Better Access Scheme

There were a number of events that raised the profile of mental health in Australia and culminated with the introduction of the Better Access initiative. Public interest in mental health was heightened in late 2005 by the publicity surrounding the inquiry into the wrongful detention of psychiatric patient Cornelia Rau as an illegal immigrant, and the release of the Mental Health Council of Australia's 'Not for Service' report.[5][6]

A 2006 Senate inquiry into Australia's mental health system called for sweeping changes to mental health services. The Productivity Commission's report on Australia's health workforce was also released in January 2006 and identified a number of systemic problems relating to community access to mental health services as part of a National Action Plan for Mental Health. The commission's report recommended reforms in mental health service delivery and an extension of Medicare rebates to allied health professionals.[7] The Council of Australian Governments (COAG) raised the issue of mental health as an issue of national significance in February 2006, resulting in the Australian Government announcing a $1.9 billion increase in funding for mental health services. As part of these COAG mental health reforms, the government announced the Better Access initiative for people with mental health disorders to access services from eligible allied health professionals.[8]

The scheme built on some of the strengths of an earlier program, Better Outcomes in Mental Health Care, that was established in 2001. This program allowed GPs to claim for using psychological services after completing training in psychoeducation, interpersonal therapy and cognitive behavior therapy.[9]

Better Access was launched in November 2006 by then Minister for Health and Ageing Tony Abbott after extensive consultation with the Australian Psychological Society and other mental health groups.[10][11][12] The scheme initially provided 12 sessions per calendar year, delivered in two sets of 6 sessions, with 18 sessions available in exceptional circumstances. Additionally the scheme allowed for 12 group treatment sessions per calendar year for those in a group with 6 to 10 patients. However this was subsequently reduced to 10 individual and 10 group treatment sessions per calendar year in November 2011.[13] The reduction in the number of sessions available under the scheme was strongly opposed by psychologists and community members.[14][15]

Under the Better Access program clients of psychologists recognised by the Psychology Board of Australia as having completed an Area of Practice Endorsement in Clinical Psychology [19] are rebated $124.50 per 50-minute session.[20] Clients of psychologists who have not completed the requirements required to be recognised by the Psychology Board of Australia as having completed an Area of Practice Endorsement in Clinical Psychology receive $84.80 rebate per 50-minute session. The situation has led a breakaway group called the Australian Association of Psychologists "to push for a single rebate for psychology services, regardless of how many years the practitioner spent at university"[21].

Since the introduction of the Better Access Scheme in 2006, there has been a significant increase in student demand for places in clinical psychology postgraduate programs compared to other psychology postgraduate programs. With the exception of clinical psychology, all psychology postgraduate programs leading to an area of practice endorsement have dramatically declined including those in counselling, community, health, forensic, educational and developmental and sport and exercise psychology. In contrast, Master of Professional Psychology programs have increased over the same period.[22][23]

There have been several criticisms of the Better Access initiative since its inception. Psychiatrist Ian Hickie has raised concerns over the scheme, stating that giving psychologists Medicare rebates risks turning the profession into a “cottage industry”.[24] Hickie has previously advocated that multidisciplinary teams are the best way to deliver higher-quality mental health care and for the Better Access scheme to be capped at 10 sessions per calendar year.[25] Sebastian Rosenberg, Senior Lecturer at the Brain and Mind Centre, has also been critical of the reduced oversight of General Practitioners in the scheme, suggesting “GPs have allowed their role in Better Access to dwindle to that of glorified referrers”.[26] The Brain and Mind Centre has estimated the cost of expanding access to the scheme at $2 billion and has suggested funding for mental health services could be better spent elsewhere.[27][28] However, supporters of the scheme point out that mental health is estimated to cost the economy more than $60 billion annually in lost productivity and that Better Access has been enormously successful in providing accessible, effective, and relatively low cost mental health services, particularly for people with high-prevalence disorders such as depression and anxiety.[29][30]

A prominent concern of the Better Access initiative is its limited distribution of mental health care to rural, regional and remote areas. Better Access activity rates are typically greater in urban and more advantaged areas. However, this same criticism has also been leveled at other mental health services. Among psychiatrists, only one-third of the rural workforce live in rural Australia with most travelling from cities or using telepsychiatry.[31] Activity rates for Better Access Medicare items across all practitioners decline with increasing remoteness.[32][33]

There is also considerable variability between provider disciplines and Medicare items within the scheme, leading some critics to cite quality control issues.[34][35] This is particularly the case with the psychologist service providers leading to much acrimony within the profession.[36] This acrimony was recently exacerbated when the Psychology Board of Australia formally announced plans to retire the 4+2 program stating that "The 4+2 internship is not comparable to international benchmarks for training and registration, and there are significant risks associated with the two-year unaccredited internship."[37]. This acrimony has manifested primarily in groups like the AAPi and RAPS publishing claims on social media that young female psychology students were offering sexual favours in exchange for votes supporting the APS College of Clinical Psychologists in APS elections, and statements of support for psychologists under investigation by AHPRA for publicly asserting that newly graduated clinical psychologists were "bumbling fools stumbling over their textbooks" [38]. In addition, these groups have initiated social media campaigns where experienced psychologists with decades of experience, several who had represented the APPi on the MBS Review Board, repeatedly attempt to aggressively debate policy issues relating to the field of psychology with undergraduate psychology students on online student forums. [39] To date, there is no evidence of similarly aggressive behavior on the part of the same AAPi representatives towards clinical psychologists with equivalent levels of experience as themselves, even when said clinical psychologists post on the same student forums. These groups also encourage mass letter writing campaigns to Public Health Networks, such as the National Disability Insurance Scheme, and community organisations like the Black Dog Institute [40] demanding that they stop advertising positions specifying a requirement for psychologists with clinical endorsement. The same campaign also targets individual clinical psychologists in psychological practice, in the form of communications from "Australian Psychologists" demanding the targeted sole practitioner psychologists stop advertising the fact that they have completed clinical training.

The Australian Association of Social Workers (AASW) and Occupational Therapists Australia have called for a change in the official title of the initiative, pointing out that the existing title neglects the role of social workers and occupational therapists. The AASW has argued that the existing title may mislead clients into assuming that Medicare rebateable services are only provided by Psychiatrists, Psychologists and General Practitioners under the initiative.[41]

• Medicare (Australia)
• Medicare (Canada)
• Medicare (United States)
• Healthdirect Australia