Review seeks to solve Better Access flaws

A review commissioned by the Federal Government has backed the use of GP-led mental health treatment plans, with researchers identifying huge gaps in access linked to socio-economic status and location.
 
Ensuring ‘simplified’ mental health treatment plans that support GPs to work collaboratively to meet individual patient needs is one of the 16 recommendations listed in an evaluation of Better Access released this week.
 
Other recommendations in the 337-page document, which includes nine studies involving a range of institutions and overseen by academics at the University of Melbourne, address affordability issues, as well as the range and reach of other therapies.
 
On a positive note, the reviewers suggest that those who receive treatment through Better Access ‘tend to have positive outcomes, irrespective of how outcomes are measured’. 
 
However, the authors also note that not everyone using Better Access needs formal care.
 
‘Of most concern, increases in utilisation over time disproportionately favour people on relatively higher incomes in major cities,’ they also wrote.
 
The report notes that Better Access treatment services involved an average co-payment of around $74 per session from 2018–21. That cost, however, has risen significantly during the first six months of 2022 to $90.
 
For Dr Cathy Andronis, Chair of RACGP Specific Interests Psychological Medicine, the report’s findings reflect her clinical experience.
 
‘What stands out is that it confirms what we already have noticed anecdotally in our practice: that most of the services go to people who have wealth,’ she told newsGP.
 
‘We’ve got a very inequitable system, which leaves GPs still in the same position in regard to managing patients with complexity.
 
‘The majority of the most complex, most disadvantaged people don’t have the financial capacity to access those sorts of services and so GPs are left still carrying the patient as best they can in a system that is stretched, where time spent with patient is punished in our current MBS system.’
 
Lack of integration
Dr Caroline Johnson is a senior lecturer at the University of Melbourne’s Department of General Practice who represented the RACGP in the stakeholder advisory group for the Better Access Evaluation.
 
She said she was also struck by the inequities covered in the report.
 
‘The biggest bugbear for GPs is that your ability to get good mental health care depends on your postcode and your ability to pay,’ Dr Johnson told newsGP.
 
‘I think we should aspire to something a bit better than that. Mental health care is as important as other aspects of healthcare.’
 
However, for Dr Johnson perhaps the biggest take-away is the lack of cohesion the report flags.
 
‘This is a really crucial time where there are lots of other things happening in the mental health space,’ she said.
 
‘Each of these individual things are quite good ideas, but they’re not properly integrated and I think that’s the thing that this report screams out at me.
 
‘Better Access isn’t a bad thing but … it’s not well integrated with all the other bits, and this is why GPs are constantly frustrated by trying to deal with the mental health system.’
 
As part of a proposed solution, those behind the evaluation recommend Better Access include ‘other multidisciplinary models for longer-term clinical care’ and offer ‘holistic support for dealing with life’s complexities’, particularly for those with severe and complex needs.
 
GPs should also be supported to refer to the ‘most appropriate’ services within Better Access, but able to refer to other services outside of the initiative particularly for ‘low intensity’ services, the authors write. 
 
The authors also say mental health plans should be used ‘to help GPs understand the needs of individual consumers and work collaboratively with other providers to meet these needs, rather than just being a requirement for referring consumers to Better Access’.
 
‘Appropriate funding mechanisms will need to be in place to achieve this,’ they noted.
 
Dr Andronis supports that suggested change.
 
‘I believe that mental health plans need to be recognised as being not just a tick-a-box referral system for a psychologist, but to go back to what they were intended to be originally, which is an assessment in detail for the needs of a particular patient,’ she said.
 
Additional sessions scrapped
The researchers also recommend that funding for 10 additional psychological therapy sessions, introduced during COVID-19, should continue – although they note that most of the sessions were taken up by existing users and comprised 15% of treatment sessions in 2021.
 
Yesterday, however, Federal Health and Aged Care Minister Mark Butler announced funding for the subsidised additional sessions would cease at the end of the year, leaving the previous 10 sessions still in place.
 
‘The additional services aggravated waitlists, aggravated barriers to access particularly for lowest income Australians,’ Minister Butler told reporters on Monday.
 
‘Their access, which was already inequitable before the introduction of these services … actually [deteriorated] over the course of this period.
 
Dr Johnson does not necessarily think that decision, which has been criticised by other Federal politicians, damages the prospects of the report’s other recommendations being put into place.
 
‘It really does depend on how they align all the other bits of the mental health system to work together,’ she said.
 
Both Dr Andronis and Dr Johnson hope that the system can evolve to allow for a more sophisticated assessment of individual patients’ mental health needs.
 
‘At the moment, it’s a pretty blunt instrument,’ Dr Johnson said.
 
‘It really depends on the person coming in being identified, and then being in the right postcode, and with the right wallet, to pay for the service.’
 
Dr Andronis points towards the Initial Assessment and Referral Decision Support Tool (IAR-DST), which is already in use for mental health care triage in some Primary Health Networks – and also brought up in the Better Access evaluation.
 
‘That tool is something that will hopefully allow GPs to be able to better assess more holistically what a particular person needs,’ she said.
 
Dr Johnson is also open to the idea of encouraging patients with milder symptoms who are prognostically in lower risks groups to try less expensive, less intensive interventions, including digital services.
 
‘They’re probably helpful, and also would free up some of the other services for people with greater need,’ she said.
 
Other recommendations in the report include suggestions for boosting workforce numbers and distribution. Greater affordability could be facilitated with bulk-billing incentives and changing rules around the Extended Medicare Safety Net, the authors also wrote.  
 
They suggest more psychological therapies could be added to those available under Better Access, provided they meet National Health and Medical Research Council evidence standards.
GP Dr Caroline Johnson was struck by the inequities covered in the Better Access review.
 
Next steps
Prior to this review, the last major evaluation of the Better Access initiative took place in 2008, two years after it was introduced to support access to mental health care through MBS rebates.
 
There were two stages to the most recent review, with an initial stage considering how effectively the scheme worked, and a second stage considering solutions to any issues highlighted earlier.
 
Minister Butler said he will try to bring relevant stakeholders together early next year for a ‘very frank discussion’ about the report, and how to preserve Better Access benefits and distribute them more equitably.
 
GPs are reporting the growing mental health burden as the issue causing them the most concern about the future, but Dr Johnson says she remains hopeful that positive change is possible.
 
‘I can’t really comment on the Government’s appetite, other than that I think they know that it is a major problem, they know that there’s a great need and they have a system that’s not quite fair in who it’s reaching,’ she said.
 
‘I hope that they will recognise that with some tweaking they could hopefully get better value for money and better equity.’
 
The full report, as well as an executive summary, conclusions and recommendations, are now available on the Department of Health and Aged Care website.
 
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Better Access review mental health mental health treatment plan socio-economic status