This section presents the key findings related to the impact of the Better Access initiative on the development of a skilled, knowledgeable and integrated workforce.
4.7.1 Summary of impact on workforce and models of care
4.7.2 Provision of interdisciplinary primary mental health care
4.7.3 Access to primary mental health care training
4.7.1 Summary of impact on workforce and models of careDuring the consultation process, stakeholders and interviewees were asked to comment about a number of aspects relating to the skills of the mental health workforce and the nature of the way they work together under the Better Access initiative. Overall, providers and professional bodies did not believe that the Better Access initiative had promoted interdisciplinary primary mental health care. Providers from AHP and medical professions identified a number of barriers to providing interdisciplinary care. These included:
- absence of an MBS item for case conferencing limiting information sharing, integrated care planning and coordinated care;
- a confusion among AHPs about the confidentiality of patient information and the need for greater clarification on exchanging information between AHPs and GPs; and
- limited understanding of the professional roles and capabilities between the different allied health professions, a factor perceived to be limiting referrals to social workers and occupational therapists and the provision of multidisciplinary care.
The small area consultations and several consultations with AHPs in rural and regional areas suggest that, in areas where public mental health services are not available or are more difficult to access, individuals with higher acuity and more complex care needs are being managed by GPs and AHPs through the Better Access initiative. Sometimes, this is in conjunction with ATAPS and other funding that is available.
As indicated in section 1.3, a key objective of the Better Access initiative was to improve outcomes for people with mental disorders through supporting GPs and primary care services by providing education and training to better diagnose and treat mental illness. At the time of the consultations, Better Access specific training through the Mental Health Professional Network (MHPN) had only recently commenced. As such, the consultations did not identify any significant improvements in access to training for GPs and AHPs.Top of page
4.7.2 Provision of interdisciplinary primary mental health careThe overwhelming view provided by professional bodies, health departments and providers was that the Better Access initiative had not promoted the provision of interdisciplinary primary mental health care. Professional groups representing both medical practitioners and AHPs reported that interaction between health professionals primarily consisted of a written referral from the GP to the AHP to initiate therapy, and a written report back to the GP from the AHP following treatment. Notably, these stakeholders thought that this level of interaction was inadequate.
AHPs and medical practitioners most commonly cited the absence of a Medicare item number for case conferencing as the principal barrier to coordinated care. Representatives from all AHPs argued that, without specific remuneration for multidisciplinary activities, there was little incentive for treating clinicians to participate. They noted that the issue of remuneration for non-direct client work was a particular issue for occupational therapists, general psychologists and social workers because of the lower rebate payable for the services that they provide.
Another barrier to the provision of coordinated interdisciplinary care was concerns regarding patient confidentially. It was reported by a health department that some allied health professionals believed that they could not report back to GPs about the client's treatment and progress without breaching client confidentiality. Subsequently, it was suggested that there was a need for clarification about the necessity of information sharing between mental health professionals and the GPs and interdisciplinary care of the client.
A further barrier to interdisciplinary care identified by AHPs and GPs was the lack of understanding of professional roles and capabilities between professional groups. Through the consultation process, it became evident that different professional groups believed that some providers from other professional groups did not fully understand their role and skills in the provision of mental health care. For example, some GPs reported that they were unclear about when to refer to a social worker or an occupational therapist versus a psychologist. Similar views were evident in the November 2007 survey of mental health professionals undertaken for the Mental Health Professional Association (MHPA) which highlighted that "there is limited understanding of the specific roles that occupational therapists and social workers have in regard to the Better Access initiative".70 Some, although not all, of these same provider groups recognised that the lack of understanding between professions was a significant hurdle to comprehensive multidisciplinary care. Additionally some of the comments from AHP suggest they have limited understanding of the role and capabilities of the general practitioner in providing primary mental health services within a generalist paradigm.
Some providers identified the geographic separation of medical practitioners and AHPs as a barrier in the provision of coordinated and integrated care. A number of GPs and AHPs recognised that some of the most effective communication occurred incidentally (i.e. 'corridor conversations'), and that the separate offices of AHPs and GPs meant that this type of interaction did not occur. This perspective was also supported by the views of AHPs who had established practices within existing GP surgeries. These AHPs reported that the co-location had not only fostered professional respect, but also facilitated effective discussions on patient care which they perceived may not have occurred without the same level of proximity.
There was also a variation in the degree to which the Better Access initiative is perceived as a component of a comprehensive and integrated mental health system. One Division of General Practice reported that they saw they had no role in the development of relationships and referral pathways between GPs and AHPs, as AHPs were private businesses and should develop their business as best they could by contacting GPs individually. Contrasting this position, most Divisions provided some support in developing referral directories, facilitating enquiries from GPs for information on AHPs in the local area, and providing networking opportunities across local mental health services.
AHPs and public mental health service providers also reported limited contact with each other in relation to patient management. In part, this may be reflective of the Better Access initiative and the public mental health system working as complementary components of the wider health system and having different patient groups.
AHPs reported being frustrated in attempts to liaise with public mental health providers in relation to the provision of out-of-hours crisis care and/or supporting clients who may be at risk of self-harming, and presentation to the local Emergency Department. The general view of AHPs was that the public mental health system was not geared to work proactively to manage clients to remain in the community and did not want to know about the case unless a crisis intervention was required. Most AHPs also expressed concern about the lack of contact from the public mental health service if a client was admitted to hospital and in discharge planning. GPs attending consultations in which these issues were raised noted that this was an issue the Divisions had expended significant time and resources in addressing through GP liaison programs, and was an area that could benefit from further improvement.Top of page
Public mental health providers acknowledged a lack of integration with the Better Access initiative. Some public mental health providers perceived the requests for engagement from AHPs as a "dumping" of patients. They suggested that, if the individual was a client of the AHP, the AHP should manage the client as that was what they were being paid for. More frequently, the reasons provided for the lack of integration were the high demand pressures on the public mental health system and the inability to allocate the resources requested. A number of jurisdictions had proactive policies in place to better integrate with the Better Access initiative, such as policies for notification on admission and pre discharge and routinely considering the Better Access initiative as one service option in case planning.
The critical views of the Better Access initiative were tempered by the results of the online survey of public providers, more suggestive of an interplay between public mental health services and an overlap in client group. Overall, respondents indicated that workers within their organisations were aware of services offered by the Better Access initiative (62 per cent); that services offered by the Better Access initiative complemented the services their public mental health service provided (66 per cent); that the Better Access initiative increased referral options for individuals using their services (63 per cent); and that the Better Access initiative improved the mental health system. Interestingly, around 20 per cent of respondents rated themselves as unsure of the above questions, suggestive of opportunities for better education of public health providers of services available through the Better Access initiative.
That there is an overlap in client group between the Better Access initiative and the public mental health system was noted by a majority of AHPS and is also supported by the results of the online survey of public mental health providers. Fifty four per cent or respondents to the online survey of public mental health providers disagreed with the statement that "Better Access has no real impact on the client group my service works with"; 24 per cent of respondents disagreeing with the statement that "Better Access provides referral options for people they would not normally provide services to"; and 21 per cent reporting a perception that "Better Access has reduced demand for their public mental health services". The responses to online survey questions of public mental health providers exploring the relationship between the Better Access initiative and public mental health services are reported in Table 9 below.
The distribution of responses across states and the client profile of respondents limit the analysis of response by state or service type.
Table 9: Interface between the Better Access initiative and public mental health services
|In relation to the public mental health service in which the respondent works||Agree||Unsure||Disagree||N/A|
|Better Access complements the services that my organisation provides|
|Workers are aware of services offered by the Better Access initiative|
|Worker within my organisation know how to refer people to services available through the Better Access initiative|
|The Better Access initiative has increased options for referral for individuals using my service|
|The Better Access initiative has improved the mental health system|
|The Better Access initiative provides referral options for people contacting my organisation who we would not normally provide services to|
|The Better Access initiative has reduced demand for the services that my organisation provides|
|The Better Access initiative has had no real impact on the client group that my service works with|
4.7.3 Access to primary mental health care trainingThe degree to which the Better Access Initiative has contributed to increased education and training to better diagnose and treat mental illness was difficult to assess at the time of consultations as the rollout of planned training was just commencing.
During the consultations, providers, professional groups and State and Territory health departments were asked to provide opinions about whether those delivering the care were aware of, and were accessing, primary mental health training. In response to these questions, stakeholders largely focussed on the training needs of GPs. In relation to awareness of available training, it was suggested that GPs knew about the training, or where to get information about available training.
GPs, GP representative bodies and State and Territory health departments all provided views about the extent to which GPs were accessing primary mental health training. Many of these stakeholders and interviewees believed that GPs were not accessing primary mental health training at a level required to deliver high quality primary mental health care. At the time of the consultations very little of the training planned to be provided had commenced.
A significant number of AHPs and Level Two trained GPs raised concerns about the level of mental health skills by GPs who had not received mental health training. They argued that, under the Better Access initiative, GPs now held significant power in relation to mental health care assessment and planning, but did not necessarily have the skills to undertake these tasks and that training to acquire these skills was not mandatory.
A number of AHPs, particularly clinical psychologists, also argued that the information contained within the Mental Health Treatment Plan did not replace the need for them to conduct their own assessment and treatment plan. Supporting this argument was a recent APS survey that found many psychologists judged the information provided by GPs to be inadequate and that they needed to conduct their own full diagnostic assessment of 86 per cent of clients referred under the Better Access initiative.71
Though not replacing the need for the AHP to undertake their own assessment and care plan, it would seem that generally the information provided in the GP Mental Health Care Plan was helpful. In the consultation survey 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. The survey also noted that the quality of Mental Health Treatment Plans and information provided to consumers was improving.
A small number of psychiatrists also raised concerns about GPs' skills in mental health assessment and referral. Examples were given of patients being sent to a psychologist instead of a psychiatrist, with subsequent delays in appropriate care. An AHP professional group also raised issues about patient assessment by GPs and their ruling out of medical causes, for example a heart related medical condition being misdiagnosed as an anxiety disorder. Most AHPs reported examples of clients who self referred and rather than a referral by a GP. Some GPs raised concerns about the service provided by the AHP. The time delay in the role out of professional education and training meant that this had not occurred to any extent at the time of the consultations being conducted and the above comments highlight the importance of multidisciplinary education and training being provided to all professionals involved in primary mental health service delivery.
In response to concerns about the GPs' skill levels in relation to primary mental health care, a number of professional groups argued that relevant training should be mandated. They contended that often those GPs in most need of training may well be those avoiding it. All AHP in addition to GPs are now required to participate in ongoing professional education in this area.
A number of GP and AHP bodies reported that at the inception of the Better Access initiative, they were provided with a small amount of funding to provide their members with basic information about the Better Access initiative. The information focussed on topics such as how to attain a Medicare provider number or the type of information required to write a Mental Health Treatment Plan. In some areas, local groups developed referral databases of AHPs for GPs. The focus of these activities was to provide information about how health professionals could use the new system, as opposed to upskilling them in relation to Treatment Planning and best practice in primary mental health care.
Critical to interpretation of the views presented about primary mental health training was the fact that the Better Access initiative specific training had only recently become available. Aside from this basic information, it was clear that providers had had little access to any specific the Better Access initiative training. It was reported that the planned interdisciplinary training through the MHPN had been delayed. One professional group reported that specific training had only recently commenced, but was now available, with plans to complete 250 workshops by the end of the 2008/09 financial year. This MHPN training reportedly focussed on understanding the respective roles and skills of the interdisciplinary team, improving referral networks and the provision of good clinical practice. An important aspect of these workshops was that each of the core professional groups (e.g. APS, RANZCP, RACGP, AASW and Australian College of Mental Health Nurses - ACMHN) had agreed to award continuing professional development points for attending these workshops.
Given that the MHPN workshops were only recently made available, it was unsurprising that the level of awareness in relation to this training was low. When asked about primary mental health training, GP representative bodies and individual GPs referred almost exclusively to the Better Outcomes training, rather than any training specific to the Better Access initiative.
When questioned about the awareness of their members in relation to primary mental health care training in general, GP professional bodies generally considered that most GPs knew either what training was available, or how to get information about training options. These stakeholders reported that information was widely circulated by Divisions, using targeted advertising, and publicising through existing Divisional Networks. They also identified Divisional Mental Health Liaison Officers as being central to providing information and promoting awareness. Apart from the GP professional bodies, no other stakeholder groups offered views about the level of awareness of GPs (or other medical practitioners) in relation to available primary mental health training.
The online survey of GPs, psychiatrists and paediatricians, and online survey of allied health providers explored the impact of the Better Access initiative on training.
Of the 193 GPs responding to the survey, 78 (40 per cent of total GPs) reported that the Better Access initiative had improved access to clinical training. Psychiatrists and paediatricians responding to the survey did not address this question.
Of the 417 allied health providers responding to the survey questions on training, 152 (34 per cent) reported that the Better Access initiative had affected access to clinical training within their discipline and, of these, 96 per cent (or 23 per cent of total respondents) reported that it had improved access to training. Of the AHPs 37 respondents (9 per cent of total respondents) responded that the Better Access initiative did not improve access to clinical training.
Responses from the online survey of GPs, psychiatrists and paediatricians and online survey of allied health providers exploring access to training are presented below.
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Table 10: Impact of the Better Access initiative on access to clinical trainingTable 10 is separated into 2 smaller tables in this HTML version for accessibility reasons. It is presented as one table in the PDF version.
Table 10a: Number of responses - impact of the Better Access initiative on access to clinical training
Has the Better Access Initiative (reponses)
Affected access to clinical training in your discipline
If access affected, has it improved access - Yes
If access affected, has it improved access - No
If access affected, has it improved access – Nil response
Total valid responses
Table 10b: Percent of responses - impact of the Better Access initiative on access to clinical training
Has the Better Access Initiative (percent)
Affected access to clinical training in your discipline
If access affected, has it improved access - Yes
If access affected, has it improved access - No
If access affected, has it improved access – Nil response