Introduction by Croakey: The Federal Government this week released a 336-page evaluation of the long-controversial Better Access program, which made more than a dozen recommendations for improving the program.
However, many of the wider issues have been obscured by the intense focus on Health and Aged Care Minister Mark Butler’s decision to discontinue from the end of this year the extra 10 sessions that had been introduced in response to COVID, meaning patients will be able to access a maximum of 10 rather than 20 sessions each year.
Croakey editor Jennifer Doggett reports.
Jennifer Doggett writes:
The “Better Access” program was established in 2006 to provide access to psychologists via a GP referral. The scheme was capped at 10 sessions per year in 2011 but this was increased to 20 during the pandemic, to address higher levels of need during this time.
Health and Aged Care Minister Mark Butler’s announcement on Monday means that from 1 January, the scheme will revert back to the limit of 10 sessions that had been in place since November 2011.
Critics of this decision (including some from the Government’s own ranks) say this move will make it more difficult for people accessing the scheme to get the number of sessions they need to maximise their treatment outcomes.
The Victorian Aboriginal Community Controlled Health Organisation (VACCHO) issued a statement raising concerns about the implications for the health and wellbeing of the Aboriginal and Torres Strait Islander community in Victoria.
Writing in The Conversation, Dr David John Hallford, a clinical psychologist, senior lecturer at Deakin University and board member of the Australian Clinical Psychology Association, said “evidence shows that between 13 and 18 sessions are required for 50 percent of people to reliably improve in psychological therapy.”
He argues that there is a “dose-response relationship” for psychological therapy, meaning the number of people who respond to treatment will increase when higher numbers of sessions are provided.
Hallford and others argue that under-treating psychological problems can result in more serious (and more expensive) problems over the longer term, and liken the decision to restricting access to other medical treatments, such as antibiotic medications, to half the necessary dose.
If this is true, then why are some experts and mental health stakeholders supporting the Government’s decision?
Longstanding criticism
Criticism of Better Access is not new. Croakey has previously published critiques of this program by mental health experts (see here and here), who argue the program has some significant structural flaws.
Peak bodies and government agencies, such as The Mental Health Commission and the Productivity Commission, have also previously raised concerns about the targeting of services funded by this program.
A comprehensive review – conducted by a team from the University of Melbourne, led by Professor Jane Pirkis, Associate Professor Dianne Currier, Associate Professor Meredith Harris and Professor Cathy Mihalopoulos – has now made wide-ranging recommendations to improve the program.
This evaluation was designed to inform questions about Better Access across the following domains:
- accessibility
- responsiveness
- appropriateness
- effectiveness
- sustainability.
Some of the review’s key findings were:
- The reach of Better Access has expanded since its inception; in 2021, one in every 10 Australians received any least one Better Access service and one in 20 received at least one session of psychological treatment through Better Access.
- The total cost to government of Better Access services, in terms of benefits paid, was $1,213 million in 2021 (an annual average increase of four percent since 2018).
- Co-payment rates increased across most types of Better Access services with the biggest jump occurring in 2021. In 2021, 47 percent of all Better Access services involved a co-payment by the consumer (up from 36 percent in 2018) and 65 percent of Better Access treatment services involved a co-payment (up from 53 percent in 2018). For services where the consumer paid a co-payment, the median out-of-pocket cost for any Better Access service was $74.
- First Nations people use Better Access services at a higher rate than non-First Nations people; however, rates of use for First Nations people are declining whereas rates of use for non-First Nations people are increasing, and the relatively greater levels of use for First Nations people may not be commensurate with their significantly greater levels of need
- The profile of use of Better Access treatment services across income groups is not consistent with the profile of their levels of psychological distress. Those on the lowest incomes are least likely to access services.
- The wait times to treatment were longer for those in the lowest income quintile; their median wait time was 22 days whereas the median wait time for those in the highest quintile was 17 days.
- Better Access is not only reaching consumers with mild to moderate mental health conditions as it was originally intended to do, but that it is also providing services for those with more severe mental illness.
Overwhelmingly, participants experienced good outcomes from their Better Access care. Baseline self-rated mental health and the number of sessions were associated with improvement.
There is some evidence that, over the 12 months of follow-up, using five or more sessions of Better Access treatment increased the odds of significant improvement, or reduced the odds of significant deterioration, in anxiety and depression symptoms among those with a more severe prognosis
Barriers to accessing the program were mostly financial. For example, many felt that the gap payment was too high, or that taking time off work to visit a mental health professional and losing income was difficult.
Overall, the evaluators found that people receiving treatment through Better Access tend to have positive outcomes and that these outcomes are not related to sociodemographic factors like where people live or how much money they earn. They also found some evidence that a relatively greater number of sessions may lead to better outcomes.
Equity concerns
However, the report also revealed a number of equity issues with Better Access services, including finding that people on the lowest incomes were the least likely of all income groups to access services via Better Access.
It found that 5.1 percent of those in the lowest socioeconomic quintile used any Better Access treatment services in 2021 compared with 6.6 percent in the highest quintile. In the same year, only 56.5 percent of those in the lowest quintile proceeded to treatment from a plan compared with 69.3 percent of their high income counterparts.
The evaluators also identified geographic inequities, finding that people from rural and remote areas were consistently less likely to use Better Access treatment services than those living in cities.
Another criticism from the evaluation is that the program appears to be providing services to some people with relatively low levels of need, who could potentially be helped by information or support through other means.
The evaluators recommended that the program continue, with a focus on maintaining positive outcomes for those who use Better Access while also increasing access for those who are currently missing out. One way that this can be achieved is through reducing the number of services funded for each person back to ten, as was the case prior to the COVID-19 pandemic.
They also suggest that the targeting of the program should be improved, along with greater consideration given to how Better Access interfaces with other elements of the mental health system.
Support from some experts and stakeholders
Despite the criticism from some quarters, many mental health stakeholder groups and experts were quick to support the Government’s decision and reflected the findings of the evaluation report that the previous Government’s decision to increase the number of funded services had reduced access overall.
This may seem counter-intuitive but it makes sense if Better Access is seen as part a broader health system, rather than operating in a vacuum. The demand for mental health services in our health system exceeds supply, and therefore it is important that we target services to those most in need.
For example, we have a fixed number of psychologists and other mental health providers and they have a limited number of hours in which they can provide services. If they are fully occupied providing additional services to consumers (beyond the ten previously funded under the program), they will not be able to take on new patients, even if the need of those waiting for care is greater than that of their existing patients.
Increasing the number of funded services from 10 to 20 meant that consumers accessing the program received more care (which perhaps led to better outcomes – although this isn’t clear).
However, this came at a cost of preventing many more consumers from accessing any care at all, including those with higher levels of need compared with people already accessing the program.
On ABC radio yesterday morning, Minister Butler explained the Government’s decision:
“…the evaluation said additional sessions are a good thing for complex people with complex needs. But it found that that’s not who was getting it. It actually found, as well, that people with significant needs in lower income communities received substantially fewer services because of the change the former Government put in place.
“The number of new patients able to get any psychological support actually went backwards by seven percent. So a whole lot of existing patients got more service, even though they didn’t necessarily have more complex needs.”
Also speaking on ABC radio, Professor Ian Hickie, one of the architects of the original Better Access program, argued that we should be listening to the voices of those who currently cannot access Medicare-funded mental healthcare due to increased demand for extra services from those already in the scheme.
“We can’t see this decision in isolation,” he said. “As the number of services has gone up, the number of new people able to get into the program has done down, the cost of getting in has also gone up and there has been a decline in the distribution of access. There are many more people on waiting lists who can’t get in at all – they are the voiceless ones in this conversation.”
AMA President Professor Steve Robson has supported this decision. “The AMA supports the ongoing revision of mental health services to ensure they are reaching those who need them the most and we welcome a greater emphasis on directing resources to those patients who suffer complex or more severe mental health conditions,” he said in a statement.
Healthy policy analyst Professor Stephen Duckett said on Twitter: “The puzzle for me is why government kept previous generation fee for service model and didn’t move to 21st century, episode + outcome model.”
GPs interviewed for the RACGP publication, newsGP, supported the concerns about Better Access and equity. Dr Cathy Andronis, Chair of RACGP Specific Interests Psychological Medicine, told the publication that the report’s findings reflect her clinical experience.
“What stands out is that it confirms what we already have noticed anecdotally in our practice: that most of the services go to people who have wealth,’ she told newsGP.
Other experts publicly supported the need for greater equity in mental health funding, in particular for those with complex and persistent care needs.
Some commentors flagged the need for more research into the impacts of the decision and in particular stressed the need for input from people with lived experience.
Wider recommendations
While much of the mainstream media coverage has focused on the reduction in the number of sessions available under the program, the evaluation makes many other recommendations that merit consideration.
These include that for those with severe and complex needs, Better Access should be supplemented by other multidisciplinary models that not only provide more intensive, longer-term clinical care but also offer holistic support for dealing with life’s complexities.
For those with lower levels of need, less intensive options, such as digital services, should be explored.
The evaluation suggests that broad measures to recruit and retain mental health providers in rural and remote areas are likely to be more successful than ones that are tied to the MBS.
It recommends that the mental health treatment plan should be retained but should be standardised, simplified and used to help GPs understand the needs of individual consumers and work collaboratively with other providers to meet these needs, rather than just being a requirement for referring consumers to Better Access.
The evaluation says an appropriate level for schedule fees should be determined in a standardised, transparent way. Other options to increase affordability that sit within or outside the MBS should also be explored, such as bulk-billing incentives, loadings on specific item numbers, practice incentive payments, service incentive payments, and blended funding models.
The evaluation says further investigation is required to determine whether the dedicated item numbers for people living in residential aged care facilities are the best means of ensuring access to high quality mental healthcare for this group.
It also says dedicated family/carer item numbers should also be considered as a means of providing more holistic care. Again, if such item numbers were to be introduced their uptake and impact should be monitored.
As well, steps should be taken to implement routine outcome measurement as a quality assurance tool for the Better Access program. “This will require significant effort and investment in consultation and communication, system design and governance, technology, and ongoing administrative and financial support,” says the evaluation.
What’s next?
The Minister has stated that he wants a broader discussion with all the key players in mental health next year to work through the evaluation, and to determine the best way to target additional services for the small group of people with particularly complex care needs.
This is supported by many commentators, who identified this group as one currently missing out on the care they need.
Previous reports into this issue, including the Productivity Commission report, have urged the Government to take a broad and system-wide approach to mental health reform, and experts have repeatedly emphasised the lack of a mental health “system” in Australia.
For example, mental health policy analyst Dr Sebastian Rosenberg has previously written in Croakey: “Sooner or later, Australia will need to come to grips with the real problem facing mental health, which is that the integrated and multidisciplinary community-based system necessary to properly address mental health in all its complexity has never been built. Continuing to invest in primary care fee-for-service models and hospital beds won’t fix this.”
Many stakeholders believe that this will require a radical re-think of how we deliver mental health services, questioning current approaches such as fee-for-service payment systems and siloed funding programs that don’t address the drivers of mental illness.
Address wider determinants and systems
Findings from a new ACOSS report provide additional evidence of the link between social determinants and mental healthcare needs.
This report has found that community services including homelessness, mental health and family violence organisations are facing soaring demand this Christmas due to the cost-of-living crisis, continuous disasters and the ongoing impacts of COVID-19.
Out of 1,470 organisations surveyed for the report, only three percent said their main service can always meet demand.
This evidence demonstrates why the drivers of mental health problems, even when they occur outside of the health system, should be on the agenda when the Minister meets with stakeholders.
It will also be important to learn from the success of other mental health programs, such as Access to Allied Psychological Services (ATAPS), in providing services to those with access barriers to Medicare-funded services.
Ideally, mental health would also be integrated into other health reform processes, such as the Strengthening Medicare Taskforce, and into policies and programs occurring outside of the health portfolio, including in education, employment and social security.
This is a bold agenda which previous governments have not been able to achieve.
But with a Labor Government looking towards a tenure of two or three terms, a majority of Labor governments in the states and territories and a Minister who is clearly not afraid to upset some stakeholders, it may finally be possible to make progress towards the sort of systemic, coordinated and equitable mental health system that is needed to meet the needs of the Australian community.
See Croakey’s archive of articles on mental health matters
