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Better Access expansion timely, but evaluation essential

Introduction by Croakey: Fifteen mental health clinics will be established across Victoria, with six to be located in regional areas, to help address pandemic-related impacts on mental health, the Federal Government announced today. 

The clinics will be funded for one year and located at existing GP clinics, headspace centres or other community sites, with the locations to be announced in coming weeks.

The aim is to provide access to multidisciplinary teams of mental health workers, including psychologists, mental health nurses, social workers, and alcohol and drug workers.

Primary Health Networks are to establish the new clinics, and will work closely with key GP clinics, the Aboriginal Community Controlled Health Organisations (ACCHO) and designated headspace centres.

As previously reported, the widespread mental health impacts of the COVID-19 pandemic have also prompted an expansion of the Better Access program; a move that some experts say represents ‘very little added value to our national mental health response’. 

Here Dr Long Le and Professor Cathrine Mihalopoulos of Deakin University and Professor Jane Pirkis and Dr Maria Ftanou of the University of Melbourne say that the swift expansion of the Better Access program, including telehealth item numbers, has provided much-needed mental health support during the COVID-19 pandemic.

But, they caution, thorough evaluation is needed to ensure that this investment is achieving its objectives.


Long Le, Maria Ftanou, Cathrine Mihalopoulos, and Jane Pirkis write:

The Australian mental health system was facing a plethora of problems prior to COVID-19, including sub-optimal or no care for many. These problems have been identified in numerous inquiries, including current ones by the Productivity Commission and the Victorian Royal Commission.

It follows then that the Australian mental health system would and will continue to struggle to cope with the additional demands placed on it due to COVID-19. As part of the Australian Government’s response to the mental health consequences of COVID-19, a new set of Medicare-subsidised telehealth item numbers were introduced in March under the existing Better Access program.

These were designed as a complement and potential substitute for face-to-face care that was difficult for psychologists and other mental health care providers to offer because of physical distancing restrictions. They meant that people with mental health concerns could receive psychological therapy over the phone or by video conference.

These item numbers were part of a suite of measures that also included a dedicated coronavirus wellbeing support line, a new digital mental health portal, a boost to crisis support services, and a range of other initiatives that were introduced in May.

Increasing access

Until recently, any individual could receive a maximum of 10 face-to-face (or telehealth) sessions of psychological therapy under Better Access, but in early August the Government provided for an additional 10 sessions for people whose movements have been restricted by a public health order and people who are in isolation or quarantine as a result of COVID-19.

The modifications to Better Access will undoubtedly go some way to helping make mental health care accessible and affordable for those who might need it, particularly those who may be facing heightened levels of stress, anxiety and depression as a result of the pandemic and its sequelae.

Our preliminary analyses of Medicare data indicate that services delivered by psychologists via Better Access increased slightly in April 2020 compared to April 2019 (440,240 vs. 432,259), and more recent estimates suggest that the rate of uptake of telehealth services is growing. Half of the face-to-face services were replaced by the new telehealth services (Figure 1).

Figure 1. Psychological treatment services in Apr 19 vs Apr 20.

Efficiency questioned

Some have argued that bolstering Better Access may not be the most efficient mental health response in the current times. There is a view that the fee-for-service payment system which underpins Better Access (and other Medicare-subsidised services) encourages throughput rather than quality care, and may therefore not lead to positive outcomes. Other payment systems and models of service provision create different incentives, however, and their benefits are also not incontrovertible.

There is a need for rapid yet rigorous evaluation of the effectiveness and cost-effectiveness of the various responses to the mental health consequences of COVID-19, including, but not limited to, the new Better Access item numbers.

We would say, however, that there is good reason to suggest that the new Better Access item numbers are likely to be helpful in mitigating the mental health related impacts of COVID-19. We evaluated the overall Better Access program shortly after it was introduced in 2006 and showed that it improved access to mental health care for people with common mental disorders. Significant numbers of people who had not previously accessed mental health care were able to receive psychological therapy as a result of Better Access.

Positive outcomes

New consumers still make up a significant proportion of Better Access users, although the episodic nature of mental illness means that some existing consumers return to see Better Access providers in subsequent years. Our evaluation also showed that Better Access had positive outcomes for consumers, quite possibly because psychologists delivering care under the program are trained to deliver evidence-based treatments like cognitive behavioural therapy.

At the time we did our initial evaluation of Better Access, the program did not involve telehealth services. For this reason, it is imperative to evaluate whether these services are meeting their objectives, particularly in the context of the COVID-19 pandemic.

A key policy report just released by the Grattan Institute argues that the rapid roll-out of telehealth should “have been introduced long ago” (page 55) and that the challenge now is to ensure the telehealth services are not abused and that no perverse incentives are created.

Furthermore, this report states that these telehealth services should remain beyond COVID-19 as an approach to improve access to care. Similar recommendations have been made by the Go8 Universities, the Royal Australian and New Zealand College of Psychiatrists and the Australian Medical Association.

Evaluation is required to inform the current and potentially continued provision of these services to ensure that they are providing appropriate, effective and cost-effective care, and doing so equitably.

Any future evaluation of Better Access should pay heed to how the program might be improved. This requires an exploration of facilitators and barriers from the perspective of both consumers and providers.

Consumers might provide information about their motivations for taking up treatment and any roadblocks to their doing so, their perceptions of services, the positive and negative aspects of their care, and their perceived outcomes of the care.

Overcoming barriers

The range of barriers and facilitators (eg, cost and geographical barriers) that are important to consumers in normal circumstances are relatively well known. However, other barriers and facilitators that may play out during COVID-19 and beyond are not known, and designing services that are sensitive to consumers’ preferences in this context is important.

The perspective of providers also needs to be considered.

Providing care via alternative modalities to face-to-face delivery may not be easily incorporated into clinical practice, for example, particularly in the pandemic context. Delivering telehealth services may present significant challenges for psychologists, including connection issues, limitations of content delivery (eg, not being able to use handwritten visual aids during therapy), and fatigue. It may even potentially impact the therapeutic relationship. Addressing identified issues will be important if telehealth is to achieve its goals.

The Australian Government’s rapid response to the mental health impacts of COVID-19 has seen welcome investment in the expansion of the existing Better Access program.

The modifications to the program are specifically designed to address the ways in which the physical restrictions that have been put in place to manage COVID-19 may impact on mental health outcomes. To ensure that this investment is achieving its objectives, it is critical that timely yet thorough evaluation is undertaken.

Long Le and Cathrine Mihalopoulos are from the Deakin Health Economics, Institute for Health Transformation, Deakin University. Maria Ftanou and Jane Pirkis are from the Melbourne School of Population and Global Health, University of Melbourne.

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