Making equity part of the discussion on mental health (including new publications in Indigenous mental health)

Note: apologies to readers but system glitches are making it difficult to insert links at the moment.

The Australian Psychological Society recently claimed (www.psychology.org.au/Content.aspx?ID=4137) that the Better Access program had been “the most successful mental health initiative of the past 30 years”.

This followed the Federal Government’s announcement that it would put in place transition arrangements for patients requiring long-term treatment who had been adversely affected by the reforms announced in the May budget, until other service models are more developed (also in the face of a Greens threat to block the reforms).

In a story for Crikey last week (http://www.crikey.com.au/2012/02/03/better-access-program-success-in-whose-interests/), I suggested the program’s success should be judged not only on whether it had increased access to services (which it clearly has) but also on equity and effectiveness (about which there are question marks – and you can read more on some of these in the commentary at the bottom of this post)

Coincidentally, today’s edition of The Medical Journal of Australia (http://www.mja.com.au/) brings reminders of the importance of equity considerations, highlighting the unmet needs of two groups – Indigenous Australians and children in out-of-home care – and the downsides of fee-for-service healthcare.

Indigenous mental health

• Psychiatrist Ernest Hunter and colleagues describe the burden of psychosis in Indigenous patients in Cape York and the Torres Strait, including an association with “a surprisingly high rate” of  intellectual disability.
http://www.mja.com.au/public/issues/196_02_060212/hun10118_fm.html

• Anthony Jorm and colleagues report on what is known about Indigenous mental health from recent representative surveys. They conclude: “There is an inequality in mental health between Indigenous and non-Indigenous Australians that starts from an early age. This needs to be a priority for research, preventive action and health servicesSystematic review of mental health in Indigenous Australians.”
http://www.mja.com.au/public/issues/196_02_060212/jor10041_fm.html

• An accompanying editorial by psychiatrist Robert Parker gives a broad overview, describing mental illness as being “at the visible tip of an iceberg of significant social and health disadvantage”.
http://www.mja.com.au/public/issues/196_02_060212/par11561_fm.html

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Vulnerable children and youth

• Graham Vimpani and colleagues show that there is plenty of room to improve the care of children and young people in out-of-home care. They note that at 30 June 2010, 35 895 Australians aged 0–17 years lived in out-of-home care. Recent audits in two states suggested that less than 25 per cent of children receive comprehensive assessment in a timely way or have acceptable health records and health care management plans in place.
http://www.mja.com.au/public/issues/196_02_060212/vim11411_fm.html

• Elizabeth Scott and colleagues, in the first detailed publication on who is using headspace services, suggest that many of the clients are disadvantaged, with more than half neither in education or full-time employment. The analysis of the clients of two headspace sites in Sydney found that young males are well represented, and suggested that one of the reasons for the success in attracting clients was that the services bulk-billed and thus removed financial barriers.
http://www.mja.com.au/public/issues/196_02_060212/sco10481_fm.html

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Fee-for-service

Meanwhile, a letter to the journal from two doctors is a reminder that many of the criticisms of Better Access could be made more generally of programs based upon fee-for-service.

Matthew Anstey, from the Beth Israel Deaconess Medical Center in the US, and Stephen Gildfind, from The Alfred Hospital in Melbourne, write that fee-for-service models reward volume and intensity, rather than quality of outcomes, “with evidence suggesting that it results in increased numbers of patient visits, investigations and procedures,which contribute to inflation in the cost of health care.” On the other hand, salaried providers are more likely to underservice their patients, with an increase in the length and a decrease in the number of consultations.
http://www.mja.com.au/public/issues/196_02_060212/letters_060212_fm-4.html
(Sub only)

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Judging success and Better Access

Back to Better Access and whether it is really “the most successful mental health initiative of the past 30 years”. Here are some comments from Croakey contributors, and at the bottom of the post is a further reading list.

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Sebastian Rosenberg, Senior Lecturer, Brain and Mind Research Institute, Sydney Medical School, Associate, ConNetica Consulting Pty Ltd

• This program has been extremely successful in enabling psychologists in particular to enjoy the benefits of access to publicly funded Medicare payments.  A huge new private fee for service workforce has been born.  The APS has been very successful in advocating for the interests of its members, including yesterday’s decision to defer the cuts to the Program.  Conversely, I note the AMA’s disappointment at not being able to persuade similar deferrals in relation to GP services.

• The evidence about how successful the program has been for consumers is much less clear.  This does not mean it has not been successful.  It means that typically nowadays, we have failed to follow up investment in new mental health programs with detailed and independent evaluation.  The Pirkis evaluation did show some positives but had extremely limited access to consumers.  In regards to the scope of the evaluation, of the 2,429 practitioners approached, a mere five percent (or 129 practitioners) self-selected just 883 patients (an average of only seven patients per practitioner) from an initiative that provided services to 1,130,384 persons in 2009 alone and a total of 2,016,495 persons over three years.

• There is little evidence to indicate whether the program is generating collaborative care.  There is considerable evidence to suggest there are deep divisions between clinical and registered psychologists and little to indicate the BA program is driving the establishment of new collaborative arrangements between GP and allied health professionals.

• People (including Hickie et al) had been calling for much greater public access to psychology services for years before the advent of Better Access.  The decision by the Howard government to implement a flat fee for service approach has simply replicated the limitations and inequities associated with Medicare in relation to other aspects of health.  There is data to show that key groups who were missing out on care before Better Access still do (Byles et al).

• There is some concern that the rate of access to new clients under Better Access is falling.  In 2008, 68% people using the Better Access program were using it for the first time. In 2009 this figure had dropped to 57%. An initiative originally designed to offer short, focused regimens of CBT may be becoming a program of continuing care instead.  This is of course made explicit by yesterday’s deferral decision.

• While the National Survey of Mental Health and Wellbeing in 2007 showed overall access to mental health care unchanged over the preceding decade, the Pirkis evaluation indicated that the advent of Better Access had lifted the rate of access to care from 35% to 46%.  However, it is not possible to verify this claim based on the publicly available data.

• Resources in mental health are incredibly valuable.  We cannot afford to misdirect or waste them.  We do not have enough data to verify whether the existing $10m per week being spent on the BA program represents good value.  The key thing missing is the voice of consumers and carers and no money is being spent to independently secure their experiences.  Changes to the BA program are now more about professional bodies protecting industrial interests than about evidence on health outcomes.

• The Greens’ concerns about people with severe and persistent mental illness is legitimate.  But the evidence to support CBT alone for these illnesses is thin.  The Govt response in deferring the cuts is ensuring taxpayer support for an untested program on a group of clients for which it was never intended.

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Professor Wayne Hall, Deputy Director (Policy) UQ Centre for Clinical Research, The University of Queensland

The APS claim was a smidge hyperbolic.

I would agree on the basis of the Better Access evaluation that the proportion of persons with mental disorders in the past year who had received mental health care had  increased as a consequence of Better Access although we can be less clear about what sort of treatment was provided to most of these patients.

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Professor Alan Rosen, psychiatrist

It would have been a very successful program if the Commonwealth had not just repeated all the same mistakes they’ve made with my profession of having it as an uncapped program which was so poorly distributed and had no monitoring of the quality of the actual interventions done to ensure that they were evidence-based. And I don’t think there is really sufficient evidence that people are bulk billing in any numbers.

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Professor Helen Keleher, president of the Public Health Association of Australia

The challenge for the Better Access to Mental Health Care program is to demonstrate that it has increased health equity, as it claims to do. Careful evaluation of both reach; to the most vulnerable groups of people, and effectiveness of the treatment provided, is necessary to substantiate claims that the program benefits the most disadvantaged.

The program still requires a co-payment which many middle class people can afford but those on low incomes find any co-payment for health services to be prohibitive. Funding an expansion of community based public mental health services may be a better and more effective mechanism for providing accessible and affordable care for vulnerable groups. It is clear that it is people on low incomes who suffer the most from poor mental health, and have the least resources to make choices about their treatment or care.

The claim that the program is the most successful mental health initiatives of the last 30 years feels like hyperbole in the light of a lack of comparative evidence about the steady advances that have been made in mental health since the era of de-instutionalisation. There is however, a growing body of evidence about the gap between rich and poor and growing health inequities – if the Better Mental Health care program is not actually reaching the poor in our communities and is used mainly by those can access such services, then the program may in fact, however unintentionally, be contributing to increasing inequities.

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Barbara Hocking, Executive Director, SANE Australia

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Dr Matt Fisher, Research Officer at the Southgate Institute for Health, Society & Equity at Flinders University

Within my research, people in the NGO mental health sector thought that ‘Better Access’ had increased the overall number of people accessing a mental health service, and done some good at that level; but raised concerns about it being generally less accessible for lower SES populations; one reason being that the relevant services tend to cluster in higher SES areas.

In other words, the ‘success’ of it in terms of overall numbers, such as it is, may hide a failure to address health inequalities.

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Professor Ian Hickie, Brain and Mind Research Institute, University of Sydney

The principle of Medicare access to psychology was led by us in 2001 (with limited support from APS at the time). That gave rise to the Better Outcomes program.

The success is not simply related to activity – but needs to consider equity and serious return on investment issues.

The principle is still right, but it is time the professions (psychological as well as medical) took their broader social responsibilities more seriously.

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Carol Bennett, Consumers Health Forum

I am not in a position to provide detailed commentary on whether the Better Access initiative is the most effective mental health program of the last 30 years.  I would say there is no doubt that in terms of use of Medicare services, it has had one of the most rapid uptakes by health professionals and generated significant income for both GPs and psychologists.

Has it achieved better health outcomes – probably – but as with most health program evaluation before you could make a definitive statement you would have to look at actual health outcomes in comparison with other mental health programs.  This is, unfortunately, an area where we often lack relevant data.

Health consumer outcomes which should be the touchstone for any measure of effectiveness go largely undocumented and unreported.

John Mendoza, Director, ConNetica , and Adjunct Professor, Health Science, University of the Sunshine Coast, and Adjunct Associate Professor, Medicine, University of Sydney

This statement and the position of the APS over the past 6 months takes spin to a high height. The APS have spun themselves into a civil war over Better Access.

Not only has the APS attempted to gag organisations like the Mental Health Council of Australia on releasing data and providing advice to the government, the APS played a direct role in the design of the evaluation of the program.

The evaluators of the Better Access program, Jane Pirkis and Meredith Harris, said last year when the government announced the changes to the program and the reduction of the number of psych sessions, that the evaluation results support the changes. The APS cannot on the one hand claim the evaluation supporting the program and then ignore the view of the evaluators.

Furthermore, the APS knows from its own submissions to the Howard Government in 2006, that the Better access program was designed specifically for people with mild to moderate levels of disability due to mental illness. These are conditions that can be effectively treated by GPs working in collaboration with registered psychologists and occasionally other allied health workers.

Now of course the APS wants everyone to think the program is designed for people with all levels of complexity. It’s not and it puts client and practitioner safety in question.

(Meanwhile, the Crikey story links a 2009 letter that John Mendoza, as the then chair of the National Advisory Council on Mental Health, wrote to then-health minister Nicola Roxon urging reform of the program, stating that most of its members saw Better Access as a provider or supply-driven system.)

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Professor Gavin Andrews,  Sydney psychiatrist

Measured in numbers of health professionals who registered to use it and the numbers of patients who referred and the level of benefit to the patients, the system was probably right. But the extent of the take up was unanticipated and the cost considerable so it seems that the changes to the system will be a practical way of allowing the Better Access scheme to continue. Not at all bad.

Further reading

Lesley Russell’s analysis of budget reforms
http://www.menzieshealthpolicy.edu.au/new_whatsnew.php#budgetmentalhealth

“The biggest disappointment in this package is the failure to make evidence-based reforms to the Better Access program. No amount of gloss on the evaluation report, released in March, can hide the fact that evidence about the effectiveness of the Better Access program is weak, and many key population groups do not have better access to the services they need. It is hard to see how the changes made in this budget will improve the program; it appears they are more about achieving savings than improve access or outcomes.

Apparently the plan for the delivery of mental health care in the primary care sector is to confine Better Access services to those with mild to moderate mental health conditions and to expand ATAPS to cover the care of those with more complex conditions, Indigenous patients and those in rural and remote areas. But there are no mechanisms of incentives to deliver this plan or to prioritise access for those most in need, and the likelihood is that those patients best equipped to manipulate the system will get services ahead of those who need them.”

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Senator Penny Wright’s blog
http://www.penny-wright.greensmps.org.au/content/news-story/pennys-blog-minister-heeds-greens%E2%80%99-concerns-about-better-access

“The recent Senate inquiry into the Commonwealth Funding and Administration of Mental Health Services, highlighted the risk that the programs being developed by the government to take up the demand caused by the cuts – ATAPS and youth mental health services among others – would not be sufficiently geared up to meet the needs of ill consumers who had exhausted their sessions. The Greens’ report from the inquiry specifically recommended reinstating 6 sessions, in exceptional circumstances, while the alternative services were being further developed.

Indeed, after hearing the concerns of the community (1500 submissions to the inquiry and many emails and phone calls to my office), we were so alarmed by the prospect of seriously ill people falling through the gaps, that we met with Minister Butler several times seeking an interim arrangement that would address the worst effects of the Better Access changes. In November, the Greens gave notice that we would seek to disallow the government’s regulations to change Better Access.  Fortunately, that will no longer be necessary.

We have always understood the rationale behind the government’s proposed changes to Better Acces , which were first announced in the 2011 Budget, along with a sizeable increase in funding for mental health and a number of welcome key initiatives. The savings generated by the cuts are to be reinvested in additional mental health services for particularly vulnerable and hard to reach groups – through the Access to Allied Psychological Services (ATAPS) program, additional childhood and early intervention youth services and improving the coordination and accessibility of services for individuals with severe mental illness.

Our concern has always been that vulnerable people with severe mental health needs, who needed more than 10 sessions in a year, were going to be left high and dry until the other services were sufficiently geared up to fill the gap.  Minister Butler’s willingness to revise the scheme has allayed those concerns for now. Meanwhile, we will keep an active brief on the development of the alternative programs through the course of the year.”

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Summary of recent journal articles on the Better Access debate
(if you can’t access and would like a copy of any of these, please leave your details below).

• How to tackle a giant: creating a genuine evaluation of the Better Access Program
Sebastian Rosenberg and Ian Hickie
Australasian Psychiatry • Vol 18, No 6 • December 2010

• Australia’s Better Access Initiative: still awaiting serious evaluation
Ian Hickie, Sebastian Rosenberg, Tracey Davenport
Australian and New Zealand Journal of Psychiatry, October 2011, Vol. 45, No. 10 : Pages 814-823

• Australia’s Better Access initiative: do the evaluation data support the critics?
Anthony Jorm
Aust N Z J Psychiatry. 2011 Sep;45(9):700-4.

• Not Letting the Ideal be the Enemy of the Good: The Case of the Better Access Evaluation
Jane Pirkis, Meredith Harris, Maria Ftanou, Michelle Williamson
Aust NZ J Psychiatry  November 2011 vol. 45 no. 11 911-914

• Australia’s Better Access initiative: an evaluation.
Pirkis J, Ftanou M, Williamson M
Aust N Z J Psychiatry 2011; 45:726–739.

• What kind of evidence do we need for evidence-based mental health policy? The case of the Better Access initiative.
Allen N, Jackson H
Aust N Z J Psychiatry 2011; 45:696–699.

• Were the budgetary reforms to the Better Access to Mental Health Care initiative appropriate? — Yes
Jane E Pirkis and Meredith G Harris
http://www.mja.com.au/public/issues/194_11_060611/pir10582_fm.html

• Were the budgetary reforms to the Better Access to Mental Health Care initiative appropriate?
Sebastian Rosenberg and Ian B Hickie
http://www.mja.com.au/public/issues/194_12_200611/ros10581_fm.html

• Evaluation of the Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule initiative: summative evaluation.
Pirkis J, Harris M, Hall W, Ftanou M. Melbourne: Centre for Health Policy, Programs and Economics, 2011.
http://www.health.gov.au/internet/main/publishing.nsf/content/mental-ba-eval-sum

• The complementarity of two major Australian primary mental health care initiatives
Bassilios B, Pirkis J, Fletcher J, Burgess P, Gurrin L, King K, Kohn F, Blashki G.
Aust N Z J Psychiatry. 2010 Nov;44(11):997-1004.

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7 Feb: Again apologies to readers: ongoing glitches in the system are making formatting difficult. In fact the first version of this post was eaten by gremlins and in the rush to re-write last night, I omitted some of the references that were to have been included. These have now been updated, and also an extra comment from Gavin Andrews.