Psychological service provision in Australian mental health: Has Australia’s ‘Better Access’ Scheme had an Impact on Population Mental Health?

Professor Jorm’s (2018) study juxtaposes three disconnected data sets to infer an absence of association between increasing Better Access sessions and two indices of population mental health. His paper is important because it arrives during a review of Medicare Benefit Schedule (MBS) mental health items, the funding pipeline for Better Access.

Jorm’s analyses do not illuminate Better Access’ effectiveness or otherwise

Jorm’s Figure 2 and 3 show no systematic national improvement in high/very-high K10-measured distress or suicide rates between 2001 and 2015. Although these are only 2 of 24 indicators recognised in the 5th National Mental Health and Suicide Prevention Plan, they are definitely measures of interest. During the same time frame, Australian governments’ expenditure on mental health service provision rose from $2.97 billion (2001–2002) to $8.12 billion (2014–2015, Australian Institute of Health and Welfare). Consistent with data from Canada, the United States, United Kingdom and New Zealand, then, it appears that increased per capita service provision in Australia may not register in key population-level measures of mental health.

Although Better Access was a bold initiative, expanding rapidly during the window of Jorm’s analyses, it remains a small component of national expenditure on mental health. The total MBS funding of mental health accounted for only 9.5% of Commonwealth spending on mental health by 2012–2013 (National Mental Health Commission, 2014). Consequently, the lack of systematic improvement in the data of Jorm’s Figures 2 and 3 is arguably less informative about Better Access’ effectiveness than it is about other increasing draws on the mental health budget across that time.

While an association between Better Access rollout and improved population-level outcomes would have been exciting news (bucking international and national trends noted above), neither success nor failure on these distal measures can reasonably be attributed to this one player on the ever-expanding mental health team. Equally, Jorm’s speculations about the causes of an absence of improvement (the quality gap and imperfect targeting) should be directed across the board, not at the one scheme that happens to be tracked in his Figure 1.

Figure 1.

Three linked topics, little meaningful data.

What do we know about Better Access?

Politics is the art of the possible. Better Access was designed expeditiously around pre-existing social infrastructure, most obviously the Medicare system and registered health professions, and rolled out with no controlled testing or baseline data. No quality assurance data are collected through Better Access, and the scheme has been criticised for being output-blind. This limitation is, unfortunately, not unique to Better Access, ‘… There is currently no national data that allows assessment of the appropriateness, cost-effectiveness, safety, quality and accessibility of primary health care’ (Australian Institute of Health and Welfare, 2018: 2). Indeed, the National Mental Health Commission remains concerned about the paucity of useful real-time data across all levels of government.

Jorm’s study emerges from an important question about population-level impacts of government investments, but of course, a more proximal analysis of Better Access’ effectiveness would focus on the people who use it. The sole government-supported evaluation of Better Access (Pirkis et al., 2011) drew very positive conclusions: the scheme is effective and cost-effective; is reaching its target populations; and consumers report improvements on standardised measures, as well as satisfaction with the services received. This evaluation has been criticised for being based on a survey of providers, through whom consumers were recruited. Although signals in their data were consistent with findings in other data sets, the authors note that response rates (8% for psychologists and 3% for GPs, incalculable for consumers) limit the study’s conclusions.

In its current form, Better Access has some well-recognised limitations as a scheme for providing psychological interventions: there are no MBS items to incentivise team care arrangements or differential care across the severity spectrum; it does not require collection of data on treatment progress or outcome; the expensive skills of psychological assessment and case formulation are not exploited. Although Better Access has improved the ‘treatment gap’ (being primarily responsible for increases in treatment rates from 37.3% in 2006–2007 to 46.1% in 2009–2010), predicted usage biases towards metropolitan locales and higher socioeconomic status have emerged (Meadows et al., 2015). The Australian Psychological Society (mandated to defend Better Access) has argued to the MBS review that an expanded scheme could address these limitations, but this proposal does not align with emerging national strategic plans (below).

From the viewpoint of Australian psychology, there are concerns that Better Access (due to financial incentives for ‘clinical’ specialisation) has inadvertently skewed training and practice towards a medical model of mental health. For this author, it is remarkable that federally funded psychological practice in Australia operates largely through the legacy framework of diagnosis-treatment, when psychological science and public policy are embracing more contextualised and person-centric perspectives (think transdiagnostic and non-diagnostic interventions, prevention, resilience, thriving, recovery etc.).

The future of Better Access

The 2015 government response to the 2014 National Review of Mental Health Programmes and Services has significant implications for Better Access. Primary Health Networks will oversee provision of mental health services, and a stepped-care approach with a major technological component will be adopted, providing low-intensity interventions for mild/moderate problems and tailored packages of care to those with complex and severe mental illness. The details of this defensible approach are yet to be finalised, but they will tend to shrink the Better Access approach to the delivery of psychological services.

Conclusion

Better Access created a space for much-needed psychological services in the Australian mental health landscape. On my reading, Jorm’s data tell us nothing about Better Access, but they remind us again to be sceptical about mental health service planning: business as usual appears not to be working at the population level. The challenge for government now is to bring adequate science to designing, delivering and monitoring a new system in which holistic psychological services are optimally integrated with technologically delivered interventions and tailored to a stepped-care framework. It is hard to see how this can be achieved without significant investment in translational research, potentially supported by the Medical Research Future Fund.