BackgroundApproximately one in five Australians will experience symptoms of a mental disorder within any twelve month period.
A comprehensive public mental health system is in place, working collaboratively with the Non Government Organisations (NGO) and primary mental health system to support individuals with chronic and severe, low prevalence mental health disorders. This group of individuals comprise approximately three to four per cent of the total population or about 15 per cent of the total number of people who may experience a mental health disorder in any one year.
Prior to the Better Access initiative people with high prevalence mental health disorders, the majority of people experiencing a mental health disorder, had limited access to affordable psychological therapies. Introduced in November 2006 the Better Access initiative provided changes to the Medicare Benefits Schedule (MBS) and introduced education and training for the mental health workforce to encourage more general practitioners (GPs) to participate in the provision of mental health services, to improve access to psychiatrists and enhance the availability and affordability of psychological services provided by psychologists, social workers and occupational therapists in private practice.
This report presents the findings from the stakeholder consultation undertaken as a component of the evaluation of the Better Access initiative. The consultations obtained the views of approximately 1200 individuals comprising representatives of professional bodies providing mental health services, individual service providers, public mental health service providers, non government (NGO) mental health service providers, private mental health hospitals, health insurers, consumers and carers.
Achievement of key objectivesThe Better Access initiative seeks to improve outcomes for people with mental health disorders through the following objectives:
- Encouraging more GPs to participate in early intervention, assessment and management of patients with mental disorders; and to streamline access to appropriate psychological interventions in primary care;
- Encouraging private psychiatrists to see more new patients;
- Providing referral pathways for appropriate treatment of patients with mental disorders, including psychiatrists, GPs, clinical psychologists and other appropriately trained allied mental health professionals; and
- Supporting GPs and primary care service providers through education and training to better diagnose and treat mental illness.
- Across all stakeholder groups the overwhelming view was that the Better Access initiative was effective in achieving the first of the above three objectives and that it was too early to tell in respect to the fourth.
Encouraging more GPs to participate in early intervention, assessment and management of patients with mental disorders
- The predominant message from GPs were that they were doing more mental health work than ever before. The new MBS items for GPs were welcomed as recognising the effort in assessing individuals with mental health problems and developing care plans and treatment options. Most GPs noted that the capacity to refer patients to an allied health professional (AHP) provided the referral options to encourage and allow them to manage more patients with mental health problems.
- Psychiatrists noted that with the new and expanded items for psychiatrists to undertake patient assessments and care plans, GPs were more willing and capable of managing more patients and more complex patients than before the Better Access initiative.
- Nearly all AHPs noted that the number of GPs referring patients was expanding, AHP stakeholders were uncertain whether this was a feature of increased GP activity or the increased development of referral pathways.
- Many public mental health providers noted an increased capacity to refer patients to their GP for common mental health problems, and the capacity for GPs to develop and coordinate treatment options.
- Nearly all representatives of consumer groups and NGO mental health providers also noted the increased awareness and increased role of GPs in managing mental health problems.
Encouraging private psychiatrists to see more patients
- All psychiatrists consulted indicated that the new MBS item for consultation with a patient referred by a GP and expanded rebates for existing items related to patient assessment and preparation or review of treatment plans to be carried out by a GP was effective in encouraging psychiatrists to see more patients. It was noted by most psychiatrists that they and many of their colleagues were now able to allocate scheduled timeslots to see new patients. They reported a greater preparedness to see new patients knowing that the GP would provide the patient's ongoing management and that alternative specialist mental health treatment options were available through AHPs.
- Many GPs also reported that is was now somewhat easier to have a patient seen by a psychiatrist than prior to the Better Access initiative. Though it was highlighted by both GPs and consumers that it remained difficult to gain access to a private psychiatrist, particularly a psychiatrist with low fees or who bulk billed. GPs and consumers discussing difficulty in accessing psychiatrists, predominately perceived this as a result of there being too few psychiatrists.
- A very small number of psychiatrists expressed hesitations about the Better Access initiative. This related to concerns of patients being 'held onto' by a GP and not being referred to a psychiatrist and/or inappropriately referred to an AHP for focussed psychological interventions when assessment and treatment by a psychiatrist would be more appropriate and achieve a better outcome for the patient. Most perceived this is an issue for increased education and training rather than an inherent problem with the initiative.
Providing referral pathways for appropriate treatment of patients with mental disorders
- It was reported by all stakeholder groups that the Better Access initiative had both developed treatment options and developed and improved upon existing referral pathways between GPs, psychiatrists and AHPs. Service providers and consumers demonstrated an effective understanding of how these pathways worked and reported that referrals were initiated by all service provider groups (with AHPs and psychiatrists encouraging non referred individuals seeking treatment to see their GP) and consumers initiating referrals by raising mental health issues with their GP and seeking a referral to an AHP.
Supporting GPs and primary care service providers through education and training to better diagnose and treat mental illness.
- At the time of the consultations very little of the training planned to be provided through the Better Access initiative had commenced. As such, the majority of GPs and AHPs were unable to comment on the impact of the planned education and training on the diagnosis and treatment of mental illness.
- The sole stakeholder who had participated in the rollout of the education and training that was just commencing in their local area identified the approach as positive in respect to both content and the opportunity to develop referral networks across GPs, psychiatrists and AHPs.
Constraints and opportunities
- While reporting the success of the Better Access initiative stakeholders noted that the improvements in access to services and referral pathways did not equally benefit all communities and population groups. All consumer groups and public mental health providers, nearly all GP and psychiatrists and most AHPs noted that some communities and populations benefited more than others and that many communities and population groups experienced barriers in access to service that included affordability of gap payments, service availability and appropriateness of the service model to their particular needs. The small number of stakeholders from very remote communities suggested that the Better Access initiative made it more difficult to access services because of reduced availability of AHPs to provide 'fly in fly out' services through ATAPS or industry supported health care programs.
- A more detailed discussion of the outcomes of the Better Access initiative, identified constraints and opportunities for improvement identified in the consultations follows.
Improved accessThe overwhelming finding is that the Better Access initiative has made services more accessible to and more affordable by individuals experiencing high prevalence mental health disorders. GPs are providing more mental health services than ever before. There are now more allied health providers (AHPs) operating in private practice and services are more affordable. There has been some change to the way some psychiatrists provide care, increasing the number of new people able to access psychiatric input into their care.
For many consumers the Better Access initiative has allowed them to access psychological services that would not otherwise have been affordable or accessible. It has resulted in services becoming available in communities where there were previously no psychological health services. The Better Access initiative is highly valued by consumers and carers.
The improvements in access to mental health services have not been enjoyed equally across geographical communities and population groups. Metropolitan areas appear to enjoy better access to services than do rural and regional areas: to a large degree this is a reflection of general rural health workforce constraints. Due to the affordability of gap payments more affluent areas appear to enjoy greater access than poorer areas, and there is some suggestion from the consultations that there may be some shift of AHP services to more affluent areas as a result of the Better Access initiative. Conversely, some argue that over time market forces will result in a redistribution of AHPs to areas of fewer services to capture demand. In the face of high levels of unmet demand this may take some time.
Paradoxically there is the suggestion from some remote stakeholders that the increased revenue available to AHPs through the Better Access initiative has reduced the attractiveness of engagement to provide services through the Access to Allied Psychological Services (ATAPS) program and reduced service availability in rural and remote communities.
Some groups notably individuals from culturally and linguistically diverse communities, youth, older people and Aboriginal and Torres Strait Islander people also receive poorer access to services for a range of reasons. There is some questioning from some stakeholders as to whether the fee for service model funded through the Better Access initiative, is an appropriate model to engage with, provide services to and achieve the best outcomes for these population groups. A range of options to improve access within the Better Access initiative were suggested. These included the introduction of secondary consultation MBS items to provide direction and support to other workers working with disadvantaged communities, fostering their effectiveness in working in these communities. Another suggestion was the approval of an MBS item for internet and/or telephone based services to people living in remote communities or individuals requiring a bilingual therapist, or a therapist with a particular area of expertise.
Children were identified as one group that have greatly benefited from the introduction of the Better Access initiative due to the few services previously available. However, a key remaining constraint reported by respondents was that there was no MBS Item for the provision of family therapy or to see the parents (or carers) without the child present. Expansion of the MBS to include these services was seen as a valuable means to further improve the quality and efficacy of services provided to children.
It is noted that the intent of the Better Access initiative was to provide services to individuals with high prevalence mental health problems, many of whom would be effectively treated within the maximum of the 18 sessions available. That relatively low service users are the main persons accessing the services is reflected in the most current data reporting an average of five sessions per individual and suggests the Better Access Initiative is reaching its primary target group. Yet many GPs, AHPs, NGO mental health providers, public mental health providers, consumers and carers are reporting that individuals with lower prevalence and more chronic conditions are accessing services through the Better Access initiative. The concern of GPs, AHPs, consumers and carers is that for this group 18 sessions may not be enough and additional MBS items may be required to facilitate more intensive treatment plan coordination and consultation with other service providers supporting the individual in the community.
GPs, AHPs and public mental health providers also perceive the Better Access initiative as working with and complementing the public mental health system. Noting the difference in the primary target population, public mental health providers value the referral options that the Better Access initiative provides for individuals whose condition is not such that they would receive public mental health services.
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Improved affordabilityImproved affordability of psychological services provided by AHPs was perceived as another key outcome of the Better Access initiative. Despite the rebate, the gap fee remained a concern for many consumers and was a real barrier for low socio economic groups and restricted their access to services. General psychologists, social workers, occupational therapists and consumers questioned the higher rebate paid to clinical psychologists. There is also the potential that the higher rebate allows clinical psychologists to charge a lower gap payment, resulting in consumers utilising services that are a higher cost to Medicare but lower out of pocket cost to the consumer.
Operational issuesThe Divisions of General Practice (Divisions) report that the Better Access initiative has largely been implemented and GPs are aware of, and using the MBS items. The feedback from AHPs and consumers, carers and a small number of GPs suggests that the awareness and /or use of the Better Access initiative MBS items is still an area of development.
Overall though the majority (73 per cent) of allied health respondents reported the information provided in the GP mental Health Care Plan they received as good or fair and notably, 72 per cent of respondents reported that they had not received inappropriate referrals. (Attachment 1)
A small number of AHPs report receiving poor quality Mental Health Treatment Plans (Treatment Plan) and consumers and carers express concerns as to levels of GP awareness. AHPs also noted that the number of poor quality Treatment Plans was a small proportion of plans received and that the general quality was improving over time.
Conversely, GPs report poor quality reports from AHPs. Both GPs and AHPs note that the quality of information being exchanged and quality of referrals is improving as the Better Access initiative matures. It is noted that at the time of the consultations the primary care training planned as a component of the Better Access initiative was only just commencing.
A perception reported by most AHPs and some GPs was that there would be merit in considering a more simplified referral process to AHPs. It was reported by many AHPs and some GPs that a GP Treatment Plan was not required in all instances, particularly where the GP did not have an ongoing role in the management of the patient's mental health issues. Though supporting a more simplified referral process, most AHPs and nearly all GPs supported GPs retaining the gate keeping and referral role.
The implementation of the education and training program may go some way to addressing these issues and further improving awareness of and access to the Better Access initiative. This would also provide the capacity for a greater clarity on the intended target population and services that can be provided. However, the access to services by individuals with low prevalence disorders appears to be relatively widespread and is perceived and valued by service providers and consumers alike as an important component of care.