Introduction by Croakey: The Federal Government has, after 18 months, responded to an evaluation commissioned into the Better Access scheme, which was established in 2006 to provide access to psychologists via a GP referral.
Much focus around the scheme has been on how it was capped at 10 sessions per year in 2011, increased to 20 during the pandemic, and then cut back again last year; however, there are varying views about the scheme and broader issues involved.
The 2022 University of Melbourne evaluation found that people receiving treatment through Better Access tended to have positive outcomes, but it raised equity and access issues, as Croakey reported in detail then.
In separate pieces below, leading mental health academic Dr Sebastian Rosenberg and the Australian Psychological Society address the Federal Government’s response.
See also concern from the Royal Australian College of GPs about the Government’s response, calling for the system “to evolve and move away from episodic care to holistic, person-centred and integrated care”.
Sebastian Rosenberg writes:
The Federal Government’s response to the 2022 Evaluation of the Better Access Program was provided last week. It reflects the Government’s consideration of advice it has received from its Mental Health Reform Advisory Committee. The response has already been the subject of some commentary.
Some context
In 2005, in response to a series of reports about neglect and human rights abuses in mental healthcare, then Prime Minister John Howard and New South Wales Premier Morris Iemma agreed that the matter should be considered by the Council of Australian Governments (CoAG).
This brought the issue of mental health to the centre of Australia’s federated political system, acknowledging the need for First Ministers’ consideration of the issue, not just Health Ministers.
CoAG eventually agreed a $5.5 billion ‘package’ of initiatives under a National Action Plan. I use the term package loosely here, as all the governments gave themselves ample room to do whatever they wanted, under some broad headings, rather than develop a coherent, coordinated strategy designed to elicit an agreed set of reforms.
And of course, the states and territories are perfectly entitled to do whatever they want, under the Constitution and in the light of the way responsibilities for mental health are split with the Federal Government.
The AIHW’s most recent data show the states and territories responsible for $7.4 billion of expenditure from a total of $12.2 billion – this is mostly directed towards hospital-based inpatient and outpatient services. A further $4.2 billion comes from the Federal Government, mostly via Medicare and the Pharmaceutical Benefits Scheme (PBS), with the balance from the private sector (just over $500 million). In other words, the states and territories remain predominant players.
Despite the CoAG intervention, and several other investments made by all governments subsequently, mental health’s share of the total health budget is 7.2 percent, exactly the same as it was in 1992-93, when the National Mental Health Strategy began.
What’s in the response?
From this perspective, the Government Response to the Evaluation of Better Access adds little. It lists more than a dozen individual budget items promised or delivered by the Federal Government in recent budgets. It notes the advent of important new national consumer and carer consultative organisations.
The Response reports “Better Access was introduced in 2006 to increase access to mental healthcare and improve outcomes for people with mild to moderate mental health conditions. Since this time, the reach of Better Access has increased substantially.”
It is worth noting that while one study reported that access had jumped from 37-46 percent between 2007 and 2010, the most recent data from the National Survey of Mental Health and Wellbeing in 2024 suggested this rate was largely unchanged over the subsequent decade (47 percent).
The Evaluation called for better services targeting people with more severe or complex mental health needs, to complement Better Access (Recommendation 1). The Response did not deal with this, strangely focusing instead on one or other of the new budget items aimed at people with mild/moderate needs.
The Evaluation raised the very significant workforce issues facing mental health. The Response dealt with this unsatisfactorily.
It did outline the welcome work done by the Federal Government to provide more training places for some health professionals. But so much more is needed here, and not just to develop the individual practitioners, but also to equip them to work together to provide the multidisciplinary care that people with more complex needs often require. And trainees also need supervisors. Perhaps, together with the recently released Unmet Needs Study, we also need an Unmet Supply study?
The Response also rejected the notion of expanding the number of sessions available under Better Access to 20 again. Making more sessions available to a small number of people of course has the potential to reduce the number of sessions available to many.
We know many professionals’ books are already closed to new clients. This hasn’t stopped some from backing what seems a popular, simplistic idea.
And many of the people requiring sessions may well have the kind of complex conditions that in fact require multidisciplinary care, rather than just seeing the same professional repeatedly.
A person with an eating disorder, for example, may well benefit from seeing not just a psychologist, but also a nurse, a social worker, a psychiatrist, a GP, a dietician, a peer worker and so on.
Unmet need and unmet supply
Psychosocial services barely rate a mention in the Response.
Yet the Unmet Needs Study found 335,800 people aged 12-64 years with severe mental illness would benefit from 21.9 million hours of psychosocial support services. This reflects an increase of around 46,000 additional people compared to the Productivity Commission’s 2019–20 estimate of 290,000 people needing psychosocial supports.
As at June 2023, the NDIS reported just over 62,000 participants with psychosocial disability received average support packages of $71,600 each.
By way of contrast, the states and territories are spending $7.4 billion on 457,000 mental health clients – an average of $16,142 per person. Providing just this level of care to the complex population identified in the Unmet Need Study would cost $5.5 billion.
Summary
The Response is okay as far as it goes, but fundamentally focuses on the smaller questions – new funding for this program or that.
It dodges consideration of system design: the role the states and the Federal Government should play; the centrality of community-based mental health services; the role psychosocial services should play; how to better plan and account for a more integrated system overall, not just in pieces.
Particularly in relation to people with more complex needs, the mental health system needs clearer role delineation between professionals, to better utilise the different skills people have.
Finally, the Response remains wedded to the concept of stepped care, vaguely intimating this will somehow see people find their way to the ‘right’ level of care.
For stepped care to work at all, it requires not only services at every step to be available, but also someone sufficiently expert to assess what step a person SHOULD be on, if the help they receive has worked and what to do next if the person gets better or worse. Whose job is this in the system now?
Genuine mental health reform requires ongoing deep cooperation between all levels of government, together with the community sector, other providers and of course consumers and carers.
While the Response does not demonstrate how this will occur, it is intended to provide “a strong platform for the next stage of reform.” Stakeholders have been waiting a long time for this stage to emerge.
Dr Sebastian Rosenberg is Senior Lecturer, Brain and Mind Centre, University of Sydney, and Associate Professor, Health Research Institute, University of Canberra.
Catriona Davis-McCabe writes:
Patient demand for psychology services remains high, but people increasingly cannot afford treatment due to cost of living pressures and slow progress in mental health system reform.
Current cost of living pressures are having a pervasive effect on all Australians who are too frequently having to choose between everyday essentials and better mental health.
The Federal Government has a responsibility to address this issue to ensure a nationally consistent and equitable mental health system that promotes access and affordability for all Australians, and this includes the Better Access program.
The community has told us it wants more investment in psychology services right now. Further investment into the sector – including reinstating the 20 Medicare-subsided sessions for more complex mental health conditions – would make a huge positive impact for people who need psychological care.
Indeed, the initial evaluation review found that Better Access services were effective and recommended the continuation of 20 sessions.
See some of the consumer comments included in the final report from independent Better Access review:
The initiatives announced in this year’s Federal Budget were slated as helping to enable psychologists to see more high needs patients. But 10 sessions is not enough to provide effective treatment to high need patients. Providing 20 sessions for these patients can help us to ensure effective treatment.
We feel that the Government’s response to this report is just another missed opportunity to enhance the mental wellbeing of all Australians, despite the APS and Australian people repeatedly raising the red flag about these issues.
This is a point in our nation’s history when we need to double down on psychological support and investment to create a mentally resilient community.
Dr Catriona Davis-McCabe is the President of the Australian Psychological Society.
See Croakey’s archive of articles on mental health