Q&A: Better Access is failing patients

The National Mental Health Commission inquiry has made 25 reform recommendations to the Federal Government, including changes to the funding of general practice programs like Better Access.

Australian Doctor’s Serkan Ozturk asked mental health commissioner Professor Ian Hickie (pictured) to explain why the review believes those changes are needed.

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Australian Doctor: What problems did the commission find with Better Access?

Professor Hickie: The activity that is reimbursed is writing a care plan. So the commission has looked at that and asked whether that is a sensible way to spend money.

Australian Doctor: Your report talks about greater use of allied health professionals under Better Access.

Professor Hickie: Care planning by a GP alone that doesn't involve say a clinical psychologist or psychiatrist may not be the best way to come to a comprehensive care plan.

A care plan is something organised around the patient and their needs, and should engage all of the professionals that are party to that plan.

It's not a referral document, which is what it has become, from a GP to another skilled provider. A plan is an active, live, co-ordinated care mechanism.

People really should then be checking what's happening with that, building that up over time, not a simple ‘write, refer, get paid' document.

Doctors write referrals every day of the week to other doctors without expecting to receive a payment for writing referrals.

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Australian Doctor: What role do you see for clinical psychologists?

Professor Hickie: Clinical psychologists are considerably more trained in complexity and ongoing care than general psychologists.

This hasn't been a popular thing to say about psychology, but there are different levels of skills. If a person needs ongoing care beyond six psychological sessions or beyond 10 sessions, that needs to be by a skilled professional.

Many general psychologists are not trained in issues around severe personality disorders, psychosis, eating disorders, post-traumatic stress and severe anxiety.

Australian Doctor: The report also talks about Better Access failing to deliver equal access to services.

Professor Hickie: The interesting thing is that the most equitably distributed bit of Better Access are the GP payments.

The most inequitable bits are the psychology and psychiatry payments. They behave like all other medical specialists being largely focused in city areas and being focused on providing care to those from middle and upper incomes where there are significant co-payments.

Simply pouring more money into Better Access under the current arrangements where the providers choose where they wish to work, will mean specialists stay put in the well-heeled parts of our major cities.

Only GPs service a lot of the other areas. But we don't want GPs operating on their own.

We want people in rural Australia where suicide rates are higher to have more co-ordinated mental health teams supported.

If the Commonwealth cares, it needs to be proactive. If it gives a damn about rural and regional Australia and service and suicide prevention, it needs to take action with the service providers, not just let the Medicare system run as it does and not provide care in rural and regional Australia.

Professor Hickie is national mental health commissioner and director of the Brain and Mind Research Institute at The University of Sydney.