4.3.1 The delivery and take-up of certified trainingEligibility to register with MBS to provide Better Access services is based on registration through professional bodies. Better Access therefore builds upon the existing professional training requirements of the professional bodies.28 This was quite different to its predecessor, the Better Outcomes in Mental Health Care initiative (run through the Divisions of General Practice). However, some professional registration bodies (e.g. APS) have compulsory continuing professional development and, as eligibility to register with Medicare for the provision of Better Access Items is based on registration with a professional body, training is indirectly required.
Continuing professional development was primarily influenced by professional association and registration body requirements, as well as the personal interests of the individual practitioner. Each of the professional associations has their own requirements for professional certification and training. This varies from the structured and accredited courses, to the workshops, seminars and case reviews provided as continuing professional education.
The consultations identified the need to extend the content of professional development outside the parameters of the Better Access initiative, and some organisations argued that the professional associations and registration bodies should be maintained as the primary providers of continuing professional development programs.
In order to further probe the impact of the Better Access initiative on the training of mental health professionals, a question about the effect of the Better Access initiative on access to clinical training was included in the KPMG online survey for Component D of the broader Evaluation of the Better Access to Psychiatrists, Psychologists and GPs through the Medicare Benefits Schedule initiative project. A total of 203 medical mental health participants (193 GPs, 2 paediatricians, and 8 psychiatrists) completed this section of the questionnaire. Participants in the survey were asked whether the Better Access initiative had affected their access to clinical training in their discipline. The responses provided by those who answered this question are outlined in Table 4.4. Almost half of the medical mental health workforce who responded to this question believed that the initiative had affected their access to clinical training, and, of these, approximately 80% believed that their access to training had improved as a result of the initiative.
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A total of 418 allied mental health participants (131 clinical psychologists, 133 general psychologists, 153 social workers, and 1 occupational therapist) completed this section of the questionnaire (see Table 4.5). The majority of allied health professionals (64%) reported that the Better Access initiative had no effect on access to clinical training. However, of the 143 respondents who reported that the Better Access had affected their access to clinical training, the majority (90%) said the Better Access initiative had improved access.
Information from the consultations suggests that the Better Access initiative had, along with a broader emphasis on mental health within the health sector, stimulated interest in the development of mental health related skills amongst professionals (chair of GPMHSC, GPMHSC, and AGPT). To some extent it had also increased the demand for training in mental health disciplines from people wanting to enter the field. The introduction of requirements for the maintenance of continuing professional development (for GPs) since the consultations occurred is likely to further increase the demand for certified professional development training.
Subsections 220.127.116.11 to 18.104.22.168 provide additional information from the consultations regarding the take up of training for each Better Access mental health occupation.
Table 4.4 Impact of Better Access on clinical training in the medical mental health workforceTable 4.4 is presented as a list in this HTML version for accessibility reasons.
Has the Better Access initiative affected access to clinical training in your discipline?
- Yes - 87 responses (43%)
- Improved - 78 responses (90%)
- More difficult - 7 responses (8%)
- No response - 2 responses (2%)
- No - 103 responses (51%)
- No response - 13 responses (6%)
- Total responses - 190 (100%)
Table 4.5 Impact of Better Access on clinical training in the allied mental health workforceTable 4.5 is presented as a list in this HTML version for accessibility reasons.
Has the Better Access initiative affected access to clinical training in your discipline?
- Yes - 143 responses (34%)
- Improved - 136 responses (95%)
- More difficult - 7 responses (5%)
- No - 268 responses (64%)
- No response - 7 responses (2%)
- Total responses - 418 (100%)
22.214.171.124 PsychologistsPsychology representatives from the APS report that the Better Access initiative has led to an increase in demand for university level training in psychology, particularly for clinical psychology.
It was suggested that this increase in demand for clinical training was most likely to be a result of the higher rebate available for clinical psychologists as opposed to registered psychologists (ACCP). It was noted in the consultations that there is interest from registered psychologists in undertaking further training to enable them to claim the higher rebates. However, given that clinical training either requires postgraduate university studies or 1000 hours of (often unpaid) supervised clinical training subsequent to the completion of a four years of undergraduate and honours level psychology (APS, APAC, and GPMHSC), competition for places and time, as well as monetary constraints preclude this from being a popular course of action (ACCP and APAC).
Concerns were expressed by the APS about the bottleneck caused by the inability of universities to keep up with the demand for psychology training, which is exacerbated by the extra demand for places created through the Better Access initiative. According to the APS, universities report that the high cost of providing post-graduate clinical psychology courses and increasing difficulty in accessing clinical placements hampers their ability to increase the number of positions available. They are, however, adding new courses in psychology and incorporating new clinical training aspects in old courses in response to the increased demand. The lack of access to clinical placements, which are often in public services and therefore subject to the effects of what clinical psychologists report to be a 15-20% shift of senior practitioners from the public to the private sector as a result of the Better Access initiative, also has implications for the availability of supervised clinical training for those gaining their clinical qualifications in this manner.
The APS requires psychologists to undertake continuing professional development to retain membership and therefore they did not view the Better Access requirement for clinical and registered psychologists to maintain continuing professional development as likely to have an impact on the workforce. One issue they did raise, however, was that the increased interest in clinical training, particularly from rural and regional psychologists, has led to the provision of online continuing professional development for practitioners outside of metropolitan regions.
126.96.36.199 Social workersThe AASW noted that the uptake of continuing professional development for social workers had increased substantially with the introduction of the Better Access initiative. As indicated earlier, many social workers, from students to experienced practitioners, are said to be planning their careers around the capacity to work in private practice as a result of having access to the MBS rebates through the Better Access initiative. Registration for the use of MBS Items is contingent upon the maintenance of professional development and skills, thus participation in certified training has increased (and is expected to continue to do so) as social workers endeavour to maintain their professional development points. Training is predominantly provided locally by branches of the AASW through seminars and workshops.
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188.8.131.52 Occupational therapistsOT Australia indicated that the popularity of occupational therapy as an occupation has increased in recent years, and this has resulted in a substantial increase in the number university occupational therapy courses being offered. However, there was some concern about the impact of the movement of skilled mental health practitioners away from the public sector on the capacity to train the increasing number of undergraduates entering university courses.
At present, the primary method by which occupational therapists acquire advanced skills is through on the job supervision by a senior occupational therapist, although continuing professional development events are also available for and undertaken by occupational therapists. While there is currently no requirement for accredited continuing professional development for occupational therapists, OT Australia identified that this is in the process of change and that they will be increasing professional development resources, either by increasing the resources provided by the association or by facilitating access to external resources for members, to cater for the anticipated growth in participation in continuing professional development.
184.108.40.206 General practitionersThe AGPT and the ACRRM identified the increased visibility of mental health in the community as contributing to the increased the demand for mental health care amongst their clients. This increase in the demand for services is driving an increase in the number of GPs attending continuing professional development sessions in mental health. Consumer representatives suggested that an area of focus for professional development in GPs needs to be the development and implementation of care plans. This has been echoed in the consultations with GP organisations, who have also acknowledged the need for increased resources to enable GPs to audit their own care plans in order to ensure that they are providing a high level of care (chair of GPMHSC).
The consultations with GP organisations highlighted one area of concern around the lack of regulation of training through the Better Access initiative: the role of training provided through the Better Outcomes in Mental Health Care initiative in reducing the prevalence of drug-company sponsored, drug therapy focussed professional development programs. There was some concern from the GPMHSC that, without this regulated training, professional development may revert to drug-company funded training. However, this issue may have been addressed in the budget statement released after the consultations were conducted.
4.3.2 Training provisionThe information provided from the consultations suggest that the introduction of the Better Access initiative has increased the demand for mental health training, and that this is stimulating a rethink in how and who provides training to the mental health workforce. The challenge from the perspective of the training organisations that were consulted was viewed as being the ability to expand training opportunities for the workforce within the current training provider framework, while still maintaining the quality of the training.
On the whole, however, the consultations indicated that professional bodies across each of the occupations were making attempts to increase the size of the training workforce, either by introducing more staff (as reported by the MHPN) or by exploring other sources of training providers (i.e. the use of Level 2 GPs with expertise in mental health as trainers as suggested by AGPT). The use of on-line training was discussed by the APS and the ACRRM as a means by which they are delivering continuing professional development opportunities for nonmetropolitan practitioners.
One area of concern highlighted in the interviews was the report from the GPMHSC that there has been a reduction in the number of trainers applying for accreditation due to the perception that the Better Access initiative encourages GPs to handball patients to other practitioners rather than to gain mental health skills themselves.Top of page
4.3.3 Training places for medical graduatesOne question that this evaluation sought to address was whether Better Access had impacted on the availability of training places for increasing numbers of medical graduates and how this interacts with other relevant professions, including psychology, occupational therapy and social work.
The consultations revealed that it was not possible to determine whether Better Access had an effect on the availability of training places for medical graduates, as this was influenced by numerous factors. It was suggested by Universities Australia that the increase in numbers of medical graduates was viewed as having little impact on the allied mental health workforce because, given that each profession teaches its own students and provides its own clinical experience, there is no competition among the professions for clinical placements.
There was, however, an interest in multidisciplinary training to increase inter-professional understanding and the effectiveness of referrals. This interest was expressed in consultations with representatives from GP, occupational therapy, and psychology organisations.
There was some concern, particularly among GP organisations, that there will be not enough medical educators to teach the increased number medical graduates. However, Universities Australia reported that the Council of Australian Governments' commitment to inject $1.5 billion (UA) to a range of clinical education and training initiatives will enable the expansion of the range of education providers.
4.3.4 Clinical trainingThe consultations sought to understand whether Better Access had impacted on the capacity of training systems to provide clinical experience to undergraduate and post-graduate doctors and allied health professionals
According to the APS, AASW and OT Australia, the Better Access initiative has indirectly had a negative impact on the capacity of training systems to provide clinical experience to students and trainees. In particular, these organisations identify the withdrawal of senior clinical and registered psychologists, occupational therapists and social workers from the public sector, along with the marginalisation of teaching as the core business of the public hospital system, as contributing to the reduction of the skilled workforce available for supervision and the training of junior staff.
Representatives from the medical mental health workforce did not describe this same shift away from the public sector, nor was there any impact upon access to clinical placements as a result of the Better Access initiative.
Spare capacity for the delivery of undergraduate clinical training was identified in the private hospital system, however the supporting infrastructure in terms of governance, systems, quality assurance and the availability of trainers is not currently in place (Universities Australia). Another measure for overcoming shortages in the availability of clinical placements that was discussed in the consultations is the introduction of simulation centres, which are being rolled out by the Health Workforce Agency (Universities Australia). These centres would still require students to work with real patients, but they would ease the demand on resources, particularly in regional areas.Top of page
4.3.5 Regional Training ProgramsThe incorporation of mental health into Regional Training Programs for GPs is especially important due to the high level of demand that the ACRRM has observed from both its members and from patients who increasingly expect that rural GPs will be competent in mental health. Regional Training Programs provide not only the equivalent of Level 1 mental health training that is required as part of the RACGP and the ACRRM curriculum, but also extend to the provision of Level 2 mental health training (by providers such as the ACRRM), mental health sessions at conferences (i.e. the ACRRM conference), and workshops (by providers such as the MHPN).
There are differing views in the accounts provided through the consultations as to the impact of the Better Access initiative upon Regional Training Programs. While the AGPT reported that the Better Access initiative has had no impact upon Regional Training Programs, the ACCRM reported that the initiative has increased interest in mental health training from registrars to such an extent that they now lack the capacity to keep up with demand.
As a result of this increased demand, Regional Training Programs have to use their resources effectively to maximise the extent of training being provided to rural GPs and this has resulted in innovations in training. For example, the ACRRM has piloted web-based Level 2 mental health training for rural doctors, with the pilot funded under the Better Access initiative. They are now developing on-line continuing professional development for these GPs to maintain their mental health skills. This reduces the time and travel requirements for the GPs involved and also for training staff.
According to the GP organisation representatives (chair of GPMHSC, GPMHSC, and AGPT), despite time constraints registrars do take up mental health training through Regional Training Programs. It was noted that registrars understand the importance of mental health training, and that they understand the financial benefits of being able to access the Better Access MBS Items, especially because they are able to use the Better Access Items for clients whilst they are still a registrar.
28 During the consultation period a budget decision regarding the inclusion of compulsory training for GPs involved in the Better Access initiative was made, such that those GPs who have completed the GPMHSC accredited training (previously termed 'Level 1' training) will be entitled to claim for a higher rebate than those who have not (Department of Health and Ageing, 2009a).