Australia's Better Access Initiative: Still Awaiting Serious Evaluation?

Abstract

There are few more heated issues in Australian mental health than determining the value of the Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule (Better Access) initiative. In our view, the need for genuine, well-designed and ongoing evaluation of its impacts has never been seriously addressed [1]. Sadly, the publication of aspects of the extremely limited government-purchased ‘patient outcomes’ evaluation [2] adds very little to our knowledge base.

An historical and primary care policy perspective

Enhancing affordable and equitable access to relevant psychological therapies has long been at the heart of reforming primary care-based mental health services in Australia [3–5]. In the late 1990s, the SPHERE Project (based on an evaluation of 46 515 ambulatory patients attending 386 general practitioners) demonstrated the extent to which those attending general practice in Australia with significant mental disorders were unable to access skilled psychological interventions [6–8]. Over the same period there was community and professional concern at the rapid expansion in pharmaceutical treatments for anxiety and depression in primary care settings [9].

In July 2001, after an intensive campaign led by beyondblue: the national depression initiative, acting in partnership with mental health consumers and the relevant medical and psychological professional groups [10,11], the Howard Government introduced the landmark Better Outcomes in Mental Health Care (BOiMHC) programme [12]. For the first-time, specialized psychological services were supported financially through our standard general practice systems [13,14]. This was a major breakthrough for mental health and a fundamental re-orientation of Medicare Australia towards direct support for skilled professionals, including psychologists and other health workers, to deliver evidence-based interventions.

Though funding was limited (AU$$120 million over four years), the design and payment elements rewarded coordinated and collaborative care by general practitioners and other skilled professionals. The provision of ongoing collaborative care, and not simply cross-referrals between health professionals, has been highlighted by the Institute of Medicine of the National Academies (IOM) as one of the most important drivers of enhanced quality in mental health practice [15]. Distributing payments through Divisions of General Practice, rather than paying directly to largely urban-based providers, also helped to overcome both geographical and socio-economic barriers to care.

In April 2006, in response to community pressure to expand access, the Howard Government committed $$538 million over five years and replaced the BOiMHC with the new Better Access initiative [16]. This change in focus was largely in response to many of the professional groups who lobbied hard for a return to traditional fee-for-service payments and extension of the scheme to non-medical providers with limited clinical training or experience. Better Access was the largest single part of the Australian Government's contribution to the 2006–2011 Council of Australian Governments' (COAG) National Action Plan on Mental Health, and recognised the value the community placed on moving beyond medical and more institutionally based forms of mental health care [3,17].

As a consequence of those political decisions, Better Access moved the goalposts away from provision of quality services (with its linked focus on enhancing outcomes) to promoting entry to any service (with the focus on access). In opposition, the Australian Labor Party countered by promising a return to a more equitable balance of services, driven by population need rather than professional convenience or incomes. Subsequently, the Rudd Government released the first data on the impacts of Better Access, and analyses by the Mental Health Council of Australia (MHCA) demonstrated the predicted inequities (which are intrinsic to the Medicare model) related to socio-economic status and geography [18,19]. Repeated examination of subsequent data by the MHCA, and the recent Summative Evaluation [20], have confirmed those same trends (Table 1).

Table 1.

Utilisation of Better Access MBS item numbers

	Prevalence of any 12-month mental disorder (%) [21]	Better Access MBS item number
	Prevalence of any 12-month mental disorder (%) [21]	2710	2713	80010	80110
Item description [22]		Preparation of a ‘GP Mental Health Treatment Plan’	General practitioner mental health consultation lasting at least 20 minutes	Psychological assessment and therapy for a mental disorder by a clinical psychologist lasting at least 50 minutes (up to 12 planned sessions per year)	Focused psychological strategies for an assessed mental disorder by a registered psychologist lasting at least 50 minutes (up to 12 planned sessions per year)
Total occasions of service to May 2011 [23]		2 456 756	3 172 020	3 844 131	6 554 155
Total MBS benefit paid to May 2011 [23]		AU$$384 197 207	AU$$220 373 258	AU$$458 371 433	AU$$539 648 497
Provision of services to younger Australians aged 15 to 24 years (n, % of total services) [23]
All	26.4%	407 277 (16.6%)	421 344 (13.3%)	573 316 (14.9%)	906 129 (13.8%)
Female	30.1%	270 360 (11.0%)	283 283 (8.9%)	392 021 (10.2%)	619 041 (9.4%)
Male	22.8%	136 917 (5.6%)	138 061 (4.4%)	181 295 (4.7%)	287 088 (4.4%)
Provision of services to Australians aged 35 to 44 years (n, % of total services) [23]
All	23.3%	547 829 (22.3%)	743 506 (23.4%)	892 906 (23.2%)	1 560 726 (23.8%)
Female	25.9%	354 945 (14.4%)	472 337 (14.9%)	605 030 (15.7%)	1 060 336 (16.2%)
Male	20.8%	192 884 (7.9%)	271 169 (8.5%)	287 876 (7.5%)	500 390 (7.6%)

The 2011 budget reforms

Modelling of the further growth of Better Access for the 2011 Budget process predicted that the initiative was expected to cost at least AU$$4 billion over the next five years [24]. Consequently, the Gillard Government has now begun to revise the initiative. This has occurred largely in the policy and fiscal context of developing a 10-year road map to guide the next round of broader mental health services reform. The 2011 Budget introduced limited reforms, focused mainly on reducing remuneration for the planning role of general practitioners but also introducing minor reductions in the number of psychological services by non-medical practitioners [25].

Neil Cole, Consumer Advocate and Member of the National Advisory Council on Mental Health (NACMH; 2008–2011):

Better Access is simply middle class welfare masquerading as a mental health scheme. The cost is so high that other more important concerns are not being addressed. If one third of the money spent on Better Access went to much needed public housing, most of the homelessness experienced by people with mental illness would be solved. [Cole N: personal communication]

The challenge now for the Gillard Government is to achieve an appropriate balance between population-based initiatives, health services reform (particularly integration of primary care and more specialised services), increased support for housing, employment, education and other social services for those with mental illness and systematic evaluation. To achieve that balance, it will rely increasingly on evidence from the field to guide future choices.

Questions that still require answers

…it was beyond the scope of the evaluation to consider whether Better Access is an appropriate policy initiative. [20, p.45]

As we have detailed elsewhere [1], the key questions surrounding Better Access relate specifically to the extent to which it represents a major improvement over prior systems (e.g. pre-2001 general practitioner-delivered care or BOiMHC 2001–2006). The somewhat newer question is whether it is superior to alternative systems, particularly those that can be delivered by Internet-based technologies [26,27]. Further, even if Better Access does indeed have better service delivery characteristics than either previous or alternative models, are those benefits being achieved in a cost-effective manner, and what are the work-force implications of rapidly expanding this mode of service delivery? In agreement with Jorm [28], the next level of questions relate not just to health service effectiveness but wider population-health impacts (e.g. reduction in suicide, self-harm, income support, non-participation in education and employment).

However, Jorm [28] distorts the public debate about the adequacy of the evaluation by framing the question as ‘do the evaluation data support the critics?’ (p.1). By contrast with Allen & Jackson [29], he fails to ask whether we actually have any substantive data on which to continue to promote such an expensive and intrinsically-flawed service delivery model? That is the fundamental health services question that has preoccupied the major critics – who include a broad group of consumers, medical and psychological health professionals and health commentators. For Jorm's [28] more limited set of questions, in our view, either the available evidence demonstrates clearly the inadequacies of Better Access or the questions simply cannot be answered by the sub-standard evaluation or any other available data sources (see Table 2).

Table 2.

The Better Access evaluation – Jorm's [28] questions that still deserve answers

Jorm-identified criticisms	Hickie, Rosenberg & Davenport commentary	Jorm conclusion
1. ‘It has produced a big blow-out in cost’ [28, p.700]	Proven Not only is the current cost quickly headed to over three times the original predictions in four years [1,25], despite recent budget changes it will continue to grow rapidly [30] The cost blow-out has had an adverse impact on the Australian Government's willingness to develop other complementary or alternative mental health programmes [24] If Better Access is not substantially reformed (particularly with replacement of simple interventions like CBT with technology-enhanced alternatives) there will be a substantive limit of the development of other high priority programmes	Proven But perhaps the expenditure is justifiedThe cost per episode is acceptable
2. ‘It hits patients with out-of-pocket expenses’ [28, p.700]	Proven As bulk-billing rates for these new psychological services (34.6% of psychological therapy and 42.6% for focused psychological strategies [20]) are so much lower than other general practice-based services (92.7% [20]) we are in danger of reinforcing the traditional cost barriers to psychological care The true bulk-billing rates reported from the actual Medicare data are much lower than those reported by surveys of members conducted by the psychological professions [e.g. 31,32] The cost is not small. As the average co-payment per service is $$35 and as the modal number of treatments is five (in addition to any co-payment to the general practitioner), the cost to the patient per episode is in the order of AU$$200 [20]. The range for such services, however, has been reported to be $$0–$$480, based on six sessions per person [20] and the gap in payment recommended by relevant professional psychological associations	Proven But perhaps this helps to curtail the growth in the programme and helps to keep government (as distinct from patient) expenses lower
3a. ‘It has failed to deliver equitable access in rural… [and remote]… areas’ [28, p.701]	Proven Major evidence in Australia from a range of sources about lack of access to mental health care and specifically psychological care from the Medicare analyses and other data sources [33] For those in most remote areas access to services may be as low as one-sixth of that in city areas [34]	Proven But since everyone gets some services this may be justified
3b. ‘It has failed to deliver equitable access in… socio-economically disadvantaged areas’ [28, p.701]	Proven Major evidence of reverse economic gradient, with 1 385 364 services (generating fees of $$176 843 753) for those with greatest socio-economic resources as compared with 547 063 (generating fees of AU$$58 516 903) in those with the greatest socio-economic disadvantage [20] Clearly providers are catering preferentially to those with the greatest capacity to pay additional out-of-pocket expenses. This appears to reflect both a desire to see more patients from the highest income groups as well as provide more sessions per patient (where there are also the lowest bulk-billing rates and the highest co-payment costs)	Proven But perhaps the disparity is acceptable
4. ‘It discriminates by age and gender’	Proven The 2007 National Survey of Mental Health and Wellbeing data for those aged 16 to 24 years, clearly demonstrate the highest prevalence rates for all common disorders (22.8% for men, 30.1% for women [35]) and yet the lowest usage of services (13.2% for men, 31.2% for women [36]) For gender the 2007 data clearly indicated that the much lower rate of service use by men (27.5% versus 40.7% [36]) is not explained by much lower prevalence rates The much lower proportions of Better Access usage [20] for men (1 643 579 services versus 3 020 402 for women) and for younger individuals (655 158 for those aged 15–24 years versus 1 085 370 for those aged 35–44 years) cannot be attributed to prevalence differences The data are also clear for all services (2009: 57.3/1000 for 15 to 24 year olds versus 80.0/1000 for 35 to 44 year olds [20]), despite the highest prevalence rates in young people	Not conclusive May be acceptable if reflective of differences in prevalence rates for anxiety and depressionIn some instances the elderly do badly as well
5. ‘It provides services to the worried well rather than to those with serious mental disorders’ [28, p.701]	Inconclusive data Contrary to the assertion by Pirkis et al. [2] our critique of the evaluation never raised this issue The small and self-selective data of Pirkis et al. [2] are insufficient to address the question seriously The alternative population-based data source suggested by Jorm [28] is very small (175 subjects) and again insufficient to address the question The more substantive issue is the relative distribution of services relative to severity of illness and disability Serious comparative and longitudinal studies within the key health service settings, with sufficient power to address the issue, are still urgently required	Not consistent with available data Though the data are very limited
6. ‘It funds services for those who were already receiving them’ [28, p.702]	Highly likely that care was already being provided to at least 30–40% of these patients Our critique has simply highlighted the reality that many psychological services existed pre-Better Access (and BOiMHC) and that one of the immediate effects would be that those already receiving (often longer-term) care from psychologists would now receive Medicare benefits, and that the actual fee per treatment charged may well rise (due to part of the fee being met by Medicare) The Summative Evaluation data [20] provide some support with estimates by the different professional groups ranging from 38% to 56% of subjects reporting previous care The summative evaluation [20] notes that alternative data from the BEACH studies of general practice [37] do NOT demonstrate any increase in the rate of active management of cases of anxiety, depression or substance misuse The data with regard to the number of episodes provided to those in the highest socio-economic quintile [20], also indirectly support our assumptions that those who could afford to pay were previously receiving care but now transferring part of the cost to Medicare Further, the decline in new cases seen (68% in 2008 to 57% in 2009 [25]) and the very small rise in percentage of individuals with disorders estimated to receive care (2008–2009 versus 2009–2010 increasing from only 45.0% to 46.1% [20]) are also consistent with these views Sadly, the issue has actually been very poorly evaluated directly, relying on provider-entered data from a small sample of highly selected patients or a very small population-based sample who were not asked directly [2]	Not consistent with available data Though the data are very limited
7. ‘It devalues the specialised skills of clinical psychologists relative to other psychologists’ [28, p.702]	Never assessed Jorm [28] puts the argument that the ‘outcome’ data are sufficient to put aside this critique The comparisons of outcomes of clinical psychologists, general psychologists and general practitioners are based on self-selected uncontrolled data sources [2,20,28] All of those associated with the data warn against any direct comparisons of this type, or using this data for this purpose A range of studies related to patient complexity, relative outcomes, cost-effectiveness, identification of comorbidity, contribution to collaborative care, and capacity to engage and better manage more complex cases are urgently required	Not proven Clinical psychology doesn't deliver better results
8. ‘It has failed to encourage evidence-based psychological treatments’ [28, p.702]	Not known The two data sources preferred by Jorm [28] provide completely conflicting results The relevant detailed studies have not been done to address this issue Provider reporting is very unsatisfactory and self-serving Technologically based methods for CBT delivery, that have greater treatment fidelity, availability and flexibility, are now available [e.g. 38,39]	Not relevant Outcomes don't seem to depend on treatment
9. ‘It has produced a drift of psychologists from the public to the private sector’ [28, p.702]	Not known Available evidence [20] is very limited and very indirect Needs to be addressed directly and has major long-term workforce and access implications	Not proven
10. ‘It has failed to develop collaborative care’ [28, p.702]	Proven Major independent groups, such as the IOM, describe simple referral practices as the least collaborative form of practice between professionals [15] Jorm [28] seems unaware of previous schemes or alternative models that specifically fund more collaborative systems of care BOiMHC to Better Access represents a clear deterioration in the quality of collaborative care services	Not proven

The inadequate evaluation

John Mendoza, former Chair of the NACMH (2008–2010):

In my role as Chair of the NACMH, I clearly indicated to the Minister that I did not believe the evaluation, routine data collection and reporting systems would sufficiently contribute to the evidence-base, or to enable the Government to be confident that each of the Better Access items are sufficiently effective when compared to other treatment and therapy options. It will only establish that Better Access assisted those who volunteered through their provider to participate in the evaluation – a clearly biased patient and provider sample. [Mendoza J: personal communication]

By contrast with Mendoza's warning, Jorm [28] in his remarkably sanguine review of the evaluation, suggests that ‘we have to make the most of what evidence is available, however imperfect’ (p.2). The triad of defences that ‘The new services have proved very popular’ [28, p.2], the limited scope of the evaluation, and that some population-based data are not in disagreement with the evaluation, are the style of responses we normally expect from government rather than the academic sector.

In regard to the scope of the evaluation, of the 2429 practitioners approached, a mere 5% (or 129 practitioners) self-selected just 883 patients (an average of only seven patients per practitioner) from an initiative that provided services to 1 130 384 individuals in 2009 alone and a total of 2 016 495 individuals over three years. In terms of other clinical outcomes data, closer inspection showed it to be extremely limited [40,41, Hitch D: personal communication]. Furthermore, all patient-level clinical data were entered by providers themselves, including prior use of mental health care [2].

The Summative Evaluation of Better Access [20], and the Jorm editorial [28], place considerable weight on implied support from a separate analysis that utilized data from the 2007 National Survey of Mental Health and Wellbeing [42]. Importantly, that survey relied on what the authors themselves describe as ‘unverified, retrospective self-report’ [42, p.106]. Further, the authors conducted very detailed sub-analyses (for demographic, prevalence and type of disorder and patterns of health service use) on only 175 individuals. They concluded ‘the relatively small numbers available for some comparisons…may have limited the power…to detect some differences in sociodemographic profile and treatments received’ [42, p.106]. Of interest, the patients reported receiving psycho-education and non-specific counselling as distinct from the (provider-reported) provision of cognitive behavioural therapy (CBT) emphasized in the report by Pirkis et al. [2].

Finally, Pirkis et al. [2] acknowledged that they did not address the possibility of inequity of service access. However, in terms of the number of Medicare Benefits Schedule (MBS)-subsidised Better Access services received in 2009 [20], there is clear socio-economic inequity. The highest quintile/least disadvantaged part of the treated group received 1 385 364 services compared with 547 063 services in the lowest quintile/most disadvantaged group. This socio-economic inequity simply continues the pattern previously reported for access to antidepressant therapies [43]. More recent analyses of the National Mental Health and Wellbeing Survey, suggest that socio-economic discrepancies may actually have increased between 1997 and 2007 [Meadows G: personal communication].

Evaluation of new service systems and Internet-based models

Helen Christensen, Professor and Director, of the Centre for Mental Health Research, College of Medicine, Biology and Environment, the Australian National University:

Internet applications have a place in the treatment of people with anxiety and depression. They can be tools to promote self-help, or to guide self-help, and they offer effective treatment to people in the community without access to help, with a preference for these forms of treatment and who cannot travel for psychological treatment. Moreover, they release clinical psychologists and others from the behavioural teaching required to implement CBT, to focus more on individuals with complex, severe, and potentially life threatening conditions, who need sustained and challenging interventions.' [Christensen H: personal communication]

One of the major, perhaps unintended, consequences of the focus on enhancing the quality of services for those already in care, has been much less emphasis on promoting early intervention (particularly in those aged 16 to 25 years) or developing alternative delivery models. The early successes of alternative primary care pathways for young people (largely delivered through the headspace, Australia's National Youth Mental Health Foundation network of services [44,45]) and the increasing use of the Internet to deliver structured psychological treatments [46–48] have now created other major competitors to Better Access.

Both these new pathways engage key population groups that do not use traditional primary care and appear to deliver services in a much more cost-effective manner. Specifically, the relative cost advantages of e-health services can hardly be ignored. When comparing face-to-face group CBT with Internet CBT for social phobia, Andrews et al. [39] found both to be equally effective, but reported that Internet therapy required less clinician time and was 13 times more cost-effective. Contrary to clinician beliefs, Andrews et al. [39] also reports that over 95% of people attending the St Vincent's Public Hospital (Sydney) Anxiety and Depression Clinic opt for Internet CBT over face-to-face CBT. He proposes that no travel costs, the ability to redo lessons and the convenience of doing the lessons at any time were the principal reasons that underpinned this strong patient preference.

Other independent studies have addressed these issues. For example, Mihalopoulos and colleagues [49] assessed the incremental cost-effectiveness of panic disorder supplemented by a psychologist or general practitioner compared to usual care, finding savings of AU$$4300 per disability-adjusted life year (DALY). More recently, Warmerdam et al. [50] reported positive results for the relative cost utility and cost effectiveness of Internet CBT for depression. Spek [51] compared Internet (€323 per person) with group treatment (€1830), with a saving of €151.50 for significant change associated with Internet compared to group treatment. The clinical effects were the same for the Internet and group interventions.

MoodGYM, a preventative e-health application developed by Christensen and colleagues [38], delivers a minimum effective dose (two or more sessions) to approximately 11 048 users annually, at a cost of $$5 per person or $$72 for each DALY averted. In the broader set of trials reviewed by her Australian National University group, Internet-based interventions are associated with effect sizes of 1.0–1.2 in clinical samples, and that these effects are similar whether the individual is ‘tracked’ by a counsellor or received automated email messages. In our own work with general practice in Australia, we have demonstrated the feasibility and efficacy of usual general practitioner care supplemented by Internet-based CBT, with no need to refer to another provider [52].

As we have just seen with the 2011 Budget changes to Better Access, the cost characteristics of face-to-face services inevitably mean that limits need to be introduced quickly to any programme that responds to community need. To May 2011, over six million ‘CBT-like’ services had been delivered by registered psychologists at a cost of more than $$500 million (to government), or approximately $$82 per service or $$410 per treatment delivered (average of five sessions, see Table 1). There is an additional $$150 per person on average of direct cost to the patient. The relative value of MoodGYM in full operation (at $$5 per person treated to government and free to the patient) is clear. Additionally, it is not limited by workforce capacity constraints, training requirements, work practices or geographical distribution of providers.

Gavin Andrews, Professor of Psychiatry at the University of New South Wales and St Vincent's Hospital, Sydney Australia:

Only the medical colleges and the other professional associations, and the Federal Department of Health and Ageing, still think that patients want to see the doctor or the psychologist. Actually they just want to get better as quickly and cheaply as possible. [Andrews G: personal communication]

Are more people in need receiving care?

One of the more important propositions arising from work derived from the Summative Evaluation [20] is that access to care for those with a mental disorder has increased from 37.4% to 46.1% (during the period 2006–2010) as a consequence of the introduction of Better Access. The data, however, do indicate that in the 12-month period to 2009–2010 there was just a 1.1% increase despite this being the highest year of utilisation of Better Access [20].

The data analyses also assume that there has been no change in the rate of overlap in use of Commonwealth and state-funded services since the introduction of the initiative. One of these assumptions was no change in the overlap of patient populations between state/ territory and Commonwealth mental health services. However, if one assumes a more realistic increase in overlap between these patient populations (e.g. range: 1% to 3%, average: 2%), the estimate of the increase in service use may be as modest as 37.4% to 44.1%.

Is this the best way to purchase care?

On the most optimistic of interpretations, for a price tag of $$1.5 billion, the Government purchased a maldistributed (by socio-economic, demographic and geographical parameters) 8.7% (range 4.2% to 13.4%) increase in active treatment of primary care-based mental disorders. That is, most people with disorders are still not receiving care. It is also important to note that neither BOiMHC or Better Access were designed to meet the genuine needs of those with more severe, complex or ongoing disorders. While the 2011 Budget has for the first time placed much greater emphasis on developing new care systems for those with severe or persisting illness [30], those who would benefit from prolonged psychological therapy (e.g. borderline personality disorders, eating disorders, chronic depression, complex medical and psychological problems, severe anxiety with substance misuse) are still likely to receive no or very inadequate care [53]. The reality is that no level of government has ever accepted responsibility for provision of effective care packages for these groups.

As we move into the next 10-year plan, the lessons from the last decade of primary care-based reform are clear enough: those who genuinely wish to promote better access to short or longer-term psychological care (particularly that which promotes earlier intervention, more collaborative care, greater equity, minimisation of financial burden, support for more skilled practitioners who can deal with greater complexity, greater flexibility in delivery modes and greater cost-effectiveness), will be in search of better policy options than the current Better Access initiative.

John Mendoza, former Chair of the NACMH (2008–2010):

When chairing the NACMH, there was a consensus (but not unanimous) view in the wider mental health sector that Better Access was largely a provider or supply-driven system. While there was a view that the huge demand and uptake of the services by patients was evidence that Better Access was a successful initiative, it was not the broader view! The majority view was that the initiative in its current design was unsustainable and importantly, not the best buy when compared with collaborative care models. [Mendoza J: personal communication]

Acknowledgements

The quotes in this editorial are provided with the full knowledge and consent of those referenced.

Declaration of interest; IBH was the Chief Executive Officer (CEO) of beyondblue: the national depression initiative during the development and early implementation of the 2001–03 BOiMHC program. He also led the development of the earlier SPHERE: a national depression project, which was supported by the NHMRC, the National Mental Health Strategy and as outlined in the original publications (Med J Aust 2001; 175 Suppl Jul 16) a series of pharmaceutical companies, most notably Bristol-Myers Squibb and subsequently Pfizer Australia. SR was Deputy CEO of the Mental Health Council of Australia (MHCA) during the period 2005–09. IBH, SR and TAD were part of a consortium led by the Australian Institute of Health and Welfare, which included the MHCA and Brain & Mind Research Institute that tendered unsuccessfully for the evaluation of the Better Access initiative.

References

Rosenberg

Hickie

. How to tackle a giant: creating a genuine evaluation of the Better Access program. Australas Psychiatry 2010; 18:496–502.

Pirkis

Ftanou

Williamson

. An evaluation of Australia's Better Access initiative. Aust N Z J Psychiatry 2011; 45:726–739.

Hickie

Groom

McGorry

Davenport

Luscombe

. Australian mental health reform: time for real outcomes. Med J Aust 2005; 182:401–406.

Hickie

. National health reform: it's time for a decision. Med J Aust 2009; 191:382–383.

Rosenberg

Hickie

Mendoza

. National mental health reform: less talk, more action. Med J Aust 2009; 190:193–195.

Hickie

Davenport

Hadzi-Pavlovic

. Development of a simple screening tool for common mental disorders in general practice. Med J Aust 2001; 175:S10–S17.

Hickie

Davenport

Scott

Hadzi-Pavlovic

Naismith

Koschera

. Unmet need for recognition of common mental disorders in Australian general practice. Med J Aust 2001; 175: S18–S24.

Hickie

Davenport

Naismith

Scott

Hadzi-Pavlovic

Koschera

. Treatment of common mental disorders in Australian general practice. Med J Aust 2001; 175:S25–S30.

Mant

Rendle

Hall

. Making new choices about antidepressants in Australia: the long view 1975–2002. Med J Aust 2004; 181:S21–S24.

10.

Hickie

Groom

. Surveying perceptions of the progress of national mental health reform. Australas Psychiatry 2004; 12: 123–125.

11.

Hickie

. ‘Not in your lifetime, Ian!’ Med J Aust 2009; 191: 638–642.

12.

Mental Health and Special Programs Branch, Commonwealth Department of Health and Ageing. National Mental Health Report 2002: Seventh Report. Changes in Australia's mental health services under the first two years of the Second National Mental Health Plan 1998–2000. Canberra: Commonwealth of Australia, 2002. [Cited 15 July 2011] Available from URL: http://www.health.gov.au/internet/main/publishing.nsf/content/mental-pubs-n-report02

13.

Hickie

Pirkis

Blashki

Groom

Davenport

. General practitioners' response to depression and anxiety in the Australian community: a preliminary analysis. Med J Aust 2004; 181:S15–S20.

14.

Better Outcomes in Mental Health Care. Australian Government: Department of Health and Ageing. [Cited 15 July 2011] Available from URL: http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-boimhc

15.

Institute of Medicine of the National Academies. Improving the quality of health care for mental and substance-use conditions: Quality Chasm series. Washington, DC: National Academies Press, 2006.

16.

Howard

. Better Mental Health Services for Australia, Media Release, 5 April 2006. [Cited 15 July 2011] Available from URL: http://pandora.nla.gov.au/pan/10052/20061221-0000/www.pm.gov.au/news/media_releases/media_Release1858.html

17.

MHCA. Not for service: experiences of injustice and despair in mental health care in Australia. Canberra: Mental Health Council of Australia, 2005. [Cited 15 July 2011] Available from URL: http://www.hreoc.gov.au/disability_rights/notforservice/summary/index.html

18.

Crosbie

Rosenberg

. Mental health and the new Medicare services: an analysis of the first six months. Canberra: Mental Health Council of Australia, 2007. [Cited 15 July 2011] Available from URL: http://www.mhca.org.au/documents/publications/COAG%20MBS%201st%20Report.pdf

19.

Crosbie

Rosenberg

. Mental health and the new Medicare services: second report. Canberra: Mental Health Council of Australia, 2008. [Cited 15 July 2011] Available from URL: http://www.mhca.org.au/documents/publications/COAG%20MBS%202nd%20Report%20Sept%202008.pdf

20.

Pirkis

Harris

Hall

Ftanou

. Evaluation of the Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule Initiative: summative evaluation – final report. Melbourne: University of Melbourne, 2011. [Cited 15 July 2011] Available from URL: http://www.health.gov.au/internet/main/publishing.nsf/content/mental-ba-eval

21.

Australian Bureau of Statistics (ABS). National Survey of Mental Health and Wellbeing: summary of results, 2007 – Data cubes. Canberra: ABS, 2007. [Cited 15 July 2011] Available from URL: http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4326.02007?OpenDocument

22.

MBS online: Medicare Benefits Schedule. Australian Government: Department of Health and Ageing. [Cited 15 July 2011] Available from URL: http://www.mbsonline.gov.au

23.

Medicare Australia. Statistics – item reports. Australian Government: Medicare Australia. [Cited 15 July 2011] Available from URL: https://www.medicareaustralia.gov.au/statistics/mbs_item.shtml

24.

Roxon

Macklin

Butler

. National mental health reform – ministerial statement. Canberra: CanPrint Communications, 2011. [Cited 15 July 2011] Available from URL: http://www.budget.gov.au/2011–l12/content/ministerial_statements/html/index.htm

25.

Rosenberg

Hickie

. Were the budgetary reforms to the Better Access to Mental Health Care initiative appropriate? - No. Med J Aust 2011; 194:595.

26.

Christensen

Hickie

. E-mental health: a new era in delivery of mental health services. Med J Aust 2010a; 192:S2–S3.

27.

Christensen

Hickie

. Using e-health applications to deliver new mental health services. Med J Aust 2010b; 192:S53–S56.

28.

Jorm

. Australia's Better Access initiative: do the evaluation data support the critics? Aust N Z J Psychiatry 2011; 45:700–704.

29.

Allen

Jackson

. What kind of evidence do we need for evidence-based mental health policy? The case of the Better Access initiative. Aust N Z J Psychiatry 2011; 45:696–699.

30.

Australian Government. Budget 2011–12. [Cited 15 July 2011] Available from URL: http://www.budget.gov.au

31.

Whiteford

Doessel

Sheridan

. Uptake of Medicare Benefits Schedule items by psychologists and other mental health practitioners. Clinical Psychologist 2008; 12:50–56.

32.

Bassilios

Pirkis

Fletcher

. The complementarity of two Australian primary mental health care initiatives. Aust N Z J Psychiatry 2010; 44:997–1004.

33.

Australian Government Department of Health and Ageing. Mental Health Service in Rural and Remote Areas program evaluation (version 1.3). Final evaluation report, 2011. [Cited 15 July 2011] Available from URL: http://www.health.gov.au/internet/mentalhealth/publishing.nsf/Content/9958DC4DF5382204CA2577B5007B7767/$File/MHSRRA%20Final%20Evaluation%20Report%20190111.pdf

34.

Mental Health and Chronic Disease Section, Medical Benefits Division. Post-implementation review of the Better Access to Psychiatrists, Psychologists and General Practitioners through the MBS Initiative: MBS items. Canberra: Australian Government Department of Health and Ageing, 2009.

35.

Australian Bureau of Statistics (ABS). National Survey of Mental Health and Wellbeing: summary of results, 2007. Canberra: ABS, 2007. [Cited 15 July 2011] Available from URL: http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/4326.02007?OpenDocument

36.

Burgess

Pirkis

Slade

Johnston

Meadows

Gunn

. Service use for mental health problems: findings from the 2007 National Survey of Mental Health and Wellbeing. Aust N Z J Psychiatry 2009; 43:615–623.

37.

Britt

Miller

Charles

. General Practice Activity in Australia 2008–2009 (General Practice Series No. 25, Cat. No. GEP 25). Sydney: University of Sydney and the Australian Institute of Health and Welfare, 2010.

38.

Christensen

Griffiths

Korten

. Web-based cognitive behavior therapy: analysis of site usage and changes in depression and anxiety scores. J Med Internet Res 2002; 4:e3.

39.

Andrews

Davis

Titov

. Effectiveness randomized controlled trial of face to face versus Internet cognitive behaviour therapy for social phobia. Aust N Z J Psychiatry 2011; 45:337–340.

40.

Mackey

Capitanio

Erikson

. Treatment outcome benchmarking data for private practice settings. 33rd National Conference of the Australian Association of Cognitive and Behavioural Therapy, Melbourne, 2010.

41.

Mackey

Capitanio

Erikson

. Treatment outcome benchmarking data for private practice settings. 11th International Mental Health Conference of the Australia and New Zealand Mental Health Association, Surfers Paradise, 2010.

42.

Harris

Burgess

Pirkis

Slade

Whiteford

. Policy initiative to improve access to psychological services for people with affective and anxiety disorders: population-level analysis. Br J Psychiatry 2011; 198:99–108.

43.

Page

Swannell

Martin

Hollingworth

Hickie

Hall

. Sociodemographic correlates of antidepressant utilisation in Australia. Med J Aust 2009; 190:479–483.

44.

Scott

Naismith

Whitwell

Hamilton

Chudleigh

Hickie

. Delivering youth-specific mental health services: the advantages of a collaborative, multi-disciplinary system. Australas Psychiatry 2009; 17:189–194.

45.

Scott

Hermens

Glozier

Naismith

Gaustella

Hickie

. Targeted primary care-based mental health services engage young Australians in treatment. Med J Aust 2011 (in press).

46.

Griffiths

Farrer

Christensen

. The efficacy of Internet interventions for depression and anxiety disorders: a review of randomised controlled trials. Med J Aust 2010; 192:S4–S11.

47.

Burns

Davenport

Durkin

Luscombe

Hickie

. The Internet as a setting for mental health service utilisation by young people. Med J Aust 2010; 192:S22–S26.

48.

Andrews

Cuijpers

Craske

McEvoy

Titov

. Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: a meta-analysis. PLoS ONE 2010; 5:e13196.

49.

Mihalopoulos

Kiropoulos

Shih

ST-F

Gunn

Blashki

Meadows

. Exploratory economic analyses of two primary care mental health projects: implications for sustainability. Med J Aust 2005; 183:S73–S76.

50.

Warmerdam

Smit

van Straten

Riper

Cuijpers

. Cost-utility and cost-effectiveness of Internet-based treatment for adults with depressive symptoms: randomized trial. J Med Internet Res 2010; 12:e53.

51.

Spek

. Cost-effectiveness of Internet-based versus group treatment in subthreshold depression: secondary analysis of a pragmatic randomised trial. First International E-Mental Health Summit, Amsterdam, the Netherlands, 2009.

52.

Hickie

Davenport

Luscombe

Moore

Griffiths

Christensen

. Practitioner-supported delivery of Internet-based cognitive behaviour therapy: evaluation of the feasibility of conducting a cluster randomised trial. Med J Aust 2010; 192: S31–S35.

53.

Burgess

Pirkis

Slade

Johnston

Meadows

Gunn

. Service use for mental health problems: findings from the 2007 National Survey of Mental Health and Wellbeing. Aust N Z J Psychiatry 2009; 43:615–623.