Mental health is a particularly fraught area of public policy (as you may have noticed from recent Crikey/Croakey articles on the budget announcements).
You could write a book about all the reasons for this, including the rivalries within and between the various professional groups, the stigma, the history, the difficulty of achieving that mythical “whole of government approach”, the diversity and complexity of the problems which fall under the blanket banner of “mental health”, and the forces which drive health policy and politics.
In short, it’s complicated (which is why last night’s announcements can legitimately be seen as “encouraging, worrying, disappointing, and promising”.)
Below are two pieces which give some historical and current context to the cutbacks to the Better Access program that have upset the Australian Medical Association, Royal Australian College of GPs, and Australian Psychological Society. These reduce the Medicare rebate for GP mental health care plans, and cap the total number of allied psychological consultations available each year at 10 rather than 12.
The first is a bit of historical context from me. The other is by Paul Smith, political editor at Australian Doctor.
A blast from the past
Melissa Sweet writes:
Five years ago, I wrote a story for the Sun-Herald about the intense jockeying that was occurring between professional groups fighting for their share of what was then being seen as a historic investment in mental health by the Howard Government and COAG.
In the lead-up to the meeting of Australian government leaders this Friday (July 14, 2006), the buzz has been deafening. It is the furious sound that bees make around a honey pot. The “honey pot” holds the billions of dollars that governments are planning to spend on improving services for people with mental illness as part of reforms being pushed through the Council of Australian Governments. And the din is the sound of professional groups fighting for their share of the harvest.
Several mental health advocates told me they were concerned about the likely introduction of a program (which subsequently became known as the Better Access Program) to enable new MBS items for psychologists and other providers. They warned that this fee-for-service model was likely to improve services in affluent metropolitan areas but not elsewhere.
Here is some of what they said:
Professor Ian Hickie, executive director of the Brain and Mind Research Institute at the University of Sydney, said governments should learn from 30 years’ experience of fee-for-service medicine, which had failed to deliver equitable access for people in rural, remote and other disadvantaged areas. Instead of expanding Medicare to cover some psychology services, the Government should be developing services involving teams of health professionals which are fairly distributed across the community, he said. Professor Hickie was concerned that professional interests appeared to be dominating the agenda. “The community voice iı in danger of being drowned out once again by the provider voice,” he said. “The danger is that the Government only has ears for the providers.”
Rob Knowles, who was then chair of the Mental Health Council of Australia and a former Victorian health minister, said that expanding the fee-for-service model may lead to better services for the better off. “Not only would we see more psychologists setting up in better off areas but we would also run the risk of seeing a drift of psychologists from the public to the private sector,” he said.
Barbara Hocking, executive director of the charity SANE Australia, said she was concerned that psychologists may end up following the path of private psychiatrists, who tend to be based in affluent areas and are scarce outside cities. “Much more sensible in my view would be to go down the salary line and put more psychologists into general practices as well as working alongside groups of private psychiatrists and to have more in community services so people can access them,” she says.
Dr Peter Cotton, a psychologist, said reforms should encourage all practitioners to work together and to provide services across the community. “The last thing anyone would want to generate is yet another professional group that has carte blanche because the Medicare tap has been turned on,” he says.
Also at that time, a report prepared for COAG by a team led by Professor Gavin Andrews, professor of psychiatry at St Vincent’s Hospital, urged governments to take a “radically different” approach from the past. Instead of juggling the demands of stakeholders, they should design systems of care around patient and community needs, said the report.
Janet Meagher, a spokeswoman for a non-government organisation providing services to people with persistent mental illness, the Psychiatric Rehabilitation Association, urged governments to support new programs rather than ploughing more money into “failed approaches”. “At the end of the day the government seems to be listening to professional groups rather than to the community and to the consumer groups who are the people who are the victims of failed services,” she said.
At that time, many advocates called for independent monitoring to assess the impact of the increased investment, and to ensure accountability so that patients across the country could expect the same standard of services. Insiders to COAG processes said the lack of such accountability mechanisms helped explain why mental health reform efforts had been such a spectacular failure over the past decade.
Fast forward five years.
Finally, we are to get a National Mental Health Commission, hopefully to provide improved transparency and accountability, and there will also be a formalised structure for promoting community input into policy.
As you may have seen in Crikey today, Ian Hickie is pleased to see cutbacks to the Better Access program. This recent evaluation found some basis to many of those concerns raised back in 2006 (although, not suprisingly, interpretations of the evaluation’s findings vary).
But as Paul Smith reports below, others are not so happy, and there are questions about how the new policies will unfold.
General practice has taken a battering in this budget on mental health
Paul Smith writes:
The $300 million being sucked out of the GP care plans is significant. And if you want to be blunt about it, the decision to introduce time-based items and drastically cull the rebates shows the government does not think highly of the way these items have been used over the past five years.
The suspicion has always been that the worried-well, living in affluent over-doctored areas, have benefited most from Better Access funding, funding that would have been better spent on other people living elsewhere. There has also been the suspicion that the care planning element has been cursory at least, more of a money-generating exercise than comprehensive treatment successfully targeting those in need.
The BEACH data doesn’t bear that out – apparently the average clinical time doctors spend on these care plans is 28 minutes, not including the coordinating part which is often dealing with family members, social services, housing. The claim will be hotly debated by critics, by the government itself, but the GP groups argue that these care plans items are not the basis of six minute factory medicine.
The GP groups are in uproar, accusing the government of “slapping general practice in the face”. Apparently they were given a cursory one hour briefing with minsters about a week before last night’s shock announcement – even then there were given few clues as the size of the axe that was about to fall.
For the RACGP and the AMA the issue is simple. Few other schemes have delivered so much, to so many with mental health problems. In their view, slashing the funding for this work is going to hit vulnerable patients hard. It also undermines prevention and early intervention – the well-worn mantra of the Labor government over the last four years.
The point is that the government – even if it was justified in worrying about the uncapped cost of Better Access – had two policy options. It could have gone for a restructure of the existing care plan items. This option could have resulted in the items being structured in a way that gave GPs the necessary flexibility to tailor care packages to the needs of patients – particularly for those with moderate or serious problems. But that hasn’t happened.
Instead the government – no doubt influenced by the arguments pitched by Professor Ian Hickie at the Brain and Mind Research Institute – decided fee-for-service in general practice was not, on its own, the mechanism to deliver. So they decided the cash-for-care planning – at least some of it – should be diverted via the Medicare Locals.
Money (in the form of a capped budget) will fund an expansion of the Access to Allied Psychological Services Program (ATAPS) – with an estimated 185,000 patients to be treated over the next five years. Money (again in the form of a capped budget) will also end up in a program – also run through Medicare Locals – targeting those with serious and persistent mental health problems.
This also raises issues. The AMA is warning that GPs risk being pulled from the centre of patient care when third-parties get involved.
Whether those warnings proved unfounded will depend on the evolution of the Medicare Local networks over the coming years and whether they retain close links with GPs on the ground.
It should be stressed that ATAPS, run through the divisions of general practice, has had widespread – even if not universal – support from GPs. Few have complained of becoming a side player when it came to deciding what treatment and support patients need through ATAPS.
But when you move away from fee-for-service funding and start channelling it through new entities like Medicare Locals – with new governance and management structures, new approaches to primary care – there are fewer certainties on who will be in control of patients’ management, particularly when the subsidies for GP management have been reduced so drastically.
Will it be the patient’s GP or will it be the bureaucracy, the bureacracy that is handling the cash? That’s a legitimate question to ask.
There is also a wider, more fundamental issue raised by the government’s revamp. The mental healthcare plan items and the dental items, both the brainchild of the Howard government, blew their budgets in spectacular fashion.
I suspect it has been a fiscal experience that will ensure government policy makers of the future will have a serious aversion to any policy plan resourced from an uncapped budget.
In short, those mental health and dental items might become the last large-scale health reform modelled on fee-for-service Medicare.
As witnessed by the reaction of the RACGP and the AMA this morning, that may not be good for general practice and its patients.
• This article was first published by Australian Doctor