Bet­ter Ac­cess does what its name says

The Weekend Australian - Travel - - HEALTH - DON TUSTIN

THE last Gov­ern­ment in­tro­duced a Bet­ter Ac­cess scheme that used Medi­care to im­prove ac­cess to psy­cho­log­i­cal ther­apy for Aus­tralians with men­tal health con­di­tions. The Bet­ter Ac­cess scheme was re­cently crit­i­cised in The Week­end Aus­tralian by writ­ers who de­scribed it as poorly de­signed’’ and dys­func­tional’’. The Bet­ter Ac­cess aim was to pro­vide non­med­i­ca­tion ther­apy to a wider range of Aus­tralians. Un­der ear­lier schemes fewer than 40 per cent of peo­ple with men­tal con­di­tions re­ceived any form of ther­apy. Those who missed out were in the early stages of a dis­or­der — de­nied ac­cess to state ser­vices as not yet meet­ing the en­try cri­te­rion of hav­ing a

se­vere and dis­abling ill­ness’’. Bet­ter Ac­cess up­take sug­gests the scheme is suc­cess­ful.

The last Gov­ern­ment re-ori­ented men­tal health ser­vices — the com­mon­wealth took on re­spon­si­bil­ity for pro­vid­ing early in­ter­ven­tion ther­apy that is co-or­di­nated by GPs. The states re­tained re­spon­si­bil­ity for peo­ple with mul­ti­ple and com­plex needs re­quir­ing more in­ten­sive ser­vices such as hospi­tal, cri­sis care, ac­com­mo­da­tion sup­port, and case-man­age­ment that co­or­di­nates the skills of a multi-dis­ci­plinary team. It is fair to say that state ser­vices con­tinue to sup­port peo­ple with the high­est need, while Bet­ter Ac­cess pro­vides early in­ter­ven­tion for a wider range of peo­ple.

Many points in the re­cent ar­ti­cles are con­tro­ver­sial. Ian Hickie stated the re­form process is still di­rected by the same state-based bu­reau­cra­cies that failed to de­liver pre­vi­ously’’ (‘‘The com­mu­nity will ex­pect the Rudd Gov­ern­ment to get it right’’, 8/3). In fact, Medi­care and the fed­eral Gov­ern­ment over­see Bet­ter Ac­cess based on re­fer­rals by GPs — th­ese op­er­ate in­de­pen­dently of state ser­vices.

Les­ley Rus­sell (‘‘Men­tal health money misses the most needy’’, 8/3) and Hickie each claimed that co-or­di­nated teams pro­vide the best care, and crit­i­cised ther­apy by in­de­pen­dent providers. How­ever, ev­i­dence that case co-or­di­na­tion de­liv­ers bet­ter ser­vices ap­plies only to those with mul­ti­ple and com­plex needs.

There is am­ple ev­i­dence that early in­ter­ven­tion ther­apy is pro­vided well by reg­is­tered clin­i­cal psy­chol­o­gists de­liv­er­ing ser­vices di­rectly to clients, rather than through an ex­pen­sive case-man­age­ment bro­ker. Peo­ple re­quir­ing the ther­apy are able to co-or­di­nate their own care and are em­pow­ered by be­ing al­lowed to make de­ci­sions for them­selves in­stead of hav­ing th­ese made by a case­m­an­ager. Un­der Bet­ter Ac­cess, ser­vice de­liv­ery is in­te­grated through the GP and co-or­di­nated by the client.

Con­cern was ex­pressed that clients most in need of ther­apy can­not af­ford psy­chol­ogy fees. The Aus­tralian Psy­cho­log­i­cal So­ci­ety sur­veyed psy­chol­o­gists and found that 62 per cent of clin­i­cal psy­chol­o­gists bulk-bill. Many fol­low the private med­i­cal cus­tom of bulk-billing clients who hold a health care card. The sur­vey found the av­er­age gap pay­ment charged by clin­i­cal psy­chol­o­gists was $13.60. Be­fore Bet­ter Ac­cess, private psy­chol­o­gists had com­monly charged $170 per ses­sion.

Con­cern was ex­pressed about whether clients with the great­est need are re­ferred for ther­apy. Re­fer­rals un­der Bet­ter Ac­cess are made by GPs ac­cord­ing to pri­or­i­ties of the GP. The fam­ily GP has long been en­trusted with the care and co-or­di­na­tion of the phys­i­cal health of fam­i­lies. Bet­ter Ac­cess ex­tends this man­date to men­tal health is­sues un­der the one duty of care, with no need for a new bu­reau­cracy to re­fer clients to psy­chol­o­gists.

Ques­tions were asked about whether ther­apy ser­vices are dis­trib­uted equally. As the scheme is only one year old the ge­o­graphic dis­tri­bu­tion of ser­vices is likely to be un­even. None­the­less, Bet­ter Ac­cess has led to ther­apy ser­vices be­ing opened in sub­urbs.

I write as a psy­chol­o­gist who worked for 10 years in a state men­tal health ser­vice be­fore mov­ing into a psy­chol­ogy clinic that is sup­ported by the Bet­ter Ac­cess scheme. The psy­chol­ogy clinic serves low-in­come sub­urbs.

I now spend six hours a day see­ing clients with men­tal health con­di­tions, more than dou­ble what could be achieved in state ser­vices. My cur­rent clients de­cide for them­selves what ser­vices to use in ad­di­tion to psy­chol­ogy, and they see a range of providers in­clud­ing psy­chi­a­trists to mon­i­tor med­i­ca­tion, and di­eti­cians and gym train­ers to ad­dress side-ef­fects of med­i­ca­tion.

Clients de­cide how much to in­volve fam­ily mem­bers in their ther­apy. Clients de­cide how many ses­sions of ther­apy they re­quire, and many de­cide to take fewer than the al­lot­ted 12. Our prac­tice pro­motes self-man­age­ment by clients in place of co-or­di­na­tion by a case­m­an­ager. Our prac­tice sees a wider range of clients than the state ser­vice.

I see many im­prove­ments for clients un­der Bet­ter Ac­cess. Psy­cho­log­i­cal ser­vices are no longer re­stricted to peo­ple who can af­ford to pay private fees.

There is cer­tainly room for im­prove­ment. For ex­am­ple, moth­ers with post-na­tal de­pres­sion would ben­e­fit from prac­ti­cal help in their home rather than from hos­pi­tal­i­sa­tion as the main in­ter­ven­tion.

Ian Hickie notes, cor­rectly, that Bet­ter Ac­cess pro­vides in­suf­fi­cient in­cen­tives to pro­mote col­lab­o­ra­tion be­tween pro­fes­sion­als. But some progress has been made. The re­fer­ral path­way used by GPs in our area en­cour­ages ex­change of in­for­ma­tion within a treat­ing team, and this is ap­pre­ci­ated by clients.

My ex­pe­ri­ence is that the Bet­ter Ac­cess scheme pro­vides an ex­cel­lent foun­da­tion for de­liv­er­ing high qual­ity early in­ter­ven­tion ser­vices for a wide range of men­tal health con­di­tions, and that it should be both sup­ported and eval­u­ated. Don Tustin is clin­i­cal di­rec­tor of Ade­laide Psy­cho­log­i­cal Ser­vices, a clinic that opened af­ter the com­mence­ment of the Bet­ter Ac­cess scheme

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