs and GPs working collaboratively to manage and support individuals with chronic or complex mental health disorders and care needs. This also involved working with other support services in the community including Personal Helpers and Mentors (PHAMs), NGO services and public mental health providers to develop a package of care for the individual receiving care.
For consumers and carers the most important issue was being able to access psychological services that were not previously available and/or affordable and the benefit to them in the management and treatment of their mental health disorder.
A small number of psychiatrists, GPs and AHPs raised concerns about the types of clients receiving treatment through the Better Access initiative. They contended that some clients receiving the Better Access initiative funded services did not have a diagnosis of a mental health disorder, and were referred on the basis of a loose definition of anxiety or depression. It was reported that these clients were typically people in situational crises or relationship difficulties who needed supportive counselling, yet did not necessarily need the services offered under the Better Access initiative.
There was debate about whether the responsibility for 'filtering' appropriate clients lay solely with GPs, or whether the allied health professional providing the mental health care should assess the clients' eligibility for service through the Better Access initiative.
A sound and accurate assessment and diagnosis may be considered the first step in the provision of evidence based mental health care. However, some AHPs and Level Two trained GPs expressed concern as to the accuracy and comprehensiveness of assessments and diagnoses of many GPs, possibly up to 20 or 30 per cent of Treatment Plans48. A minority of AHPs reported receiving Treatment Plans that ranged from incomplete (one was quoted as stating "thank you for seeing this patient") to comprehensive and detailed.
Approximately five or six GPs49 (at least three of whom were Level Two trained) suggested that the variation in quality of Treatment Plans and Treatment Plan reviews was due to there being no mandatory training requirements for GPs to participate in the Better Access initiative. The Level Two trained GPs commenting on this issue perceived this as a reduction in the quality of mental health care provided by GPs. Conversely, they also acknowledged that allowing all GPs to refer to AHPs through the Better Access initiative allowed more patients requiring psychological interventions to access these services when they were not available through the GP.Top of page
While maintaining that GPs should retain the referral gateway to AHPs, a number of GPs and AHPs questioned whether the GP should be required to prepare a Mental Health Treatment Plan and Treatment Plan review if they did not have the skills to do so and its sole purpose was compliance with the referral guidelines.
AHPs reported that generally, irrespective of the referral source, a complete assessment needs to be made of each new referral to determine the most appropriate course of intervention and that the assessment and Treatment Plan provided by the GP added little value to the treatment process. This may highlight an existing lack of understanding of providers on their differing skills and roles and how best to work together in multidisciplinary primary mental health provision. It is hoped that this will be addressed in the role out of the Education and Training arm of the initiative. Some AHPs suggested that the referring GP should have the option to refer to an AHP using a more general MBS referral item not requiring a Treatment Plan, with the Treatment Plan and Treatment Plan review then being completed by the AHP. It was perceived by some that this approach would lead to more accurate diagnosis and comprehensive Treatment Plans. The advantages of transferring the assessment process (and Item number) to the AHP receiving the referral were raised by psychologists and social workers. This suggests that some AHPs are at an early stage in their understanding of the key role of the generalist GP in the meeting the needs of people with mental health problems in the community and highlights the importance of ongoing multidisciplinary professional development
GPs were less supportive of the transfer of the assessment and gatekeeping function to AHPs. A small number of GPs argued that though retaining the referral role, in some instances this should not require a GP Mental Health Treatment Plan. Referral would be through referral letter, as with referrals to other specialists. Such instances may include instances where:
- the patient was largely unknown to the GP and presented expressly seeking a referral to a specific AHP, with the GP, in essence, being asked to endorse the requested referral. This was perceived as placing the GP in a difficult position; the GP may not know the patient's history, may not know the AHP or services being offered, and may be unlikely to have an ongoing role in the management of the patient's mental health problem. In this instance, the GP Mental Health Treatment Plan was perceived as adding little value to the treatment process;
- the GP is not comfortable in relation to undertaking an assessment or have the time, experience, expertise or capacity to develop a Mental Health Treatment Plan and would simply prefer to refer the patient for assessment and treatment to an AHP. In this instance, it was suggested that the need to prepare a Mental Health Treatment Plan may prove a barrier in these patients being referred. Both of these instances highlight the importance of the role out of education for AHP to increase their understanding on the initiative and the benefits of linking the patient to a GP, and with GPs to enhance their confidence and competence in value adding to the patients care.
4.4.3 Approved interventionsAlthough all AHPs argued that the services they provided were appropriate to the needs of their clients, the perceptions on the degree to which the services provided evidence based care varied. There was debate by various AHPs as to the evidence base of approved and non-approved interventions. Despite the specificity of the approved interventions within the MBS descriptors, many AHPs argued that most interventions would fall within the definition of interpersonal therapy and that they would choose the most appropriate intervention for the needs of the client.
However, a consistent concern raised by psychoanalysts through the consultation process related to the types of therapies that were able to be delivered through the Better Access initiative. While a high proportion of the psychoanalysts were Medicare approved mental health practitioners (e.g. psychologists), they argued that restricting the types of therapies allowed under the Better Access initiative was in turn limiting the effectiveness of their treatments. They suggested that the most appropriate model would allow for a broader range of approaches to be used, including psychoanalytic techniques. In addition to their concerns about the types of therapies to be included as part of the Better Access initiative, they contended that the 12 session per year limit was inadequate, and that many patients required a longer course of therapy to meet their needs. While they acknowledged that the Better Access initiative funded therapies such as cognitive behavioural therapy were useful, they argued that their usefulness and appropriateness was limited to certain patient populations.
The outcome and number of interventions provided will be more fully explored in Components A and B of the evaluation.Top of page
4.4.4 Addressing unmet need in the communityAssociated with the concept of appropriateness, interviewees raised the issue of whether services were reaching those individuals most in need. Amongst some stakeholders and interviewees, including psychiatrists, GPs, AHPs, and state and territory health departments, was a perception that those experiencing the improved access were the 'worried well' and those who were traditionally good 'help-seekers'. They contended that those accessing services through the Better Access initiative would have accessed mental health services anyway, either self-funding or using private health insurance to minimise out-of-pocket expenses.
Similarly, there were reports from a small minority of psychiatrists, GPs, AHPs and public mental health providers that the Better Access initiative was being used to provide services for those who were not particularly 'unwell', questioning whether those receiving care actually had a mental disorder and needed the specialist assistance provided by either a clinical psychologist or other allied health professional.
Only a small proportion of psychologists contended strongly that the Better Access initiative services should be more effectively targeted to clients with milder mental health issues. They argued that early, effective interventions provided through qualified practitioners would lead to better patient outcomes and minimisation of future burden on the public mental health system.
Concerns about the level of illness experienced by those accessing the Better Access initiative have been raised in other forums. The URBIS environmental scan highlighted concerns that "services are not reaching chronically ill and disadvantaged people". According to the report, mental health professionals consulted frequently cited concerns that practitioners were opting to see the 'worried well' rather than people with significant and chronic illness. 50, 51
Other sources of information, however, indicate that it is not just those with mild illness that are accessing mental health services through the Better Access initiative. Both GPs and AHPs reported increasingly complex patients accessing services.
Table 5 below presents data from a 2008 survey conducted by the Australian Psychological Society. According to surveyed psychologists, of those presenting for treatment through the Better Access initiative, most were moderate (46) or severe (35 per cent), while a relatively smaller group (19 per cent) were classified as mild.
The perception of approximately one-third of clients experiencing more severe disorders, one-third moderate and one-third mild was one generally expressed in the stakeholder interviews across AHP groups. Although the morbidity of the client group was reported to vary over time, the reason for a general balance across groups was attributed to a range of factors:
- the general nature of clients being referred through GPs;
- although clients with more severe disorders are over represented in respect to the incidence in the general community, they are often presenting after having tried many other interventions and/or due to the limited availability of public mental health services;
- AHPs trying to balance the number of clients with more severe disorders with more moderate and mild clients to achieve a more balanced and clinically sustainable practice (to avoid 'burnout');
- more severe clients often had co-morbidities, required more time (in session and out of session) and were more likely to require discounted fees so numbers had to be capped to maintain a financially viable practice; and
- AHPs often used higher income clients with more mild to moderate disorders to allow fee discounting to low income individuals with more severe disorders and a balance was required to achieve this.
Table 5: Level of disorder of clients who presented to surveyed psychologists52Table 5 is presented as a list in this HTML version for accessibility reasons.
Level of disorder of clients who presented to surveyed psychologists:
- Severe - 35%
- Moderate - 46%
- Mild - 19%
Source: Australian Psychological Society, 2008
48 It is possible that AHPs over estimate the proportion of poor quality Treatment Plans. AHPs reported that generally Treatment Plans met the MBS requirements.
49 Out of out of 15 individual GPs consulted and national and state and territory GP representatives.
50 URBIS (2008)
51 See note 12 in section 4.2.2.
52 Australian Psychological Society "Survey of members providing Medicare-funded services under the Better Access initiative" InPsych June 2008 p. 36 Provided March 2009