This section presents the key findings related to the impact of the Better Access initiative on other components of the wider mental health system.
In considering these aspects, it is important to note that a number of changes in aspects of the mental health care system have occurred since the introduction of the Better Access initiative. These changes relate to the supply and distribution of the occupational therapist, psychologist and social worker workforce, and the manner in which the Better Access initiative interacts with the Better Outcomes in Mental Health Program, including ATAPS.
4.6.1 Summary of impact on the mental health system
4.6.2 Impact on public mental health workforce
4.6.3 Distribution of allied health professionals
4.6.4 Interaction with other related programs
4.6.1 Summary of impact on the mental health systemMost managers of public mental health services reported a perceived migration of psychologists from the public sector to the private sector as a result MBS funding availability through the Better Access initiative. The shift, where reported, was not as great as expected, and a consistent view of psychology organisations and several state and territory health departments was that, where it occurred, it was primarily a move towards a mix of public and private practice. The shift would appear to have been most felt in the smaller states and territories. A concern across public providers and psychology organisations was that this shift, where occurring, was most likely to be in the more senior positions and that this may have a longer term impact on the capacity to provide training and supervision to trainee psychologists entering the workforce. It was suggested by several organisations that there may be the need to consider new employment arrangements incorporating private practice for psychologists and shared training arrangements across the public and private sector – similar to that in place for the medical workforce. Public mental health providers reported very little, if any, shift in employment practices was noted for occupational therapists and social workers.
There were comments from the small area consultations and consultations with AHP representative bodies that the Better Access initiative may be having an impact on the distribution of the allied health workforce in private practice. This was identified as occurring at three levels:
- responding to capacity to attract gap payments, there may be a relocation of providers to more affluent areas where higher fees can be charged;
- the MBS payments have provided the ability for AHPs to establish practices in areas that would not otherwise be financially viable; and
- that new service models are developing with AHPs co-locating with GP practices to provide a more comprehensive service and facilitate cross referral.
A potentially more serious unintended impact of the Better Access initiative reported by GPs in remote rural areas may be the capacity to recruit AHPs to ATAPS and MAHS in more remote areas and/or challenging communities. One remote area reported that the cost of sessional payments by psychologists through ATAPs had doubled to match the MBS rebate to clinical psychologists and two reported that it had made it was more difficult to attract staff.Top of page
4.6.2 Impact on public mental health workforceThroughout the consultation process, providers, professional groups and health departments consistently reported that they had expected a significant shift to the private sector of psychologists from the public mental workforce following the introduction of the Better Access initiative. On the whole, these stakeholders held the view that little, if any, of this shift had in fact occurred. What shift had occurred appeared to be limited to clinical psychologists and though the numbers were small the effect on services, education and training had the potential to be significant.
Stakeholders from a number of state and territory health departments and one psychologist professional body believed that there had been little shift from the public to private sector of the AHP workforce following the introduction of the Better Access initiative. To support their claim, two state and territory health departments reported that they had low (or comparatively lower) rates of vacancies in their public mental health workforce. It was argued that there may have been an initial shift, or interest in a shift, but little of this movement was either long lasting or realised. Psychologist groups commented that many providers had shown interest in private practice, but realised the challenges in setting up a new business, even with the likely new client base through the Better Access initiative. As an example, during consultations, it was identified that, since the introduction of the Better Access initiative, the number of social workers in Australia with provider numbers increased from approximately 250 to 900. Given that concomitant shifts in the social worker workforce away from the public sector were not similarly reported, it is likely that, while social workers attained provider numbers, this may be the result of:
- social workers with already established private practices obtaining a provider number;
- social workers re-entering the workforce; and
- social workers in the public sector providing part-time public and part-time private practice.
The online survey of AHPs indicated that overall 33 per cent of respondents worked in both the public and private sector. Though not significant60 a greater proportion of social workers worked in both public and private practice than did psychologists or clinical psychologists, Table 7 below.
There were consistent views presented from psychology organisations and several state and territory health departments that any shift in workforce that had occurred was of practitioners moving towards a part time role, working across public and private sectors. One concerning aspect of this shift, however, was that the groups perceived to be moving towards a part time role may be the more senior clinicians. An APS survey undertaken in February 2008 of psychologist staff at Melbourne public hospitals indicated that, while only 12 per cent of P2 level psychologists were considering leaving the public sector, 41 per cent of P3 level psychologists were intending to reduce their hours of work for private practice in the next 12 months. A number of respondents raised similar issues as a matter of concern. Reasons for preparation to leave were relatively evenly distributed over increased opportunities and remuneration, greater flexibility, and autonomy.61 A number of psychologist bodies and State and Territory health departments suggested that incentives should be established to attract psychologists to remain in the public system, for example, by developing models that provide private practice rights for psychologists employed in the public sector.62
While, when considered as a whole, the shift to the private sector appears to be small at a national level, differences between jurisdictions were reported. Specifically, the smaller states reported that the Better Access initiative has had a significant impact on the public psychologist workforce, with practitioners either moving to private practice or reducing hours. One State health department reported that occupational therapists had been used to fill positions left vacant by psychologists. Another small state health department was concerned about the lower levels of experience and skill of the psychologist workforce remaining in the public sector following the migration of more senior staff. These two states represented a minority opinion.
A number of psychologists and psychologist groups raised concerns about the consequences of the perceived shift by experienced practitioners to the private sector on the capacity of the public sector to provide adequate supervision for trainee psychologists. It was highlighted that using the private sector as an alternative training environment raised a number of challenges, as many clients who attend private clinics are reluctant to allow students to either sit in on sessions or to accept therapy from a student. One group practice of psychologists suggested that, to address this challenge, an enhanced rebate could be provided by Medicare to clients who agree to receive therapy from a trainee or to have a student sit in on a session.Top of page
Concerns that the loss of experienced public sector clinical psychologists may result in diminished quality of care 63 64 were also highlighted in the literature. Difficulties associated with the loss of experienced clinical psychologists (particularly that associated with the Better Access initiative) were identified as including:65
- reduced availability of clinical psychology services to clients with complex and ongoing needs;
- loss of experienced supervisors at all professional levels, including students, provisionally registered psychologists, registered psychologists wishing to satisfy the requirements of professional bodies or psychologists employed in the public sector;
- difficulty in recruiting psychologists to new or vacant positions;
- specialist services being put at risk; and
- multi-disciplinary teams without psychologists
Though there was some variation in opinion between state and territory health departments and between psychologists as to the extent, if any of a shift in the psychologists to the private sector the overall deduction from the consultations is that there is some shift, the degree to which is unknown and varies across States and Territories and local areas.
In contrast, states, territories and the respective professional bodies held that view these been little if any impact from the Better Access initiative on the occupational therapy and social worker workforce. Occupational therapy, psychology and social work professional bodies acknowledged that the move towards private practice was relatively easier for psychologists, who as a profession had a strong history in the private sector. Conversely, fewer occupational therapists and social workers had experience in private practice, making the move away from the public domain relatively more challenging. The lower MBS rebate for occupational therapists, general psychologists and social workers also made the move from the public sector less rewarding than for clinical psychologists.
One occupational therapist working in private practice reported that he had obtained his Better Access initiative provider number but then found that the level of rebate meant that it was not viable to provide services to clients through the Better Access initiative. The provider continues to see only clients through DVA, workers compensation and other compensable patients, or on a full fee paying basis. A social worker also reported that it was "not worth the effort" to see clients through the Better Access initiative.
At the training level, there were a number of reports of changes in activity since the introduction of the Better Access initiative. One psychologist group interviewed reported that a university which, while not increasing the total number of psychologists in training, had increased the proportion of students in clinical psychology. In keeping with this trend, a health department from another jurisdiction reported that the number of registered clinical psychologists had also increased since the introduction of the Better Access initiative. One university reported decreasing the supervised training hours for students because of the difficulty in attracting clients. The Better Access initiative also appeared to have impacted on general psychology, with a state psychologist registration board reporting increasing numbers of trainee psychologists seeking to enter private practice.
Table 7: AHPs working in public and private practice
|Profession||Number||Percent||Number||Percent||Total number||Total percent|
Table 8: Impact of the Better Access initiative on public mental health workforce
|The Better Access initiative has reduced my organisations ability to recruit and retain:||Agree||Unsure||Disagree||No response|
4.6.3 Distribution of allied health professionalsThe capacity for AHPs to establish practices in response to market demand or personal preference was reported as driving a change in the geographic distribution of allied health professionals. This was identified as an issue of concern by a range of stakeholders during the consultation process. Changes in distribution were not equally apparent in all allied health professions.
As discussed in the section on service accessibility, there is a perceived maldistribution of the mental health workforce, with disproportionately higher numbers of AHPs available in metropolitan areas compared to rural and remote regions. A small number of GPs, psychologists, social workers and public mental health providers reported through small area consultations and teleconferences that since the introduction of the Better Access initiative there had been a further shift in location of providers, particularly psychologists, with a movement of practitioners away from rural and remote regions, to metropolitan areas. These stakeholders believed the main cause of this shift was that practitioners thought that they would be able to "cash in" on the client base made available through the Better Access initiative more effectively in urban areas. It was argued that, for practitioners to make the best of opportunities available through the Better Access initiative, they needed good ties with a referral base, i.e. general practitioners. They contended that GPs were more concentrated in metropolitan areas and, as such, they also should move to these regions. While stakeholders reported such movement in relation to psychologists, no similar trends were ascribed to either occupational therapists or social workers.
Not only did professional stakeholders report a move in a geographical sense, but there were some accounts of practitioners moving their worksites within their existing townships. State and Territory health departments and providers themselves described new models emerging since the introduction of the Better Access initiative, including psychologists starting group practices or psychologists and social workers attaching themselves to an existing GP practice.
4.6.4 Interaction with other related programsAs part of the consultation process, stakeholders and interviewees were asked to comment on the nature of the interaction between the Better Access initiative and existing mental health programs such as Better Outcomes. Most psychiatrists and GPs and some psychologists identified the Better Access initiative as complementary to existing initiatives, and as having a positive influence on the level of engagement of GPs in the range of mental health options available. Some negative influences were also identified, such as the lower numbers of GPs reportedly seeking and retaining Level Two mental health accreditation.66
Most GPs and Divisions reported ATAPS as being targeted to individuals unable to afford the gap payment usually required through the Better Access initiative and/or targeted to populations with particular needs, such as rural and remote communities, Indigenous communities or possibly even to promote access for older clients. A small number of Divisions and GPs also reported the use of ATAPS funds to provide additional therapy sessions to clients with complex care needs who had exhausted the 18 sessions provided through the Better Access initiative67.
A similar picture is presented by data analysed by the University of Melbourne in the evaluation of Better Outcomes. The results of this study indicated that the introduction of the Better Access initiative had not reduced demand for ATAPS, with the demand for services provided by both programs continuing to rise steadily.68 Several GP stakeholders and interviewees indicated a perceived flattening of demand for ATAPS following implementation of the Better Access initiative, but that demand for ATAPS was now increasing. The Better Access initiative has provided an incentive for most Divisions interviewed to rethink the targeting of ATAPS and how other services provided through Better Outcomes, MAHS and the Better Access initiative work together to improve access to mental health services.Top of page
Of note was the finding that the majority of sessions delivered through the Better Access initiative occurred in urban areas, while the provision of sessions through the ATAPS program have been relatively more equally distributed, indicating that these services may have a "relatively greater reach in rural areas".69
A number of GPs and GP representative groups noted that, since the introduction of the Better Access initiative, there had been greater engagement of GPs in issues relating to mental health. As a consequence, these GPs were undertaking greater scrutiny of the range of provisions available to administer mental health care. These stakeholders reported that there had been increased interest in how various components of the system could be used together to maximise the benefit for the patient; for example, the use of EPC items for case conferencing with other professionals (particularly as there was no funding for this activity under the Better Access initiative). The increased engagement and interest in other mental health initiatives was viewed as a positive consequence of the Better Access initiative.
It should be noted, however, that despite increased interest in the available programs, a number of GPs reported a lack of clarity relating to which programs should be used for which patients. The issue of awareness of how the MBS items are to be used was confusing for both GPs and AHPs, with both reporting difficulty in obtaining information and clarity from Medicare. A number of Level-2 trained GPs reported that, based on enquiries from colleagues, the mental health item numbers were the least understood. Both GPs and AHPs reported that understanding of how the MBS system operates was improving as the Better Access initiative matured. GPs noted that the experience with the Better Access initiative item numbers was no different to that when other new initiatives were implemented and requires ongoing information and training from the Divisions.
Not all of the interactions between mental health programs were viewed as positive. A number of GPs noted that, since the introduction of the Better Access initiative, fewer Level Two trained GPs had maintained their qualifications. It was suggested that these GPs were either simply referring patients on to AHPs under the Better Access initiative or, if providing focussed psychological strategies (FPS) themselves, were doing so using long consultation item numbers.
Another negative interaction between the two programs reported by one Division of General Practice related to the availability of AHPs in some areas. They reported that, in areas where there were shortages of AHPs (e.g. rural regions), the introduction of the Better Access initiative has led to increased competition for their services. Further, they reported that, since the Better Access initiative, fewer AHPs bulk billed and, given that ATAPS services were often targeted to those in most need, this had created an additional barrier to access.
One GP group identified that one effect of the Better Access initiative was that other initiatives implemented as part of the National Action Plan on Mental Health (e.g. the Mental Health Nurse Incentive Program or Personal Helpers and Mentors Program) have not been rolled out as far as initially expected. As a consequence, this stakeholder believed that clients who would have otherwise been supported through these other initiatives (i.e. those with more severe or complex illnesses) have instead relied more heavily on services available through Better Access. This has placed a degree of stress and expectation on the service provider through the Better Access initiative to do more than was originally intended.
59 This issue may warrant consideration in Component C of the evaluation: Analysis of allied mental health workforce supply and distribution.
60 Chi-squared 0.58, degrees of freedom = 3, P 0.90
61 Associate Professor John Gleeson, Associate Professor Warrick Brewer, "Implications of the introduction of the Better Access initiative for the public mental health psychology workforce" InPsych June 2008 Accessed 19 March 2009. Available on the Australian Psychological Society (APS) website (www.psychology.org.au).
62 Dr Rosemary Kelly, Dr Ruth Perkins "Clinical Psychologists, private practice and employment in the public health sector in Victoria" InPsych June 2008 Accessed 19 March 2009.
63 Kelly et al (2009)
64 Carey, Timothy A. Rickwood, Debra J. Baker, Keith. 'What does $27,650,523.80 worth of evidence look like?' Centre for Allied Psychology, University of Canberra, 2009.
65 Kelly et al (2009)
66 See section 4.3.1
67 Note: This may be an inappropriate use of Better Access and ATAPS and in breach of MBS rules.
68 Bassilios, B., Fletcher, J., Pirkis, J., King, K., Kohn, F., Blashki, G. Burgess, P. 2009. Evaluating the access to allied psychological services component of the better outcomes in mental health care program. University of Melbourne. Centre for Health Policy, Programs and Economics.
69 Bassilios et al (2009)