Better Access does what its name says
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