Regardless of age, sex, socioeconomic status, race, ethnicity or sexual orientation, and following the principle of equity, persons with mental disorders should be able to access, without the risk of impoverishing themselves, essential health and social services that enable them to achieve recovery and the highest attainable standard of health.
World Health Organisation Mental Health Action Plan 2013-2020
The World Health Organisation (WHO, 2013) strongly proposes that universal health coverage should be one of the principles underpinning all mental health service systems. Over the last decade the Australian Government has sought to improve access to evidence-based interventions for high prevalence mental health disorders through the introduction of several policy reforms. For example, the Better Access initiative that operates through the Medical Benefits Scheme (MBS) has significantly improved the population treatment rate for mental health disorders (Whiteford et al., 2014). However, there remain significant disparities in mental health indices among many vulnerable groups in the Australian population including Aboriginal and Torres Strait Islander people, culturally and linguistically diverse groups, and people living outside major cities. This article explores service delivery responses to addressing some of these discrepancies by improving access to evidence-based psychological interventions for all members of the Australian community who experience high prevalence mental health disorders.
What do we mean by access?
Although access to services is inextricably linked to the seminal concept of equity, there is surprisingly little consensus about what is meant by the term ‘access’. What is clearly evident in the literature is that access means more than just the availability, presence or existence of a service in terms of both health personnel and facilities. In a review of the literature on access to primary health care, Ansari (2007) concluded that access to primary health care is best viewed as the fit between personal, sociocultural, economic and system-related factors that enable the consumer to obtain a timely, required and satisfactory health service. From this stance, access includes not only the availability of a service but also whether that service is affordable (e.g., service and travel costs), accessible (e.g., proximity), organised in a way that meets consumer needs (e.g., wait times, flexibility in appointments), and is culturally appropriate (e.g., fits with health beliefs and cultural values, offers diversity among health providers, and overcomes language barriers).
In terms of access to effective psychological interventions for high prevalence disorders, there appear to be systematic barriers that need to be overcome in order for some population groups to be able to receive the benefits of treatment. Stigma remains a major barrier to accessing professional help and no doubt contributes to the fact that there are still 50 per cent of people with mental health disorders in Australia who do not access treatment (Whiteford et al., 2014). However, the mechanism of availability of psychological services through GP referral via the Medicare system appears to have contributed to a significant destigmatisation of help-seeking for mental health problems. The inclusion of mental health psychology services under the nation’s funded health system has begun to promote interventions for mental health to a similar standing to physical health services funded under Medicare, which is an extremely important development and needs to be built on.
Other access barriers for some vulnerable groups are being overcome through service delivery responses in the following ways.
Service access for children
It is generally accepted that the best chance of preventing the long-term consequences of mental illness is early intervention during childhood, yet one of the major access issues for families in Australia is the lack of availability of appropriate services. The Tier 2 Access to Allied Psychological Services (ATAPS) Child Mental Health Service (CMHS) has provided a real opportunity for children under 12 who have, or are at risk of, developing a mental, behavioural or emotional disorder to receive evidence-based psychological interventions. The CMHS addresses multiple access barriers in a number of ways. Unlike programs such as Better Access, CMHS enables early intervention such that a child with signs of or at risk of developing a mental disorder can receive psychological intervention, and provisional referrals can be made by other allied health professionals, school psychologists/counsellors, deputy principals/principals, and directors of early childhood services. This enables treatment to commence while arrangements are made to see a GP for a Treatment Plan. The CMHS also facilitates the delivery of an important component of managing child mental health problems by enabling psychologists to work on parenting skills training without the child present, which is not possible under the Better Access initiative.
Service access for youth
The high rate of mental health and substance use disorders among people under 25 is a major issue of community concern. headspace, the youth mental health initiative, was launched in 2006 and attempts to overcome many of the barriers to care experienced by this cohort, primarily by utilising the Better Access initiative to engage psychologists to deliver affordable services in appropriate environments that suit the needs of young people. A significant component of headspace is the promotion of services to young people and their inclusion in the design and delivery of services. Recent data suggest that the initiative is mostly achieving its aim to improve access early in the development of mental illness, although there are demographic groups where access could still be improved (Rickwood et al., 2014). The headspace 2011 position paper also reports the need for incentives to encourage psychologists and GPs to work with young people, including financial inducements through the MBS for the provision of mental health services to young people.
Service access for elderly people
Access to psychological services is particularly an issue for people residing in residential aged care facilities, who in most instances are not eligible for benefits under Better Access. This is an area that clearly warrants further policy reform. In the meantime, some psychologists are accessing often under-utilised funding options such as Veterans’ Affairs and the MBS Chronic Disease Management items to make services affordable to residents.
Service access for other hard-to-reach groups
This category includes people living outside major capital cities, people of Aboriginal and Torres Strait Islander descent, people from culturally and linguistically diverse communities, and those who are unable to contribute payments for gap fees. ATAPS and Better Access are designed to complement rather than duplicate each other; that is, ATAPS is specifically intended to enable access to psychological interventions for people who would otherwise find it difficult to access services. ATAPS also allows more innovative service delivery for hard-to-reach groups, as it does not have the same restrictions on service delivery that are necessary under the Medicare-funded Better Access initiative. ATAPS is also particularly suitable for people who would be unable to afford a gap fee for an MBS service (although bulk-billing does exist for services provided under Medicare). However, the costs of providing psychological treatment per session are far greater for ATAPS than under the Better Access initiative, and it appears that this is associated with the significant level of administration required for ATAPS service delivery through Medicare Locals.
ATAPS enables people living in rural and remote regions where there may be very few independently practising psychologists to obtain evidence-based psychological interventions. The ATAPS funding model can support the costof travel by psychologists from regional to outlying communities where there are no or few resident service providers. There are currently no incentives available under the MBS or funding under the Australian Government Rural Health Outreach Fund for psychologists to travel to underserviced communities to deliver services. In some geographically isolated areas the Mental Health Service in Rural and Remote Australia (MHSRRA) program helps to overcome access barriers. MHSRRA provides funding to non-government health organisations for the delivery of mental health services by psychologists, as well as other health workers. It enables some service provision in rural and remote communities that would otherwise have little or no access to psychological interventions. The evaluation of MHSRRA reported that the program had significantly improved access by not only addressing availability but also providing flexible services tailored to local needs (Department of Health and Ageing, 2011).
Another means of overcoming the tyranny of distance is through the use of technology. Under ATAPS, suitably trained psychologists can utilise videoconferencing and telephone-based cognitive behaviour therapy when face-to-face intervention is difficult. There is now substantial evidence to support the delivery of psychological services by alternative means, but the capacity for psychologists to use such technologies needs to be improved. Enabling psychologists to use telehealth for Better Access in the same way psychiatrists deliver services to rural and remote Australia under the MBS could significantly enhance access to psychological services. Incentives to attract and then retain psychologists to practice in rural areas, as are available for medicos, would also increase access to psychological services.
Since 2011, additional funding to the ATAPS program has sought to improve access to psychological interventions for Aboriginal and Torres Strait Islander people by not only making more services available but also improving the cultural appropriateness of services. For example, psychological services can be provided to Aboriginal and Torres Strait Islander people in longer sessions and with family involvement, and in conjunction with the local Aboriginal health service. Aboriginal community controlled health services are also able to provide access to psychological interventions through Better Access as a result of an innovative component in the MBS that enables these agencies and certain publically-funded clinics in remote communities in Queensland and the NT to employ psychologists, with the rebates paid to the agency.
People from culturally and linguistically diverse backgrounds have significantly lower levels of access to mental health care in the community (Department of Health, 2014). Importantly, psychologists delivering services under the ATAPS program are able to access funding to facilitate the use of interpreter services. According to the APS database, over 1,500 fully registered psychologists are able to deliver services in another language, opening the door to service delivery through Better Access. Extending the funding for interpreters to Better Access would further enhance access for these community groups.
Concluding remarks
It is apparent from this brief review that innovation and flexible and supportive funding can enable access to evidence-based psychological interventions to be improved for hard-to-reach cohorts in the Australian community. The incidence of high prevalence disorders and the disparities in mental health indices among various community groups warrant continued efforts to address the barriers that prevent vulnerable people from receiving effective psychological treatment. Given the success of Better Access in significantly improving treatment rates to date, a number of additional strategies such as those outlined in this article could easily be implemented within the Better Access framework to provide substantial improvements to access for vulnerable groups. This would then further complement the service delivery options available through ATAPS and increase the reach of access to treatment. Such measures would contribute to ensuring that all people with a high prevalence mental health disorder are able to access effective psychological treatments that enable them to become well and thrive.
The author can be contacted at [email protected]