Tomorrow, the Minister for Health, Mark Butler, is convening an urgent roundtable to discuss primary mental healthcare, in the light of the Government’s recent decision to revert to the pre-COVID limit for psychology sessions funded under the Better Access program.
Below, Dr Sebastian Rosenberg, Senior Lecturer at Sydney University’s Brain and Mind Centre, provides some advice for the Minister on how he should approach this meeting, including identifying key learnings from previous policies and programs, and also highlighting the need for a broader and longer term approach to mental health system design.
Sebastian Rosenberg writes:
The Minister for Health Mark Butler has scheduled an urgent roundtable on January 30 to discuss key changes to primary mental healthcare.
Following the publication of the evaluation into the Medicare Better Access Program in late 2022, and his decision not to extend the COVID-precipitated extension of Medicare rebates for psychological services, his stated focus is on enhancing access and equity.
Unanswered questions
In truth, the evaluation left key questions about the future of primary mental healthcare unanswered.
The overwhelming focus of the media reporting, and professional responses, was on the number of sessions that should be made available. The evaluation itself provided surprisingly few links to the evidence regarding both number and frequency of CBT treatments, which remains the subject of some debate as to what types of treatments are required for what types of problems.
The evaluation dealt with other issues only cursorily, for example, the role to be played by general practitioners in primary mental healthcare. GP participation in the evaluation was unfortunately very limited, leaving the report to make the oxymoronic recommendation of more individualised GP care but through a more standardised treatment plan. The evaluation also rather conflated the issue of complexity and severity.
While more is known about how best to respond to people with complex needs, like those with eating disorders, the evaluation provided little guidance as to how best to arrange and fund the multidisciplinary care typically necessary.
Little was done to provide new clarity to the term ‘missing middle’. For example, is a person recovering from an acute episode of bipolar disorder and well enough to go home with some community support included in this category?
And after tens of millions of services have been provided to Australians already, the evaluation reiterated a call for routine outcome measurement but provided few, if any options, as to how, at the same time noting that this work would be unique, given other areas of Medicare are not subject to outcome measurement: the only data that is routinely captured relates to activity and costs, not outcomes.
Who needs to be at Minister Butler’s roundtable for these and other issues to be effectively addressed?
An attendance list that panders to professional pre-occupations with fees, rebates and session numbers would not be sufficient.
There is clearly an intersection here between the development of appropriate treatment or service pathways, involving clinical and other care, financial or payment structures as well as accountability for outcomes. Minister Butler has suggested he is interested in pursuing broader Medicare reform. This can take time.
However, some of the solutions are already to hand and can start now.
Here’s one we prepared earlier
Back in 2012, the Rudd/Gillard Labor Government had in place a set of mental health funding arrangements that started to knit primary mental healthcare together using stronger fabric.
The Mental Health Nurse Incentive Program provided new professional support to GP practices around Australia. The Access to Allied Psychological Services Program (ATAPS) demonstrated its capacity to provide coordinated primary mental healthcare to socially and economically disadvantaged groups.
Partners in Recovery effectively coordinated care for people with more severe or complex mental health needs, including engaging long neglected psychosocial support services as part of the primary mental healthcare response.
Personal Helpers and Mentors (PHaMS) was another program augmenting Australia’s primary mental healthcare service, building psychosocial services to become more fully fledged partners to clinical care. These are just four examples. Each were relatively small scale, funded at around $50million each annually. By way of comparison, the Better Access Program costs around $30million weekly.
Each of the four programs was also evaluated and found to be effective. Each provided services under funding arrangements on a capitated or contractual basis, not dependent on fee for service or gap payments. These programs also contributed to building the role of Primary Health Networks in local mental health planning and commissioning, creating a reason for PHNs to work more closely with their state health district counterparts.
It is an irony that it was the advent of the NDIS, with ostensibly more funding coming into mental health, that was the catalyst for the dissolution of these programs.
Both Federal and State governments gave up mental health program funding as they worked to stand up the NDIS. Never funded to be more than a peripheral element of Australia’s mental health service system, the psychosocial sector in particular bore the brunt of these changes. The NDIS drove many psychosocial services, including some that had been offering mental healthcare in Australia for decades, to the wall.
The evaluation failed to mention a variant of the IAPT program which has been operating in Australia for some time. New Access uses coaches to respond to people requiring lower intensity support. It has been trialled and evaluated as effective in several states in Australia and is surely worth adding to the mix of possible reforms.
For these and other reforms in primary mental healthcare to be enacted, planning needs to engage the full range of allied health professionals. While some of these are included under existing Medicare arrangements, they represent only a tiny fraction in comparison to psychology. Others are excluded.
The role of GPs was poorly defined in the evaluation. Some see them as vital, others as gatekeepers. In the absence of alternatives, they certainly see a lot of people. GPs must participate in the reform process and articulate their role. Psychosocial services are endangered, and action is urgently required to prevent extinction. And consumers and carers, long promised a professional national voice to drive their engagement in systemic mental health design, also need to participate.
Scale of the challenge
Tinkering with Medicare will not solve core problems. Continued dependence on small business infrastructure run using fee for service is unsustainable and delivers inequitable, poor care.
We need better models of regional planning and commissioning, to make the most of the limited resources available. Primary Health Networks could and should play a leading role in understanding local needs and designing the service responses appropriate to the needs of their communities.
This local, regional planning needs to be supported by 21st century digital and telecommunications infrastructure, enabling multidisciplinary collaboration across services and settings at scale, for the better delivery of coordinated care and integration of digital mental services with other services and face to face care. The evolution of this kind of technology has been a distinguishing feature of the past decade. It is ready to add to the fabric of primary mental healthcare now, for better service delivery, decision-making, information sharing, benchmarking and systemic improvement.
The evaluation of the Better Access Program rather avoided the central questions of mental health system design, in favour of a more narrow and unhelpful discussion focusing on psychology sessions.
The meeting organised by Minister Butler is an opportunity to revisit this, drawing on a combination of evaluated and tested programs to start the process of change now, at the same time as putting in place some longer term planning, funding and technological reforms, all aimed at augmenting Australia’s primary mental healthcare capacity.
See here for Croakey’s previous stories on the Better Access program
