The importance of assessing ‘Better Access’ appropriately: Asking the right question is an essential first step

To the Editor

Jorm’s (2018) Better Access (BA) article highlights the urgent need for improved evaluation of publicly funded mental health interventions to ensure the prudent use of finite financial resources. Furthermore, Jorm notes that major determinants of mental health may limit treatment impact when such factors remain unaddressed. Importantly, however, the limitations of the data acknowledged by Jorm indicate not only the extent to which his conclusions should be questioned but also a crucial area that requires immediate attention. Improvements in the data collected are required to evaluate BA appropriately.

Perhaps the most concerning aspects of Jorm’s article are the question in the title and the measures used to answer it. Simply, it is inappropriate to ask if BA has had an impact on population health because it is not a population health intervention and K10 scores do not indicate a mental health diagnosis. By implication, we should assess the entire Medicare Benefits Schedule against the Brief Physical Health Questionnaire (Schat et al., 2005) and remove all items that have not had an impact on population health.

BA is a clinical service and must be evaluated as such. Using K10 data, Jorm (2018) claims that ‘large increases in treatment do not appear to reduce the prevalence of mental disorders’ (p. 5). The K10, however, is a general screening tool. People are referred to BA for a diagnosable mental health condition, not for high K10 scores. There is no way of knowing from Jorm’s data the extent to which the population experiencing high K10 scores overlap with the population who participate in BA. In the 2007 Australian Survey of Mental Health and Wellbeing, for example, 11% of the population endorsed symptoms of a mental health disorder but did not endorse any need for mental health care (Meadows and Burgess, 2009).

Nor was BA ever intended to be a suicide prevention program. Using a lack of decline in suicide rates to suggest that BA is ineffective, therefore, is a specious argument. Suicide is a tragic societal phenomenon that requires effective solutions generated by cooperation, rather than competition, among important potential contributors.

Jorm’s (2018) conclusions are indefensible given the data and the methods used in the context of the initiative being considered. It is unquestionably important to evaluate clinical services to ensure they are appropriate, effective and efficient. Such evaluation, however, requires clarity about both the questions being asked and the purposes for asking them.