Mental health care is a ‘game of snakes and ladders’ without a coordinated, publicly funded pathway for patients with complex needs, says Professor Ian Hickie.
It’s taken over 18 months but the federal government has finally released its response to the independent evaluation of the Better Access scheme, with one expert saying it was time for “serious commitment” and no more “snakes and ladders”.
In August 2021, the University of Melbourne undertook an independent evaluation of the Better Access scheme, releasing their final report containing 16 recommendations in December 2022.
The scheme, which began in 2006, allows GPs to refer some patients for 10 MBS-subsidised psychologist appointments each year.
Approximately 1.3 million people receive therapy through the program yearly.
Over a year and a half later, the federal government has released a response to the evaluation, albeit in a Friday night news dump with no fanfare, welcoming the report and committing to “delivering a more equitable, comprehensive and sustainable mental health system”.
“There are significant gaps in services for people with mild mental health concerns and limited supports available for people with complex needs,” reads the government response.
“The mental health system is fragmented and difficult to navigate.
“The system needs to evolve and move away from episodic care to holistic, person-centred and integrated care.”
Out of the 16 recommendations made by the independent evaluation, the government fully supported seven (1, 2, 3, 7, 8, 13 and 15) and supported two others “in principle” (6 and 11), all of which were already underway or complete.
It noted six recommendations (4, 5, 9, 10, 15 and 16) for “further consideration” and rejected one (12) to introduce additional treatment sessions as part of a tiered model under Better Access.
The required “whole-systems approach” to reform will involve “solutions to not only Medicare-subsidised services, but also to services across the system – from early intervention services to multidisciplinary services for people with complex needs,” said the government.
Speaking to The Medical Republic, University of Sydney Brain and Mind Centre co-director Professor Ian Hickie said that while the private system – both general practice, psychiatry and psychology – “plays an important role” in mental health care, a successful and equitable health system had to involve a coordinated and accessible public system outside of hospitals, particularly regionally.
“People aren’t going to get [equitable care] if it relies entirely on the private MBS system,” he told TMR.
“It’s always going to be difficult, because in Australia, that’s a small business model that preferentially funds professionals in city areas.”
But rather than simply “throwing money at new initiatives”, like the new Medicare Mental Health Care Centres potentially fragmenting care, the key was coordination, said Professor Hickie.
Currently, patients with complex needs pass through a “game of snakes and ladders”, through various facets of the system and often ending back at their GP to “start again”, he said.
GPs are the main gatekeepers of the Better Access scheme, as only patients with a Mental Health Treatment Plan prepared by a doctor can access it.
Professor Hickie said that there was “no point being a gatekeeper [of mental health care] when there’s nothing on the other side”.
Patients needed “smart assessment” of needs when entering the system and clear pathways for publicly funded care laid out, no matter the area, he said.
“We have enough access points.
“What we don’t have is coordination and ongoing care.”
The only evaluation recommendation not supported was to maintain 20 subsidised sessions in the Better Access scheme.
In early 2023, the health minister Mark Butler halved the subsidised sessions.
Professor Hickie reiterated his support for the move, which was “controversial among health professionals”.
“Limiting the amount of care has resulted in more people getting care, and waiting lists, interestingly, as reported by Australian Psychological Society recently, have gone down because more people are getting in.”
Professor Hickie said the Better Access scheme had moved away from the original intent of ensuring access was affordable and equitable.
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While the program’s predecessor, Better Outcomes, employed distributional mechanisms to ensure money from the program was funneled regionally, most of the Better Access funding remains where there are higher practice densities of doctors: in metropolitan areas.
Professor Hickie was hopeful, after the meeting of mental health and health ministers of all levels last Friday, that all levels of government would offer “serious commitment” to “operate collectively” to coordinate care.
“[I am hopeful] that health ministers take a much more proactive role, so it does not become a fight just between treasurers, in which case we won’t see progress.”
He also put in a plug for outcome-based funding.
“We had it back in 2001 through to 2005 and the professionals didn’t like it, because they got paid at the end of an episode of care, not for every activity along the way.”
