Introduction by Croakey: Mainstream media debate over the Better Access mental health program has primarily focused on the number of eligible sessions funded by Medicare.
But, as raised previously in Croakey, there are more fundamental problems with this program that need to be addressed so it can best meet the needs of the Australian community.
Below Professor Ian Hickie, Co-Director, Health and Policy, at the Brain and Mind Institute, suggests some major structural reforms, including a more sophisticated approach to identifying the needs of people presenting with mental health concerns, in order to identify those who need to see a mental health professional and those whose needs would be best met by psycho-social rather than clinical services.
He advocates for increased support for team-based and multidisciplinary care and to broaden the referral pathway to include other health professionals, in addition to GPs.
Ian Hickie writes:
When it comes to discussing health reform in Australia, more energy is spent debating the merits of re-arranging various Medicare item numbers than promoting any serious structural change.
This has been most evident in mental health over the last six months, where much media and public attention has focused on whether reimbursement of 10 or 20 sessions with a psychologist is the most important decision for Health Minister Mark Butler to make.
There is no doubt that the most important mental health issue for the Federal Minister in 2023 is structural reform of the Better Access Program.
Sadly, the fundamental inequities that are built into the way psychological interventions are currently delivered has been of little interest to those professionals or service users who currently derive the most benefit. And they are the ones who, to date, have dominated the media and public discourse.
Systems focus
By contrast, the Minister has made it clear that his highest priority is getting many more of those in real need into the system. Additionally, these services need to be available to those with a limited capacity to pay high out-of-pocket costs and those who live outside the centres of our major cities.
Of course, these things are ‘system-level’ matters and not the immediate concerns of those people who already receive care or the practitioners who focus on those who are already in their offices.
Most professionals highlight that their services are linked to the underlying payment models. They claim they are in no position to change those arrangements or implement alternatives that would increase access or deliver more equitable outcomes. Further, most emphasise their preoccupation is providing the best (‘evidence-informed) options available for those they see and not buying into any ‘system-level’ discourse.
So, what options does the Minister have?
If left to the professional groups, it would be to reinforce existing small business-orientated and existing work practices, ideally supplemented by increased reimbursement for the services they now deliver.
The clear alternative for the Minister is to challenge some of the basic assumptions. At least on the issue of increased equity he has made his intentions clear.
Options for reform
So what other issues should be on the table?
Here are some to consider:
- that all initial triage and referrals to more specialised care need not be limited to GPs
- that the vast majority of people who are distressed and presenting for care do not necessarily need additional clinical care by a mental health practitioner
- that when psychological care is not working, many people do not require more intensive periods of care to be provided by the same sole practitioners, most notably psychologists
- that team-based and multidisciplinary care is urgently required for those people with more complex and ongoing difficulties, and this is not limited to those with eating disorders
- that the outcomes of care can be systematically collected and used to determine ongoing needs for clinical or psychosocial care.
Those assessment systems currently promoted by the Commonwealth, and most notably the Initial Assessment and Referral process and its linked Decision Support tool (that is now being distributed widely by Primary Health Networks), fall into the trap of simply aggregating a broad range of psychosocial and clinical needs into one composite score.
The end result is to recommend that the vast majority of people need further psychological care.
These process fail to disentangle clinical from psychosocial needs (for example, financial, housing, employment, social support, education), and push more into forms of clinical care which fail to address those wider social issues.
Clinical care vs psychosocial support
What the Minister actually needs is a better way of differentiating those who really need more expert clinical care from those in need of greater social support. The former is the preserve of mental health professionals. The latter is better provided by those organisations with skills in the psychosocial arena.
In reality, a more sophisticated tool (ideally based on simple patient-reported rather than clinician-elicited characteristics) would direct many people to self-care strategies, ongoing monitoring or psychosocial support. This could happen direct from the community (operated by Primary Health Networks) or from existing primary care clinics (general practice and others).
Our estimates are that at least 30 percent of those currently being referred onto psychologists and other mental health practitioners by GPs could be diverted to these other effective but non-clinical options.
The end result would be considerable increase in the availability of mental health professionals to provide clinical care. For this to function, those other non-clinical services need to be available locally, and more obviously commissioned by PHNs.
For that 70 percent in need of psychological care, we must move away from the notion of fixed ‘doses’ of care (6,10,20 or more sessions). The available data, and much research on short interventions, indicate that many people’s clinical needs can be met in less than six sessions.
We need to reward those practitioners who use their time with people most effectively and so progress to seeing more new people in the time available. Practice-based incentives for short-term therapies, and providing those services particularly to disadvantaged groups, are a readily-available and very desirable funding mechanism.
Independent assessments
For those who do require more intensive, skilled or prolonged psychological care, then we need to accept that this requires, first, an independent assessment of that need. That is, an assessment conducted not by the practitioner (or team) who is going on to provide that more expensive and complex care.
That assessment needs to include the capacity to identify key diagnostic features (OCD, PTSD, personality disorder, severe depression, eating disorders, bipolar or psychotic disorders), the type of intervention(s) required and the skill-level of the practitioner(s) who can provide that intervention.
This assessment process is not a simple ‘tick and flick’ exercise, which has become so common in much of the current mental health planning and referral processes. It is achievable through utilisation of both client-completed assessments combined with online or face-to-face assessment by a skilled practitioner.
Here we need to specifically make use of GPs with evidence of additional specialist skills, clinical psychologists, mental health nurses and psychiatrists. Reimbursing this role for private practitioners, as well as linking this function with new initiatives such as the head-to-health hubs, is essential.
Once that assessment is made, we estimate that about 30 percent of those currently using Better Access could move into those more complex and longer (and not necessarily time-limited) forms of care, as long as the outcomes of that care are being continuously tracked and reviewed.
Multidisciplinary and team-based care
The care itself needs to be increasingly focused on multidisciplinary and team-based care for relevant disorders (for example, eating disorders, major mood disorders, personality disorders) and the use of specific techniques (such as exposure therapies) that are often avoided by less experienced clinicians. Here the emphasis needs to be on continuous review of progress and not simply on a fixed number of sessions by any one or team of professionals.
There is much work to be done by the Minister, and the mental health sector, in 2023.
For real progress to be made, serious structural reform needs to be on the table.
See here for Croakey’s archive of stories on mental health.
