Across all states and territories, all interviewees reported improved access to mental health services as a result of the Better Access initiative. Respondents across all states and territories also reported that the Better Access initiative was relatively well established, that GPs were generally aware of the Better Access initiative and that referral pathways were developing as the Better Access initiative matured.
The major limiting factors to access were the variations in the distribution of psychiatrists, GPs and AHPs across and within the states and territories and the gap payments remained an issue especially for people from a low socioeconomic background. This was perceived to be reflective of general health workforce issues and not specific to the Better Access initiative.
Interviewees noted that the Better Access initiative increased the range of communities able to access mental health services because of AHPs establishing local practices and/or having skills specific to the local community.
Several NGO services indicated that as a result of the Better Access initiative, services were now available in areas where there were none previously. This included communities where the AHP was the sole mental health provider. They also reported that, due to the specialisation and area of interest of some AHPs, there are now more services available for special needs groups.
Public mental health providers also indicated that, as a result of the Better Access initiative, there were more referral options for individuals contacting their services.
A couple of AHP peak representative bodies noted that, as the Better Access initiative increased the financial viability of private practice, AHPs were not tied to working in areas where they could work part-time in public practice. This was reported as a positive factor in increasing the ability of AHPs to establish practices in areas where there were few public mental health services. One AHP representative suggested that, as a result of the Better Access initiative, the market would work to improve equitable access as practitioners established practices in areas to capture local demand and where there were previously few other services.
Conversely, there was a more strongly represented view that the Better Access initiative, although increasing overall access, would not necessarily address inequity in access across population groups and geographical locations. A number of public mental health providers, and GP, NGO and psychiatrist representative groups noted that there was no incentive built within the current rebates that encouraged the provision of services to disadvantaged communities or higher need individuals. In local consultations, all providers noted that AHPs tended to be located in the more affluent areas of the community. The socio demographic inequity in service provision and access to services was seen to relate to:
- the disparity in rebate and recommended fee for AHPs, particularly general psychologists, social workers and occupational therapists, requiring gap payments;
- no means testing of the rebate or level of rebate;
- no financial incentive to bulk bill priority population groups. It was further noted that the administrative delays of up to five weeks between the lodgement of the Medicare Item number and payment further discouraged bulk billing; and
- disadvantaged communities and higher need individuals often requiring a greater level of input and effort than that reflected in the Medicare Items. This may include case conferencing with other agencies, preparation of reports, secondary consultation and liaison and information sharing.
One rural and remote Division of General Practice identified a perverse effect of the Better Access initiative reducing services to rural communities. The Division reported that, prior to the Better Access initiative, it was able to recruit clinical psychologists to provide a 'fly in fly out' service through ATAPS, at a fee of $55 per session plus travel and accommodation costs, two days per week. Subsequent to the Better Access initiative, providers increased their fee to $125 per session (reflective of the MBS rebate) plus expenses, effectively halving the number of sessions that could be provided through ATAPS. The Division indicated that, in response to this difficulty, DoHA agreed to allow the AHP to bulk bill patients on the second day of their visit in order to maintain the same volume of services. (Note: the stakeholder was referring an exception under section 19(2) of the Health Insurance Act20.) While maintaining the same volume of services, this more than doubled the cost of service provision paid for by the Commonwealth. The Division felt that this solution was not sustainable as they were finding it increasingly difficult to attract AHPs to provide outreach services to remote communities. The Division reported that AHPs were increasingly reluctant to undertake the additional travel time, expend the effort required to provide services within disadvantaged communities and experience the disruption to their urban practices for less money than they can make from their practice in the city or larger regional centre.
One consumer from a remote mining community reported that, prior to the Better Access initiative, the mining company had provided 'fly in fly out' psychologists but, subsequent to the Better Access initiative, they were no longer able to recruit to this position and the service had ceased. The respondent noted that there were now no mental health services available in this community, other than those provided through the local Aboriginal Medical Service. It was reported that services from the Indigenous health service were not available to mine employees or their families except in an emergency.
Most public providers reported increased difficulty in recruiting and retaining clinical psychologists as a result of the Better Access initiative, reducing the availability of clinical psychologists to the public mental health system. Conversely, most clinical psychologists reported that it was a devaluing of skills and expertise in the public mental health system that resulted in a shift to private practice and that the Better Access initiative was a facilitator, rather than a cause, of this shift.
A consistent theme from social workers participating in the consultations and online survey was that there appeared to be a bias in referrals to psychologists by GPs and that GPs did not have a full understanding of the expertise and services offered by mental health social workers. A number of consumers participating in the consultations and online survey also perceived a bias towards psychologists at the expense of other AHPs.
The online survey of GPs provided more detailed information on GP referral patterns, Table 2 below. Though 77 per cent of GPs reported referring to clinical psychologists, less than 60 per cent reported referring to psychologists and only 20 per cent to social workers and ten per cent reported referring to occupational therapists.
Exploring this further with a number of GPs in later consultations suggested that GPs may have a limited understanding of the expertise of social workers and occupational therapists. GPs reported that they generally felt more comfortable referring to psychologists. In subsequent consultations stakeholders and interviewees proposed a range of reasons, when queried. These included the following:
- Numerous GPs reported being more familiar in working with psychologists through ATAPS, due to a historically greater number of psychologists in private practice.
- When asked about why they referred to psychologists rather than social workers, GPs often stereotyped social workers as 'helping people with social problems' and occupational therapists as 'working with children'.
- Many GPs perceived psychologists as offering a more 'evidence based' and medical model of care, consistent with their own practice.
- GPs indicated that they received more information from psychologists on the practices in their local area, the range of services provided by psychologists and their areas of expertise.
- In a number of Divisions of General Practice, the Australian Psychological Society (APS) had been proactive in producing referral directories of local psychologists and distributing these to GPs.
- A few psychiatrists noted that GPs had less experience in working within multidisciplinary care teams as part of their clinical training, and were not exposed to the clinical expertise of mental health social workers and occupational therapists.
- Social workers reported feeling less comfortable approaching GPs in relation to the services they provided than did psychologists. Social workers also appeared less comfortable and confident with the concept of private practice as a business.
The online survey of GPs collected information of factors influencing GP choice of AHP to refer to, Table 3 below. Professional skill and competence was sighted as primary reason by 93 per cent of GPs, followed by cost (85 per cent), location (74 per cent) and area of specialisation (50 per cent). Professional group was only reported by 34 per cent of GPs as a factor and information on waiting times by 27 per cent of GPs. One GP indicated that they did not refer to AHPs.
It was also notable in the course of the consultations that the APS demonstrated a higher level of organisational efficiency and established communication networks than did either the Australian Association of Social Workers (AASW) or Occupational Therapy Australia (OT Australia). It was easier for the evaluation to identify and access the appropriate spokesperson for the APS at a national and statewide level for interview than it was for the AASW and OTA: information was more quickly disseminated through the APS to its members and appeared to capture a greater proportion of members.
Table 2: GP referrals to allied health professionalsTable 2 is presented as a list in this HTML version for accessibility reasons.
GP referrals to allied health professionals:
- Psychiatrist - 124 GPs (61%)
- Clinical psychologist - 157 GPs (77%)
- Psychologists - 120 GPs (59%)
- Social worker - 40 GPs (20%)
- Occupational therapist - 21 GPs (10%)
- Total respondents reporting nature of referrals - 203 GPs
Table 3: Factors influencing GP choice of referralTable 3 is presented as a list in this HTML version for accessibility reasons.
Factors influencing GP choice of referral:
- Professional skill and competence - 122 GPs (93%)
- Cost - 112 GPs (85%)
- Established relationship - 97 GPs (74%)
- Location - 89 GPs (68%)
- Area of specialisation - 66 GPs (50%)
- Professional group - 45 GPs (34%)
- Information on waiting times - 36 GPs (27%)
- Not applicable i.e. do not refer to allied health professionals - 1 GP (1%)
- Total respondents reporting factors influencing choice of referral - 131 GPs
20 Sub-section 19(2) of the HIA states that a Medicare benefit is not payable in respect of a professional service that has been rendered by or on behalf or under arrangement with:
(a) the Commonwealth;
(b) a State;
(c) a local government body; or
(d) an authority established by a law of the Commonwealth, a law of the State or a law of an internal territory.
A Medicare benefit is not payable unless the Commonwealth Minister for Human Services and Health directs otherwise.