Impact of Australia’s ‘Better Access’ scheme on population mental health: Response to commentaries

The Better Access scheme was introduced in Australia in late 2006 in order to expand the availability of psychological treatment under Medicare (Australia’s national universal health insurance scheme). The scheme resulted in a large increase in the provision of mental health services by general practitioners, clinical psychologists, other psychologists and allied health professionals, while there was little change in services by psychiatrists. The Australian government commissioned an evaluation of the scheme, which was published in 2011, but this was limited by the data available and was the subject of criticism. In order to help fill the evidence gap, I did a time series analysis of changes in the prevalence of psychological distress and in the suicide rate from 2001 to 2015, which straddled the introduction of Better Access in 2006 (Jorm, 2018). I concluded that there was no change in either indicator following the introduction of the scheme. In discussing these findings, I considered a number of possible reasons for the apparent lack of impact of Better Access on these population mental health indicators: (1) the dose of treatment has not been sufficient to produce population change, (2) services are not going to the people with the highest need, (3) the quality of the treatment provided is low and (4) provision of treatment does not address the major determinants of mental health and there needs to be more emphasis on prevention. Finally, I noted the limitations of the data and called for better data to be collected through a new National Survey of Mental Health and Wellbeing.

The journal has published a number of Commentaries on my article, some of which reinforce my conclusions, while others dispute the choice of outcomes I examined or my interpretations of the data. Below are my responses to some of the points raised.

Two of the commentators argued that there had in fact been a reduction in the prevalence of high-plus-very-high psychological distress following the introduction of Better Access, although they agreed that the prevalence of very high psychological distress had not changed (Lee and Frost, 2019; Mihalopoulos, 2019). There was indeed a small reduction in high-plus-very-high psychological distress in the 2011–2012 National Health Survey, but this trended up again in 2014–2015. However, since the publication of my analysis, data from the 2017–2018 National Health Survey have been released. I have added the new data in Figure 1. It can be seen that the small reduction in 2011–2012 was a temporary blip and that the prevalence rates have not improved since 2001.

Figure 1.

Prevalence (%) of psychological distress by year.

Some of the commentators questioned the appropriateness of using prevalence of psychological distress (as measured by the K10 questionnaire) and the suicide rate as outcomes for evaluating Better Access. The choice of outcomes was constrained by the availability of national data. However, the two outcomes examined have been identified in Australia’s Fifth National Mental Health and Suicide Prevention Plan. The Plan lists 24 nationally agreed indicators which can be used to track the progress of the Plan. These include ‘Proportion of adults reporting very high levels of psychological distress’ and ‘The number of suicides per 100 000 Australians’. Another indicator is ‘Population access to mental health care’, which is reflected in the data I presented on per capita use of Better Access services and has clearly increased. There are other indicators in the Plan that are potentially relevant to the evaluation of Better Access, including ‘Proportion of consumers and carers with positive experience of service’, ‘Change in mental health consumers’ clinical outcome’ and ‘Prevalence of mental illness’. However, there is presently no data on these that can be used to evaluate the impact of Better Access.

In relation to the K10, Carey and Bradford (2019) argue that this is a screening tool rather than a diagnostic measure and that people are referred to Better Access for a diagnosable condition. It is correct that the K10 is not diagnostic and is limited as an assessment of an individual. However, my use of the K10 was for monitoring the mental health of the population rather than for assessing individuals.

Carey and Bradford (2019) and Lee and Frost (2019) argue that Better Access is not a suicide prevention programme, so the suicide rate is an inappropriate indicator to use. I agree that the Australian government’s aims in setting up Better Access did not include suicide prevention. However, critics of the evaluation of Better Access commissioned by the Australian Government did argue that reduction in suicide is an outcome that should be examined. Furthermore, in outlining the rationale for a ‘systems approach’ to suicide prevention in Australia, Christensen (2016) stated that

Psychosocial treatment is one of the strongest tools shown to impact suicide rates and to reduce suicide risk, so psychologists who deliver therapy are central to the approach. Cognitive behaviour therapy and dialectic behaviour therapy are core, effective therapies for lowering suicide ideation in adults and young people.

Given this claim, it seems reasonable to ask whether large uptakes in psychological therapy have in fact reduced the suicide rate.

Mihalopoulos (2019) agrees that the K10 and suicide rates are important outcome measures but argues that there are other important outcomes that need to be examined, including possible reductions in costs in other aspects of the economy, quality-adjusted life years (QALYs) and social and economic participation. I agree that these broader outcomes need to be examined, but did not do so because the data do not exist. If Australia gets a new National Survey of Mental Health and Wellbeing, it is to be hoped that such broader outcomes will be covered.

Conclusion

I welcome the debate on the Better Access scheme that has stemmed from my article. Rigorous evaluation of programmes is necessary to ensure that they are benefitting the community as intended. Better Access is one of a number of reforms that have been rolled out nationally in Australia in recent decades in response to advocacy. This reform had a good rationale, namely, many people with diagnosable mental disorders were not getting treatment and there was abundant evidence from randomised controlled trials that psychological treatment can reduce symptoms. Modelling had shown that increasing the uptake of treatment should reduce the burden of mental disorders in the population. However, in practice, the expected gains have not been evident. The major lesson I take from the example of Better Access is that there needs to be greater caution in rolling out reforms nationally. These need to be rigorously tested in pilot trials before national dissemination to ensure that the benefits are present under real-life conditions. Too often, evaluations are carried out retrospectively after national roll-out has occurred and it is difficult to then reallocate the resources if the benefits are not as expected.