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Audit Commission proposals on mental health, homelessness “without context, understanding”

The recommendations of the Federal Government’s National Commission of Audit on mental health are “without context or apparent understanding” and will only add to the inequity that people with a mental illness already experience, says Sebastian Rosenberg, Senior Lecturer at Sydney University’s Brain and Mind Research Institute. See his post below on the recommendations on mental health, disability support, employment support, the NDIS, and homelessness.

In further reaction to the Commisson’s report, released yesterday, Dr Andrew Gunn from the University of Queensland, is blunt about the consequences of the Commission’s proposal that even concession card holders should be hit with a $5 GP co-payment:

I’m a GP who visits hostels that house people with severe mental health problems. Many have paranoid schizophrenia and are reluctant to sign a medicare form to be bulk billed.

My patients have appalling health status, die young and desperately need more medical care — but there isn’t a snow flake’s chance in hell that they’ll pay $5 to see me.

See the Croakey wrap from yesterday for more reactions to the Audit report.

***

Sebastian Rosenberg writes:

The only thing worse than being talked about is not being talked about, said Oscar Wilde.  With this strained mixture of fear and anticipation I began to search the five kilogram National Commission of Audit (NCOA) report for references to mental health.  Australia’s deficit in relation to the provision of adequate, high quality mental health care is well known.  The Commission had better have understood this.

I don’t think they did.

The report certainly plainly states (at Recommendation 40) that responsibility for mental health is characterised by “overlapping funding and service delivery responsibilities and a lack of coordination across jurisdictions”.

On this basis it supports the current review being undertaken by the National Mental Health Commission, asking that it pay particular attention to “removing the significant duplication between the Commonwealth and the States that currently exists in mental health services”.

It seems strange that the NCOA felt confident enough to assert this duplication when (at section 8.6) they also state how hard it is to actually establish an accurate picture of services and expenditure in mental health, whether the right amount of money is being spent in the right areas.  The NCOA here is clearly wishing the National Mental Health Commission the best of luck in its review.

But what is worse is the apparent failure of the NCOA to acknowledge the paucity of services and the huge variability in the quality of mental health care across Australia, as acknowledged in many previous national and state reports in this matter.  In fact, the real area of duplication across state and federal governments is in their shared neglect of mental health over many decades.  This neglect is at its most acute in the area of most need – the need to establish a national system of accessible, high quality community mental health care.

While the NCOA support the National Mental Health Commission’s review, this does not stop them also calling for the abolition of that Commission, or rather, its absorption into a new Health Productivity and Performance Commission, along with natural bedfellows such as the Australian Commission on Safety and Quality in Health Care, the Australian Institute of Health and Welfare, the Australian National Health Performance Authority, components of the Australian National Preventative Health Agency, the Private Health Insurance Administration Council, the Independent Hospital Pricing Authority and the National Health Funding Body.

Across all government agencies, the NCOA makes recommendations for reviews in relation to mental health committees and groups, including the Aboriginal and Torres Strait Islander Mental Health and Suicide Prevention Advisory Group in the Prime Minister’s Department, the Australian Centre for Posttraumatic Mental Health in Defence, the National Mental Health Forum in Veteran’s Affairs and the Australian Suicide Prevention Advisory Council in Health.

It is at this point that I feel an urge to say that health policy and reform is really complicated while cutting budgets is not.

The task of mental health reform is particularly difficult.  It was not assisted by moving the National Mental Health Commission from the Department of Prime Minister and Cabinet to the Health Department and the move suggested by the NCOA would seem a further retrograde step.

The NCOA report does make the point that funding to mental health is fragmented and poorly coordinated, with the Commonwealth responsible for 21 different grant programs totalling more than $500 million in 2012-13.  This fragmentation is mirrored in the states.  But the NCOA report fails to acknowledge that merely reducing the fragmentation will not address the gap generated by mental health receiving around 5 per cent of the health budget but accounting for 13 per cent of the burden of disease. This is simplistic but illustrative. Better coordination will help but it will not be enough to bridge the gap.

More broadly than mental health, the NCOA also seeks to assert responsibility for homelessness to the states.  This is not about good policy or reform, just about reducing Commonwealth spending.  There was general relief in the homelessness and mental health sectors when Tony Abbott agreed to extend the partnership agreements in this area.  These had created new services.  Removing these arrangements would be a backward step in addressing homelessness.

The NCOA is also keen to reform employment support services, including reducing the average cost per jobseeker.  While Australia’s unemployment rate remains quite low, our success in finding employment for people with a mental illness is poor.  It is likely that a significant proportion of Australia’s current pool of unemployed people have a mental illness, diagnosed or undiagnosed.  Generalist employment support services often lack the expertise to assist people with a mental illness back to work.  Funding incentives paid by the Federal Government to employment agencies often discourage providers from taking on hard to place cases.   Cutting the employment support services for the unemployed will not help these people find and keep a job.  They need specialist support services and a system of funding for employment service providers that pays incentives to take on the ‘difficult’ cases, not shove them in a too-hard basket.

On the back of inadequate support to get a job, it seems additionally cruel then for the NCOA to also recommend reducing the Disability Support Pension (DSP).  Psychiatric disability is now the largest component of the DSP, accounting for almost one third of the 825,000 Australians receiving that pension. Nobody supports malingerers.  But after enduring poor access to mental health care, problems with housing and frequent unemployment, it really does seem unfair to then reduce access to a pension for many people with a mental illness.

Just in case somebody with a mental illness does slip through the net and find government support through the newly minted National Disability Insurance Scheme (NDIS), in order to promote fiscal sustainability the NCOA also recommends slowing the roll out of the Scheme.

I find it passing strange too, for an audit so keen to pursue efficiency, that so little was made of the Better Access Scheme.  Now costing taxpayers around $12 million each week, the NCOA reports that the Scheme has driven an average annual increase of 11.2 per cent in Medicare-subsidised mental health services over the five years to 2011.  Yet the NCOA did not even see fit to recommend a review as to whether these precious funds are being properly targeted and yielding good outcomes.  Another job for the National Mental Health Commission perhaps, while it still exists.

Overall, people with mental illness are already getting a grossly unfair deal.   This is not acknowledged by the NCOA.  Instead, the NCOA has reported as if strangers in a strange land, without context or apparent understanding.

On this basis, the NCOA report confidently makes several important suggestions which could make things even more unfair for people with a mental illness. I rather hope Australia is not that kind of country.

Related Posts

Comments 34

  1. Ben Mullings says:

    Most people will agree the NCOA report was problematic. But with respect Sebastian, we should avoid cherry-picking data to criticise the Better Access to Mental Health Care program.

    Australia’s investment in psychological care must be put in context as to the overall cost of mental health disorders to our society when such conditions are left untreated. Mental health disorders cost our economy an estimated $5.9 billion annually from lost productivity alone (http://www.ncbi.nlm.nih.gov/pubmed/20113304). If we factor into that the loss of workforce participation those estimates rise to $20 billion each year (http://www.abs.gov.au/AUSSTATS/abs@.nsf/lookup/5C38C3D5C0E26826CA25773700169C88?opendocument).

    When we start talking big figures people’s eyes tend to gloss over, so let’s put those figures in terms of some recent purchases we have made as a country. Last week our Government announced that we are purchasing 58 Lockheed Martin F-35 fighter jets at a cost of $210 million each. If we purchased just one less fighter jet, then the savings could allow 123,820 people with a mental health disorder to access psychological treatment for 20 visits. If you’re like myself and appreciate the value of fighter jets, then think about it like this: by helping people access timely treatment we could purchase over 25 more fighter jets in the gains from addressing the source of lost productivity. And when we factor in workforce participation, those estimates of $20 billion lost each year correspond to 95 more f-35 Joint Strike Fighters. It’s false economy to scrap psychological care.

    But the more important point here Sebastian, is to compare the cost of psychological care via Better Access to other programs such as ATAPS. If we don’t do that, then the rationale to cut spending on Better Access amounts to saying that we should cut off people’s access to psychological care. Going by the most recent figures we can see that in the last financial year ATAPS reached 52,300 people at a cost of $1,644.34 per person (http://www.health.gov.au/internet/main/publishing.nsf/Content/annual-report2012-13/$File/2.1%20Outcome%2011%20Mental%20Health.pdf). The average number of sessions under ATAPS is 5 visits, which means that ATAPS costs Australia an average of $328.87 per visit to deliver psychological treatment. By comparison, the Better Access program delivers psychological care to over 500,000 people each year for an average of $84.80 per visit.

    It’s obvious that the Better Access program is far more cost-effective than the alternatives.

  2. Tully Rosen says:

    Psychological treatment is highly specialised and very effective for some people in some circumstances. However Ben it is important to acknowledge that the journey to mental health recovery demands an individualised approach.

    Since deinstitutionalisation the community managed mental health sector has grown substantially, filling the gaps created where people across the spectrum of mental illness have found access to psychosocial support services they couldn’t possibly hope to afford on their own.

    While Better Access and ATAPS had initially improved access to psychological services for those who did not have the means to pay for mental health services themselves, Better Access was designed very poorly in terms of delivering equitable access to care.

    Beyond the overall budgetary blowout caused by uncapping the scheme, and the tendancy of Psychologists to cluster around affluent geographical locations, the lack of Better Access regulation has led to drastic increases in Psychologist fees in areas where people are willing to pay them. As a consumer, and as someone who has deep links with consumers and service providers, it has been disheartening to hear of price gouging by Psychologists as they raise their prices in line with the Medicare rebates they receive. For example, metro Psychologists who used to charge $120/hr five years ago are now regularly charging $180+/hr now. They then “take pity” on their clients when the mental health plan payments run out and drop their fees back down to somewhere closer to their original fees.

    It may only cost the government less than $100/hr on average for the service, but that is not the total cost of that service provision. Charities and community organisations providing the range of mental health supports where people need them manage much more for much less money.

    We can’t build a mentally healthier economy with more Psychologists, just as we can’t build a better system by simply adding hospital beds, building community clinics or by enhancing the community managed sector. They all need a rise, however this rise must be balanced using principles of equity, evidence, population modeling, and with value-for-money forefront in these times of austerity.

    Give me $50-60/hr for community NFP services and I could show you the huge effectiveness payoff. As it is however the NDIA are grossly underrestimating the community cost and currently paying closer to $30/hr. Perhaps charities should charge “recommended fees” closer to those of psychologists to cover the difference.

  3. Ben Mullings says:

    More people from disdvantaged areas access psychological care via Medicare than any other program nationally. Estimates show that since the program launched, over 440,352 people living in the most disadvantaged quintile of the Australian population accessed psychological treatment via the Better Access initiative. Each year that represents around 75,000 people. Statistics also show that most psychologist do bulk bill those on a low income. We all need to appreciate the scale of what we are talking about here and the fact that these figures represent actual people. The question is about how to best support those real people who need a better standard of support from Medicare. Cutting their treatment short is not only costly, but it’s also dangerous.

    I agree with you Tully, that charities and community agencies do have a place in the wider mental health care system. However, funding which is meant to be directed to psychological treatment in that setting often doesn’t end up being used for that purpose. We also need to consider issues like the training and experience of para-professional counsellors employed by such agencies. Many people who seek help are also concerned about being directed to charities and other counselling agencies with links to religious groups, particularly if they have had a traumatising experience with groups of that kind in the past. The quality of care is important.

    Although some practitioners obviously do engage in price-hiking, I doubt there is much evidence to support the view that this is going on across the whole sector, is there? Conversely, there is quite a lot of evidence to back the cost-effectiveness of the Better Access program. Can you think of any other program in Australia that delivers genuine psychological treatment to as many people for as low a cost?

  4. Ben Mullings says:

    Important to note too that people who receive psychological treatment via Medicare have a diagnosis of a mental health disorder from their GP or Psychiatrist and have asked to see a psychological care provider. Sometimes that is a psychologist, sometimes it is a mental health social worker, sometimes it’s an occupational therapist. The patient has a degree of control in their choice of preferred mental health professional, which is quite different to how cases are allocated in other settings.

    So when you say psychological treatment is “very effective for some people in some circumstances”, it is critical to be aware of exactly who we are talking about. There have been a number of evaluations which show that psychological treatment is effective for those people in the circumstances described above. My point about the article above is that the Better Access program deserves far greater support so that we can help such people, rather than criticising the fact that so many people are now receiving proper treatment for their mental health condition.

  5. Liz Brown says:

    I am one of those people who used Better Access. I am a single mother, have 3 kids with health issues, I am on carer’s payment. I separated from my abusive husband who I lived with for years and with the help of the psychologist I am seeing, I managed to get out of that relationship. I have a history of childhood abuse which saw me stay in this abusive relationship because I was acclimatised to abuse. My sister suicided because of that history. I struggle daily with stress, anxiety, panic attacks but I am pulling myself out of years of depression and finally studying and hoping to be able to work. All thanks to affordable Medicare subsidised, Better Access to a qualified and experienced psychologist who I have built a relationship and trust to help me get to this point. My psychologist bulk bills me, even though he is top of his field and can charge far more for private patients and has to close his books often. Without this help I would no doubt be dead. Whereas I will be productive and working and looking after my kids and not passing on my legacy of mental health issues to them. My history of abuse was a religious fundamentalist mother. I could not go to a religious charity for help. Better Access works and provides affordable help for people like me. It should be increased not cut. Short term cuts versus the longer term expenses of not treating mental health issues just does not make financial sense. If you have a hole in your roof you fix it, even if you have to borrow the money. You don’t let the roof cave in and allow your whole house to be destroyed, just to economise.

  6. Tully Rosen says:

    The criticism is about scheme design and comparing different types of mental health services. It’s not about removing medicare payments for psychological services.

    There should be far more access to mental health services in the community full stop. Mental health is terribly hospital-centric with little evidence to justify it. Those services that are available in the community are overbooked and poorly regulated.

    The community managed sector is far bigger than just the religious charities. They have been quietly helping people with their mental health conditions, most of the time in successful partnership with clinical services. They are also grossly underfunded in comparison to Better Access, even though they provide far more service for the same amount of money to people with and without medical diagnoses.

    They may not have the same university-college-research nexus behind them to demonstrate the evidence of every single program, but every time governments have bothered to research their effectiveness the results have been undeniable. The SPRC HASI evaluation comes to mind.

  7. Ben Mullings says:

    Again Tully, I think we can all agree that we need to better support our community managed sector. The comment about religious charities was one of quite a few issues that need to be considered, as were the issues of the training and quality of services being provided.

    I disagree with your opinion that the community managed sector provides “far more services for the same amount of money”. Can you support that with some evidence please?

    We should probably also be clear that the Better Access program is NOT hospital-centric. The program was established in an effort to try to reduce the need for hospital-based mental health care services and is widely appreciated by the medical sector for that reason.

    Evidence-based policy reforms are necessary, especially when we are talking about providing psychological treatment for people living with a diagnosed mental health disorder. If we can bring attention back to the target article for a moment, maybe that will help us all look at the problem of capping the program at 10 sessions, which is far below what the research says most people need. Only a third of people with a mental health condition will recover after 10 visits. It takes more like 20 appointments of psychological care to help the majority of people who access these services. Let’s try to keep their needs in mind here.

  8. Liz Brown says:

    Whilst I see how community services can play a major role in mental health care support so long as the administration costs are kept low. For someone who has complex mental health issues, I would be very wary of relying on the options in community service and I am not aware of services available for such complex mental health issues. Complex mental health issues requires treatment with experienced psychologists who are trained in treating patients with complex issues, such as those with complex trauma, in order to treat efficiently and get results. I could not have improved if I did not get that help. Medicare funded Better Access to psychologists is an efficient and cost effective means of treating patients with complex mental health issues. I agree hospital centric treatment is what needs to be avoided and is a last resort. Better Access treatment via a psychologist is not hospital based and it prevents people from getting suicidal and having to seek expensive hospital treatment. Access to psychologists via BA also is far cheaper than going to a psychiatrist most of whom are not trained in CBT and just give out medication which is not the answer for people with complex mental health issues. Therapy is required and BA is an efficient and cost effective means of providing that therapy if enough sessions are provided. Unfortunately I see the cuts to BA down to 10 sessions as meaning a lot of people with complex health issues are unable to get the treatment they need and left in a state of suffering and unable to work and going further and further into poverty.

  9. srosenberg says:

    Hi Ben

    Thanks for your comment. The introduction of Medicare-subsidised psychology services was the most important reform made to mental health in the last decade. I don’t think anybody is arguing it should be withdrawn. Overall rates of access to mental health care in Australia remain too low.

    The issue is about whether the taxpayer is getting best value from this costly program. While your points about efficiency are noted, my understanding is that in 2012-13 there were only around 31,500 referrals to ATAPS in comparison to almost 3m services provided under the Better Access Program in the same year. Hard to compare programs of such different magnitudes. However, I do note that the average copayment for people under ATAPS ($18.15 – https://ataps-mds.com/site/assets/files/1016/ten_year_ataps_report_final_acc.pdf) is half that of the BA program ($36.90 – http://www.health.gov.au/internet/publications/publishing.nsf/Content/mental-ba-eval-b-toc~mental-ba-eval-b-4~mental-ba-eval-b-4-3). BA may be more cost-effective but to whom?

    However, perhaps the key point of difference between ATAPS and Better Access is that the former has been subject to regular evaluation (incidentally by the same group that did the Better Access Evaluation), with over 20 reports, 14 special reports and 17 journal articles.

    As you would know the BA Program has only been evaluated once, sampling only 132 health professionals and 300 consumers (as selected by health professional – http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-ba-eval).

    Better Access has clearly helped many people. This should not stop us looking to make improvements to the Program.

  10. Ben Mullings says:

    Thanks for replying Sebastion. I just a few comments about your comparison of Better Access to ATAPS. I have worked as a practitioner under both systems and have heard from hundreds of practitioners and patients in both programs over the last few years and feel as though these perspectives should be considered. There is also quite a lot of data which shows that ATAPS is far more costly to run.

    First, using the average co-payment figures as a comparison doesn’t really make sense here because (as you are probably aware) some of the key components of ATAPS are dedicated to low income populations. Taking the average co-payment figure at face value means that the figures will naturally be skewed in favour of ATAPS.

    The Better Access is accessible to all Australians diagnosed with a mental health disorder. A great many patients have expressed frustration and despair at being blocked from accessing psychological care via ATAPS due to the gate-keeping and rationing of treatment services which occurs under that system. On our website, you will find quotes from GPs, psychiatrists, psychologists and other mental health professionals, expressing their frustration at the red tape which blocks people who desperately need psychological care from receiving therapy via ATAPS (http://betteraccess.net/index.php/information/better-policy). By comparison, the Better Access to Mental Health Care program is flexible enough to include cases which would otherwise fall through the cracks. Just as a quick illustration, the Medicare Locals office in my region refers people via Better Access to my practice when the ATAPS program has excluded them or can’t help them. The majority of psychologists bulk bill people in that situation, which means that the patient doesn’t need to pay. So when you ask “BA may be more cost-effective but to whom?” it is clearly quite cost effective to those patients and also to the taxpayer. When you compare average co-payments alone, we end up failing to consider those hundreds of thousands of people who are bulk billed via Medicare. In fairness, if we are going to compare the two programs then those people should be counted too.

    When we take a look at it in real human terms, Better Access easily reaches over 5 times the number of disadvantaged people as ATAPS does. When we examine hard to reach groups, like whether men are accessing therapy, the figures show that in the first 6 months of 2013 alone the Better Access program provided therapy to more men than ATAPS did across the last decade (http://betteraccess.net/index.php/information/archives/82-news/181-more-men-use-better-access). We need to remember these are real people and the Medicare system has enormous reach and national consistency.

    I don’t know how much time you have spent reading into those ATAPS evaluation reports, but if you have, I am sure you will agree that they are -very- basic. Most of the data those reports analyse is the equivalent to the routine data collected via MBS items for the Better Access program. Correct me if Im wrong, but none of the ATAPS reports are anywhere near as comprehensive as the evaluation that was conducted for Better Access is 2011. In addition, there have been about the same number of journal articles written about the Better Access program as ATAPS too, with quit a few of those articles talking about both. All of the major reviews reinforce the point I am making that the program is cost-effective, reaches an enormous number of people in Australia (including the disadvantaged), and as a result of those facts the program is responsible for a big increase in the treatment rate of people diagnosed with a mental health disorder. Some journal articles about Better Access go even further, suggesting that the program has reduced the dependance of our population on medication (https://www.mja.com.au/journal/2012/197/3/better-outcomes-or-better-access-which-was-better-mental-health-care). Therefore, it would be misleading to suggest that Better Access has not been subject to regular evaluation. Both programs have received about the same attention.

    Both the Better Access program and the ATAPS program are clearly helpful. The question is really about the optimum cost-effective way to delivering psychological treatment which is inclusive for all people. As I mentioned in my first comment, the average cost per visit under ATAPS is around 3 times higher, at $328.87 per visit. Over the last 3 years we have tried directing more money and resources at ATAPS so that the program could reach more disadvantaged people, but that didn’t work. The additional $31 million which was directed at ATAPS in the last financial year only saw ATAPS seeing an additional 13,200 people. At an average rate of 5 appointments, that translates to a cost of $468 per visit, which is even more costly (http://betteraccess.net/index.php/information/better-policy). Redirecting even more of our mental health funding away from Medicare and into ATAPS doesn’t make sense. I believe ATAPS still has some place for highly targeted programs, with appreciation for the point that they do cost a lot more to run.

    Sebastion, we shouldn’t take the $12 million figure you cited out of context. If that’s what the Better Access program costs, then please spare a thought for how many people are receiving treatment for their condition. I don’t know where you got that figure from, but if that’s true, then we are talking about close to 100,000 people (or more) receiving psychological care each week. Yes, it costs money to support that treatment via Medicare. However, the figures above show that it would be costing us around 3 times more if we relied on the alternative programs.

  11. Liz Brown says:

    Um I hear a lot about whether the tax payer is getting best value for its money. What about whether the person with mental illness is getting the best treatment to ensure that they can become reproductive and contribute to the taxes in this society? As it stands

    Ok I would like to switch this argument around of whether the tax payer is getting the best value for money and say what about whether the person with mental illness is getting the best treatment so that they can become productive in society and pay some of those taxes. Also so they can not be reliant on welfare and charity. Are you advocating for the mentally ill or the taxpayer? Fact is that ATAPS has is not available to a lot of chronically ill patients and in cutting Better Access down to 10 sessions a whole load of people who could have been getting help and becoming productive have been left with no help as 10 sessions is not enough and ATAPS is not available. So the cost of this political banter is that the program that was working and was very cost effective has been cut. ATAPS is expensive to administer and so tightly controlled and not available to the numbers that Better Access is able to help. These are human beings who have been abandoned and left without the therapy they require. What has been the human cost to these people who are left to suffer and their families who have to bear the burden and the kids who are likely to inherit mental illness, plus lets remember the good old tax payer who is now paying for welfare of that non-productive mentally ill person and expensive hospital intervention and drugs and the early teen mental health intervention for their kids. What has been the true cost to the tax payer of cutting an effective system for the promise of ATAPS which never delivered. leaving thousands stranded.

    And I would also like to check out if the calibre of psychologists required for treatment of complex mental health such as the results of complex trauma are available in the ATAPS program? And once you have had your 18 sessions in ATAPS do you have any option to continue seeing the therapist you so need to have built up a relationship with or is that it, because as you know 18 is some magical number that is supposed to fix some statistically average mentally ill person living in the perfect World?

  12. Tully Rosen says:

    When you’re holding a hammer everything looks like a nail.

    There are many effective services out there, psychological treatment being one very important part of that. However Psychologists are not the only solution. They are a very expensive solution, second only to Psychiatrists.

    Every mental health profession claims itself as the most important service that should be made available. What I would like to see is the major piece of Commonwealth work be made public that brought together all the professions and planners and actually quantified a coherent system of mental health services, public, private and non-government, with the likely need and level of staffing required.

    It was called the National Mental Health Service Planning Framework. Mental health stakeholders were being told about endlessly about its immense value and imminent arrival right up until late last year. This project needs to be made public so that we can all see how much of a gap exists between what-is and what-should-be.

  13. Ben Mullings says:

    Tully, the services of mental health professions in the Medicare system are NOT expensive. The figures presented in the above comments clearly show that Better Access is the very least expensive program to deliver evidence-based psychological care. Yesterday I asked you the following question, which I would still like a reply to please:

    Can you think of any other program in Australia that delivers genuine psychological treatment to as many people for as low a cost?

    Please understand how important that question is, because if we are going to criticise the cost of treatment we need to consider what alternatives we have. The current alternatives are either (a) no evidence-based, (b) not delivered by mental health professionals, or (c) far more expensive. If the suggestion is that we don’t need evidence-based treatment provided by mental health professionals, then let’s be up front about it. How might the public feel about that proposal?

    And can you also please show us some data to support your claim that the community managed sector provides “far more services for the same amount of money”?

    I put it to you that your claim cant be supported when we factor in the number of people helped, and when we compare the total cost to deliver the same services side-by-side. Medicare only pays for treatment. It does not pay for rent, holidays, sick pay, superannuation, administration, reports, supervision, meetings, and so on – which all need to be factored towards the costs of the community managed care sector. Having worked in a number of such agencies, I have seen for myself how large amounts of mental health funding ends up being redirected away from direct care. We still need agency-based services, but we must be honest and transparent about the genuine costs involved here. Saying that you can deliver the same service for less money is not true.

    It’s counter-productive saying that psychological treatment is too expensive when it is clear that so many Australians benefit greatly from those services. If you’re going to criticise the cost of treatment, then please keep in mind that you are criticising the fact that so many people are accessing treatment. That’s where the cost comes from. As people recover they are able to contribute more to our society, including in many cases, positively generating more funding to our economy.

    Every single mental health report from the last two decades has called for us to improve the rate of treatment for people with a mental health disorder. Australia is finally starting to lift those percentages. What are we trying to achieve by criticising the fact that so many people are now beginning to access psychological treatment?

  14. Tully Rosen says:

    I’m not questioning Psychological treatment. I am questioning the insinuation that psychological treatment holds some kind of evidence-based primacy over other mental health treatments. Why aren’t you sticking up for the Social Workers, OTs and Nurses providing services through Better Access?

    There is strong evidence for CBT and a few other talking therapies developed primarily by Psychologists. Tell me how many Psychologists genuinely restrain their practice to just CBT and the therapies with gold-standard evdidence. When they move into the other therapies it is hard to distinguish a Psychologist from a counseller or psychotherapist, except for the fees that they charge.

    When it comes to the strongest evidence it is for medical treatments, drugs and a referral, but I doubt anyone would argue that this is sufficient.

  15. Robyn Lingard says:

    I am a mental health social worker with a masters in clinical counselling, regularly follow and contribute to, and see the Alliance of Better Access Facebook group as representative of my view. I am in private practice where vast majority of my clients depend upon Better Access to receive my services. Better Access has meant that middle income clients can access 10 sessions of professional therapy. Without this Medicare subsidy, middle income clients cannot afford multiple sessions of therapy. ATAPs is not available to them because they do not have concession. Low income and middle income aussies need medicare subsized counseling for multiple sessions otherwise they cannot afford the service. So instead of seeing someone like myself who is only refundsed $74, they instead present to their gp or their emergency department. These latter services cost far far more than regular visits to me! Many of my clients are struggling to stay in employment or in their marriage. Better Access has enabled them to receive therapeutic support to keep in their jobs, either stay in their marriages or at least separate as well as possible – which is a cost effective outcome, if we just want to consider the economic benefits of building individual’s mental health. One way to reduce the costs of BA for our nation is to eliminate the visit to gps after the 6th session for clients who are not on any anti-depressant medication.

  16. Liz Brown says:

    With my experience of complex mental history and trying to unravel the mess my life has been left because of the abuse and having just left an abusive relationship I think you will find most people with complex mental health issues also require counselling and not just CBT. I get a combination of CBT, psychotherapy and counselling in one session. Now if I had to visit 3 different practitioners I think that would cost the system much more. So I think my psychologist is great value for money.

    As for the comment about strongest evidence for medical treatment is drugs, where did that evidence come from? I don’t think anyone except the drug companies would be advocating that drugs are more effective than psychological treatment.

  17. Ben Mullings says:

    I notice that you didn’t answer either of my questions, Tully. I have asked twice now if you could please share the information backing up your claims. Given that you haven’t done that on either occasion, I’m going to take it that you dont have any data on hand to support your opinion that the community managed sector provides “far more services for the same amount of money”. Similarly, I will take it that you are not aware of any other program in Australia which delivers genuine psychological treatment to as many people for as low a cost. Me either.

    I have to add that I am a bit confused by the suggestion that my points are only relevant to psychologists. If you scroll back up to the top of this thread, you will see that at 3:50pm yesterday (4th comment down) I pointed out that one of the biggest strengths of the Better Access scheme is that it allows a person to choose their preferred mental health professional and I specifically named both social workers and occupational therapists, who work alongside psychologists in that program. Throughout this discussion thread I have talked about ‘psychological care/treatment’ and refer to ‘mental health practitioners’, ‘psychological care providers’ and ‘therapists’ – not psychologists. The only instances where I have referred to psychologists by names is when I cited the rate of bulk billing which is evident from surveys and other research involving psychologists. My personal view is that all mental health providers strong contributions and offer diversity and flexibility to the system.

    The Better Access program allows mental health professionals to select from a range of psychological interventions to suit the different needs of people seeking therapy – not just CBT. You will find the full list of approved interventions on page 14 of the Better Access orientation manual (http://betteraccess.net/docs/Better-Access-Manual.pdf). There is a strong and growing evidence-base to support the efficacy and effectiveness of these interventions. In the evaluation of the Better Access program conducted in 2011 around 90% of consumers reported that they received CBT (http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-ba-eval), which is a finding that is confirmed by practitioner surveys and other data. Given that other interventions besides CBT are available in the scheme, that represents rather strong support for the idea that psychological care providers in the scheme do deliver evidence-based treatment. The highly effective results of the program, in terms of improved symptom severity scores, would also lend support to that position.

    I am glad you raised the issue of comparing medication to psychological treatment, but I must disagree with your conclusions. In the case of depression for instance, meta-analytic research of controlled studies sometimes show that antidepressants provide a slightly better advantage in the short-term, but that longer-term results are usually better achieved with CBT (http://pro.psychcentral.com/2014/cognitive-behavioral-therapy-versus-medications-for-depression-how-do-they-compare/005268.html#). One of the better reviews in recent years is freely available online and demonstrates that when we exclude therapists with unclear training in psychological care from the analysis, then medication no longer has any advantage even in the short-term (http://www.safranlab.net/uploads/7/6/4/6/7646935/psychotherapy_vs._ssris_2011.pdf). That point is very important to consider in the context of your suggestion that we can rely para-professional counsellors instead of mental health professionals. Training, supervision, ethical standards, experience, and reflective practice, all make a positive difference.

  18. Ben Mullings says:

    CORRECTION: My personal view is that all mental health providers *MAKE* strong contributions and offer diversity and flexibility to the system.

  19. Robyn Lingard says:

    Better Access has enabled quite a number of social workers with either/or postgraduate qualifications in mental health and work experience in mental health to move into private practice. Our clients do not have access to private health insurance so for us, Medicare is the only assistance our clients can access. Private practice has enabled many of we mental health social workers to provide the quality of service we have wanted to give but have not always been able to provide when working within the constraints of an organization or for another practitioner. I frequently give my individual clients 60 – 75 minutes/session, couples for 90 – 105 minutes even though I am only funded really for 50 minutes. My experience which is supported by many of my private practice colleagues is that we are more able to be flexible for our clients needs, decide our own hours, provide a location that we believe is best for our clients, and really help our clients feel special; not a number. We can only do this because Medicare under Better Access gives our clients a decent income; add on a small gap and we have a practice where we can see people in areas not commonly serviced by other practitioners. One of the positives of BA was that it enabled practitioners to move to outlying suburbs in the larger cities whereas previously practitioners were more located in the more affluent suburbs. Better Access has its faults, for sure, but it has been the only scheme that has enabled more practitioners to provide this personalized cousnelling that enables clients to choose their own practitioner with clear guidelines of how many sessions. A major problem with Better Access is the cutting back of sessions from 18/year back to 10/year. For gains to be more stabilized I see my clients needing these 18 sessions/year if needed; 10 sessions is something but tends to just place some people into a holding pattern, while others make progress but then fall backwards waiting for their next batch of sessions in the following year.If Better Access is cut further or scrapped, our nation will pay dearly in returning to pre-Better Access days when more people were accessing medicare through gp visits and needing the emergency department of hospitals. Mental health issues will not go away if the funding is cut; they will just reappear more costly, just like prior to Better Access.

  20. Frank Breuer says:

    My 2 cents … Maybe I quickly introduce myself: I am a German trained Clinical Psychologist of 15 years, working in my 5th year now in private practice in Australia. I have 5 years of post-graduate CBT training and over 1000 professional development hours.

    Well first of all, having worked in a country in which 25 sessions are considered short term therapy, and 45 sessions of CBT are considered “standard long term therapy” (all bulk billed by the way) I am gobsmacked about the discourse around mental health ie. ”Better Access”, the medicalised approach in treating mental and behavioural disorders (ICD10) and very limited number of sessions in this otherwise great country.
    I can wholeheartedly say from both experience and training, that CBT has more to offer than any good therapist could practically deliver in a reasonable number of sessions, including long term.

    Whilst Medicare wants us to use CBT, practically it is not possible to provide adequate CBT treatment in the current environment, due to the limited number of sessions.

    10 sessions allow NO therapy in private practice that adheres to any CBT standards, with perhaps the exception of mild adjustment or acute stress disorders or the like. I can do a lot in 10 sessions, like crisis management, psycho-education, identifying maladaptive pattern and an introduction in mindfulness but cannot provide proper depression therapy or social phobia treatment, not even with uncomplicated presentations.

    This does not even take into account that approx 40% of clients display challenging personality traits which interfere with standard CBT therapy in a way that makes treatment longer.

    CBT has it’s merits and an established place. However, according to research, one should not be disrespectful of other therapies. There are truck-loads of evidence that psychological therapy in general is effective and cost effective. In an 885 pages book, “From confession to profession” psychotherapy researcher Klaus Grawe pointed already in 1994 out the huge cost saving potential of psychological services in general. (Bookmark: http://trove.nla.gov.au/version/44293842) In German language only unfortunately.

    Other psychotherapy schools (psycho-dynamic, systemic, humanistic and last and least gestalt) are almost equally helpful, as the different evidence-based treatments share similar principles.

    The question whether psychological therapy is superior to other mental health treatment, ie. medication, was also answered already 20 years back: the relapse rate when treated with medication only is significantly higher than when treated with psychological services only, hence for a long time a dual approach was supported.

    Today we can say, that with the exception of psychiatric disorders and severe depression, medication has a poor responder rate, i.e. perhaps between 50-60%, for Antidepressants, if that. That means, medication as treatment cannot be relied upon. Dr Michael Yapko, a respected researcher, points out: “Our social lives directly shape our brain chemistry and powerfully affect the way we think and feel; our brains change with positive life experiences and can change as much with social circumstances as with medication. Drugs may address some of depression’s symptoms, but they cannot change the social factors that cause and perpetuate it.” 
Drugs don’t teach you skills, e.g. problem-solving, clarifying conflicts, consideration of others, respect, empathy, self-control, self-care etc pp which are required to proactively manage life’s challenges, but psychological services can.

    Steering back to fee-for-service Better Access Scheme, psychological therapy in private practice is able to treat a wide range of psychological problems and therefore should be the pillar or one of the pillars in mental health service provision in the community, which by the way is cost-effective, although I would like to see the “mental health care plan” removed as its provision cost the tax payer 50% of the Better Access budget.

    The population has not only a need but also a right to have access to affordable and professional psychological treatment, as it does with medical treatment. I agree that a mental health reform is complex and definitely more difficult than cutting funding. But it’s possible and desirable.

  21. Liz Brown says:

    This build up to this budget is leaving a lot of vulnerable people like me in a state of fear and apprehension. Not good for my anxiety and I am suffering panic attacks because of it One of my concerns is that this government will cut spending on mental health further. So sorry if I repeat myself from other posts but perhaps my story will help people understand how important it is to ensure mental health care is not cut and BA is maintained.

    One of my big concerns here is the cost of not treating people with mental illness effectively in the long term most importantly because of the humane issues and the huge cost to the economy.

    There is so much talk here about short term tax payer value for money and comparing the cost of programs based on this flawed principal in my opinion. It seems to me to based on a fundamental misunderstanding about mental illness and that this notion that “a bit of counselling will get people over it, or give the m a pill and shut them up”

    I think as someone who has experienced abuse from my childhood, and now suffers the effects of complex mental illness because of it, I would like to make clear, that the effects of not treating people with complex mental illness is intergenerational. My mother was severely mentally ill, she had probably had PTSD and borderline personality disorder, never treated. My sister and I were abused throughout our childhood and beyond. We grew up with such fear engrained into us, that it changed who we were and who we could have been. If I could try to encapsulate the engrained fear and self-hatred and lack of any self-worth that invades your every waking thought and the nightmares in your sleep I would. But, no words could describe it. Plus the physical symptoms of panic attacks, anxiety, stress, that lead to other health problems and the figures that people with mental health issues die much younger than those who don’t at another cost to the tax payer and economy.

    My sister was severely mentally ill because of it. She never worked, was involved with several abusive men and suicided. Not sure how much she cost the tax payer in her life-time an awful lot, since she was in and out of hospital, long stays, on a concoction of psychological drugs (which she eventually overdosed on).
    I also have mental illness. I studied, and worked but suffered mentally silently for years from panic attacks, bulimia, self harm and the physical symptoms of irritable bowel syndrome. I tried to work round it, I married an abusive man who was physically, and emotionally controlling and abusive. My childhood set me up as it did my sister for accepting that kind of treatment because you are so easily manipulated into thinking it is your fault and you are worthless. I had years of that kind of abuse. After I had kids I was triggered back to my childhood environment and the continuing mental and physical abuse from my spouse meant I was getting more and more depressed and unable to function. I could barely make phone calls, drive, my confidence was down to virtually zero. I could not work. I am quite sure I would have ended up dead eventually as I was going more and more crazy. And the effect on my children would probably have been to pass on my mental illness to them.

    I finally saw a psychologist who was experienced and qualified to recognise I was suffering from the effects of complex trauma. Something you don’t get over with a bit of counselling, but with time and qualified, experienced help I am now able to go back to studying and hope to work.
    A recent on line petition launched by Tracy Howe the chief executive of Domestic Violence has highlighted the number of women who are suffering from domestic violence is epidemic and women are dying. Domestic violence is not just physical it is mental manipulation and control. I finally woke up and got the psychological help to get me out of that relationship. I was convinced it was my fault and terrified he would suicide if I left him. Fact is I would have been the one who could have ended up dead and my children would have continued to suffer.

    I still suffer the mental effects of my childhood, my sister’s suicide and the abuse of my marriage. With the help of a psychologist I am working through it and not passing it on to my children.

    The costs to the taxpayer of not treating far outweigh the costs of implementing a quality Medicare assisted mental health care There are no short cuts. Better Access allowed me to see the calibre of psychologist to get the therapy I need to get out of an abusive relationship and start to recover from this mental Hell inside myself.

    Cuts to this service will see people suffering and cost more in the long run. In fact if you want to save money for the tax payer, I think you should be increasing the number of sessions to what is required for recovery. You don’t start treatment for a cancer patient and then tell them to go and suffer and die as they haven’t got better in the number of sessions that statisticians have calculated the average person should get better in , but for mentally ill patients you do. And make no mistake about this the suicide rate is epidemic and people are dying because they are not treated effectively And that costs the tax payer and the economy.

    The cut back to 10 sessions will have left those who are unable to afford further psychological treatment, in a mental HELL. I watched my sister’s decline and suicide; it is a Hell of a price to pay because my mother never got treated.

  22. John Forbes says:

    Mental health issues affect the daily lives of many millions of people in this country. As with any other health issue, their impact ranges from the mildly distressing to grossly disabling. Why is it not legitimate for a range of services to be offered? Why are consumers able to receive Medicare rebates for other health conditions for as long as they need to recover, while mental health issues continue to be treated as though they aren’t legitimate problems that so greatly affect the functioning of this country in both economic and social terms?

    I am also concerned that so much of this debate is being driven by ill-informed opinion presented as fact (especially by people who should know better), and ideological perspectives. Let’s just consider the strong evidence from around the world that the people of this country ‘need’ access to a range of high quality mental health services, including a robust and appropriately funded Better Access program. With much wider social and economic benefits so easily achievable, it should be a public health priority, not treated as an inconvenience or an unjustifiable cost.

  23. Tully Rosen says:

    We all do agree that mental health services are grossly under-resourced. However if you’re not talking about funding priorities at this time in Australia’s political landscape then you have your head in the ground.

    Everybody yells from the rooftops that their practice model is the one with the best evidence. The “strongest” evidence is almost always seated in a painfully old-school medical model and negates the equally important community service aspect of mental health need. The biggest growth industry in mental health is (and should be) in the peer workforce. I would argue, as would many mental health consumers and carers, that this is the priority for people needing help at the higher end of mental health severity.

    Medicare rebates for mental health services are incredibly important. However the Medicare system is uncapped and poorly controlled. A Psychologist in the public system makes $80-90,000 per year. A Psychologist in the private sector makes anywhere from $100,000-300,000 per year. That money is coming from the community either through the government or direct payment. Don’t tell me there isn’t some self interest at play here.

    By all means increase the availability of Better Access sessions, but CAP the price that allied health professionals can charge on top.

    Just because the private medical professions can get away with exhorbitant fees doesn’t mean that everyone should be able to.

  24. Ben Mullings says:

    Tully, the reason evidence-based practice is so important right now is -because- the mental health care sector is under-resourced right now.

    Have a look through the comment thread above you will see that the evidence from research has been presented. We are simply trying to show you the evidence for your own consideration. I would still like to see some evidence to support what you’re saying, so that we can all consider the merits of your point. Unfortunately if one doesn’t make their case properly it is harder to justify investment of the scant resources we have.

    Your suggestion that we cap the upper limit of fees charged is certainly worth considering – but I must object to your attacks on psychologists. Doing that is very counter-productive and divisive, given that we would all like to see the funding for mental health care improved. Frankly, it is unprofessional to demonise psychologists (or any other group of mental health professionals) with suggestions that they are self-interested and overpaid. I believe you are genuinely interested in mental health care, and if that’s true, can I suggest that you focus instead on improving our system rather than trying to cut others down? Let’s try to be respectful about the positive contributions that everyone can make to this under-resourced sector.

    Can I also ask, is it accurats to say that letting people access psychological care via Medicare is a “painfully old-school medical model”? We have only been able to do that since 2006, which isn’t that long at all. I think it’s a step in the right direction and I know that thousands of Australians out there who live with a mental health condition feel the same way too.

    My point is that we can all work together to improve and build on our mental health care system in Australia. I hope that Sebastion Rosenberg and some of the other crew from the ‘Brain and Mind Research Institute’ hear me on this, because it seems that every year leading up to May we hear from the same few people (on Crikey! and MJA mostly) criticising the cost of psychological treatment. Let’s not cut each other down when what we are really trying to do is improve the system, okay?

  25. Ben Mullings says:

    As a point of interest to this debate, I would also like to bring to everyone’s attention some data on the rate of bulk-billing by psychologists – which is probably about the same for other psychological care providers in Medicare. There are several sources of evidence on that point.

    First, we have a large practitioner based survey from the APS showing an average rate of between 48% and 62% of psychologists who provide bulk billing: http://www.psychology.org.au/inpsych/medicare_survey/

    Second, we have MBS data showing that between 25.9% and 30.4% of all psychological treatment services are bulk-billed: http://www.gpqld.com.au/content/Document/3%20Programs/06_Mental_Health_2/COAG/Important%20Better%20Access%20Utilisation%20Data.pdf

    Now factor in the proportion of disadvantaged people who utilise Medicare for mental health care. If the argument is that Better Access could be reaching more disadvantaged people, then those rates of bulk-billing would suggest that those disadvantaged people who are accessing psychological treatment are not paying out of pocket fees in the vast majority of cases. It clearly isn’t that difficult to find a psychologist who does bulk bill, and amongst those who do bulk bill, the data seems to indicate that they do that for a significant proportion of their patients.

  26. John Forbes says:

    Tully, your obvious bias against psychologists is clouding your ability to present a cogent argument. You’ve moved very much into the “my opinion is fact and my opinion is right” zone, especially when you make outrageous claims that can’t be substantiated, because they’re plain wrong.

  27. Tully Rosen says:

    I have a strong bias toward Psychologists actually. I’d be dead without them.

    I do have a problem with the planning of the Medicare system and the geographical and socioeconomic problems it entrenches.

  28. Ben Mullings says:

    Yes – the Medicare system generally does have some geographical and socioeconomic problems. Let’s not throw the baby out with the bathwater.

    And here’s an idea – how about we try to help the massive number of people who rely on Medicare who happen to also be disadvantaged and more difficult-to-reach?

    Criticising the cost of psychological treatment in the Medicare system, without appreciating the massive number of people who receive treatment in that system, is not going to help us build on our mental health care services across Australia.

  29. Tully Rosen says:

    Though that was genuinely new information about Psychologist bulk billing Ben. Thank you for that.

  30. Tully Rosen says:

    The problem is Ben, the policy environment is not interested in population health approaches in isolation.

    We’re being asked whether we want to lose an arm or a leg. Perhaps in another few years mental health may receive the sort of serious systemic support it needs, but the tide has gone out from the last big funding boost and we have to make some hard decisions as a country.

    I’m not going to argue point to point about evidence because if you seek it you will find it, albeit you may have to work a bit harder and go overseas for the NGO literature. Again, I am trying to make the point that you will see less evidence from services that are more poorly resourced. Most community services don’t even have access to journal databases, let alone the kind of tertiary institutional partnerships of allied health. Governments certainly don’t think it’s their responsibility to fund evaluation of non-clinical services.

  31. Ben Mullings says:

    Tully, I think you might misunderstand where we are coming from. We are merely pointing out the evidence that investing in Medicare supported services is cost efficient. Criticising that investment is counter-productive when we actually need to expand some of our existing programs, including Better Access.

    Even so, there remain some questions:

    1. Given that 15 to 20 visits of psychological care is the minimum recommended treatment for common mental health conditions (http://www.betteraccess.net/index.php/information/evidence-based-reform), should we expand the system to cover closer to 20 visits? The grandfather of cogntive therapy, Dr Aaron T. Beck, seems to think so – so much so that he personally wrote to our Minister for Health suggesting that optimal care would be achieved at around 24 visits, not just 10 as it presently stands (http://www.betteraccess.net/index.php/information/father-of-cbt).

    2. Can we get even better results for patients and further reduce the barriers to care by removing a few of the GP review requirements? Our group has consulted with people who use the system and with mental health professionals to develop a model of care which would meet that aim (http://www.betteraccess.net/docs/MODEL.pdf).

    3. Could the system be improved by having a consistent Medicare refund across all psychological care providers? We have heard from many patients who are frustrated that they get a lower Medicare refund when they see their preferred therapist rather than a Clinical Psychologist. The system can be improved by implementing a fair and equitable standard to recognise advanced competencies in mental health care spanning all professional groups. Differential Medicare rebates drive up gap fees and restrict patient choices, particularly for low income earners.

    I hear what you are saying that there is less evidence supporting other programs, but that’s why you need to be more careful about the claims being made. When so there is little funding available we need to be honest about the state of the current evidence and cautious about dedicating our precious few dollars towards programs with limited support. By comparison to other programs the Better Access initiative has a massive amount of evidence showing that expanding funding to that program would be worthwhile. That’s why it is so disheartening to see repeated criticism, from the same few people, about the cost of people accessing treatment.

    Again, nobody here is attacking the value of services provided in the community managed care sector – so can we please stop trying to undermine the value of investment in psychological care? Let’s work together here!

  32. Robyn Lingard says:

    Better access allows not only cbt but also interpersonal therapy (IPT). At a 2 day workshop I attended this year, this includes working with grief, attachment, and communication skills training. It focuses upon the central role of emotion and relationships. I have found over the past several years of being in private practice under Better Access, that IPT provides a great alternative to CBT with certain clients. I use CBT and IPT plus other therapies as the client requires. Also re some comments about whether the Australian health system will benefit more from peer support workers or therapists….this is an odd argument. I have some peer support workers as clients and they say that they can do some things but they need therapists like me to do therapy. Surely this argument is a ludicrous as saying our medical system only requires nurses aids and no doctors. (no offence intended toward nurses aids – I love all people medical when I am physically sick).

  33. Tim Heffernan says:

    Thank you all this discussion, especially Liz for her lived contributions. Robyn, we Consumer/Peer Workers can sure “do some things”.

    Like – RECOVERY. Rather that than therapy!

  34. Tim Heffernan says:

    Thank you all for this discussion…

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