The recent completion of three major reports for the Australian Government's health reform agenda presents an enormous opportunity to reshape the Australian health system and improve health services delivery to all Australians.
An inescapable theme running through all three health reform reports is the huge burden of disease resulting from major health problems that are caused or exacerbated by lifestyle and psychosocial issues and the need for better prevention and management strategies. A major part of the solution to tackling this enormous challenge is to find ways of bringing about large scale behaviour change. No-one pretends that this will be easy, but the profession of psychology, with its expertise in human behaviour change, should be playing an integral part in the reforms to address these challenges. Psychologists need to be centrally involved in efforts to prevent and better manage lifestyle-related disease and those that are exacerbated by mental health factors, as well as mental disorders themselves.
A second major theme across all of the health reform reports is the importance of a strengthened primary care sector delivering integrated, multidisciplinary care from an appropriate mix of health professionals. The contribution of the psychology profession to the health and wellbeing of Australians is continuing to grow, and this has been particularly apparent in the primary care sector. The huge uptake statistics for the psychological services delivered under the Better Access initiative since 2006 are indicative of a previously unmet community need for psychological treatment and demonstrate the efficacy of providing services through the primary care system. It is clear that the expertise of psychologists can be better utilised to meet the changes in the population's health needs across a range of areas in an enhanced primary health care sector.
The APS has engaged in a major advocacy campaign in the context of the Government's health reform agenda, focusing primarily on these two major themes given their prominence in the recommendations for reform. The advocacy efforts have included provision of detailed submissions to all reform discussion papers, participation in numerous consultation processes since the release of the major reports, preparation of a 2010 Federal Budget submission, and an initiative to train a select group of psychologists from across Australia to become APS strategic leaders at a local level as the health reforms are finalised and implemented. A summary of the key recommendations put forward by the APS for a reformed Australian health system is presented below.
A reformed health system needs to better utilise the knowledge and expertise of psychologists to meet the challenges in the health system and changes in the Australian community's health needs identified in the reform reports. Cost-efficient and effective psychological interventions can assist efforts to address the identified challenges in chronic disease management, the requirement for preventative and early intervention health approaches and the needs of an ageing population. The community can gain access to psychologists' expertise through expanding government-funded programs to include subsidised psychological interventions in private practice services or through funding more positions for psychologists in hospital and community-based organisations. Psychology needs to increasingly embrace electronic modes of delivery of interventions to keep pace with community expectations of developments in information technology and the efficiencies this provides (see article e-Interventions and psychology: Time to log on for a review of e-Interventions in psychology).
Preventative health
Long-term improvements in health outcomes require the implementation of structured and scaled preventative health interventions that include access to evidenced-based psychological interventions. Preventative health is about behaviour change and helping people to maintain those changes in behaviour. This is the core of applied psychology and psychologists have developed many effective strategies for helping people to modify health risk behaviours and maintain healthy behaviours through identifying and managing underlying cognitions and emotions. These applied health psychology strategies have been shown to work across the lifespan, from infancy to old age, and across life settings, at home, at work and in the community (see the article on page 18 for a review of the evidence for the effectiveness of psychological interventions in the prevention of lifestyle-related chronic diseases).
Research evidence indicates that health behaviour change is a three-phase process - education and motivation, behaviour change, and behaviour maintenance. Current strategies of preventative health tend to focus on the education and behaviour change processes, with minimal, if any, focus on the maintenance of health behaviour change. Sustained health behaviour change is a complex process, and community health goals will only be fully achieved with a clear plan for all three phases of health education, health behaviour change and health behaviour maintenance.
Chronic disease management
In order to reduce the impact of chronic diseases associated with modifiable risk factors, such as diabetes and heart disease, support for long-term behaviour change needs to be embedded into the Australian health care system. Psychologists can provide motivational strategies, the tools to identify and manage underlying cognitions and emotions, and behaviour maintenance, especially for people who have complex personal situations and find change difficult. This would complement a broader system of public health promotion campaigns, community awareness projects and traditional medical care systems.
The diagnosis of diabetes, heart disease or other major illnesses typically requires the patient to change existing, or take up new, health behaviours (e.g., diet, exercise, taking medication, attending appointments for blood tests and check-ups). Patients need both short- and long-term motivation to make these medically recommended changes, and to address cognitive and emotional factors as well as in some cases anxiety, depression and self-image problems associated with their illness. Following effective psychological interventions, patients have been shown to have lower relapse rates, fewer GP visits and less frequent and shorter hospital admissions, leading to ongoing cost savings within the health care system (see the article on page 18 for a review of the evidence for the effectiveness of psychological interventions in the management of lifestyle-related chronic diseases).
Mental health
With an increased focus on prevention and early intervention, psychology has an important role to play in developing and implementing effective mental health programs, such as the Government-funded KidsMatter and headspace initiatives in which the APS has been a development partner. Early intervention for mental health problems in the community has already been enhanced through the availability of psychological interventions under the Medicare system and this initiative should be strengthened and extended. In particular, evidence-based treatments for two prevalent mental health disorders that represent a major cost to the community - conduct disorder and borderline personality disorder - could be readily made available under the Better Access initiative. Evidence-based psychological treatments for conduct disorder all involve a significant element of parent training, requiring separate assessment and treatment sessions with parents without the child/adolescent present, which is currently not allowable. Specific psychological interventions for borderline personality disorder, most notably dialectical behaviour therapy, have sound evidence of effectiveness, but borderline personality disorder is not currently listed as an eligible disorder for treatment under the Better Access initiative.
The provision of dedicated funding for specialised psychological services within the public health system is imperative to ensure people with severe mental illness have access to effective psychological interventions. Psychological treatment approaches have become well established in the treatment of severe mental illness. A recent meta-analysis identified 34 randomised controlled trials of cognitive behaviour therapy with schizophrenia and concluded that it is effective in bringing about improvements in overall mental state, severity of positive symptoms such as hallucinations and delusions, and comorbid depressive symptoms (Wykes et al., 2008). Dedicated funding for specialised services is also essential to provide discipline-specific supervision of postgraduate psychology students and ensure the future supply of psychologists with specialised training in this area.
Age-related neurological disorders
The prevalence of dementia and other age-related neurological disorders will continue to increase as the population ages. Early recognition of cognitive impairment and assessment of capacity to function independently are essential components of the management of these age-related disorders. Neuropsychological assessments should therefore be readily available within the community and should be included under the Medicare system to ensure access.
Aged care
The psychology profession has a significant contribution to make to aged care, where it is very much under-represented. The incidence of psychological disorders is at much higher rates among the aged and particularly in residential aged care facilities (RACFs) than in the general community. In one study, prevalence of psychiatric illness was 76.3 per cent at admission to an RACF (Wancata et al., 1998). Dementing illnesses, depression and anxiety are probably the most common neurological and psychiatric conditions in nursing home residents. Studies in Australian RACFs have found the prevalence of depression was 32 per cent (Anstey et al., 2007). These figures are significantly above non-institutional or community prevalence rates.
Currently these problems are commonly treated with psychoactive medication which is expensive, frequently has undesirable side effects and requires regular adjustment in order to deal with issues relating to poly-pharmacy. When pharmacological treatment is supplied for behavioural disturbances, which are particularly common in residential aged care, the medications used are frequently inappropriate or ineffective. Meta-analyses over the last two decades have shown that anti-psychotics, the most common intervention, have modest efficacy at best and frequent side effects (e.g., Schneider et al., 2006).
Psychosocial interventions in aged care settings and with the elderly generally are shown to be effective, free of side effects and cost significantly less than conventional forms of treatment. A range of evidenced-based interventions by psychologists that are shown to decrease health service demand, improve quality of life and markedly decrease disruptive features among this client population are rarely available to residents of RACFs. It is clear that the number of psychologists in aged care needs to be increased to meet the needs of this growing sector within the population.
The APS has recommended the establishment of a Primary Health Care Strategy Implementation Group with associated working groups, comprising representation of both health consumers/carers and a wide range of health professionals. This Group would advise the Government and oversee the implementation of any new primary health care system, including aspects such as the design of the health system, funding models, innovation in education and training, and evaluation of systems and workforce deployment. As part of this, a national multidisciplinary working group would be established to develop models of practice in primary care that best utilise the particular skills of various health professions.
GPs remain the core of people's primary health care treatment. The starting point for the majority of people seeking health treatment is their local GP and the public has a significant amount of trust in them. Most GPs operate under enormous pressure due to shortages in their workforce. Many people receive an excellent service, however for many others they either can't get in to see a local GP, don't have a local general practice, or, when they do gain access to service delivery, the demands on the service drive short time-based clinical treatment interventions that are insufficient to address all their health needs.
Increased access to allied health practitioners
It is clear that GPs need to be better supported as part of the health reforms. GPs should not have to be the gatekeeper to care when there are well trained allied health professionals who can provide appropriate and effective treatment. Alternative pathways that maximise the use of the skills of the primary health care sector workforce but still maintain the GP's coordination role are required.
Direct access to allied health professionals will therefore be an important development. As part of the process of direct access to allied health services, practitioners may need to be accredited where they are providing funded services such as under the Medicare system. It would also be a requirement that the person's GP is notified and provided with assessments, treatment plans and outcomes as part of the service, and payment could be made contingent on this.
Many areas of regional and rural Australia, particularly those with high numbers of Indigenous people, find it difficult to attract qualified health professionals. There are already a number of existing models of medical service delivery that bring these professionals to the people who need their expertise. The National Health and Hospitals Reform Commission has recommended the expansion of specialist outreach services. These services need to be further expanded to include psychologists and other allied health professionals so that the benefits of multidisciplinary care are also available to these Australians.
Expanded scopes of practice
There is likely to be a broadening of health professionals' roles and scopes of practice to address workforce shortages. In its review of the health workforce, the Productivity Commission recommended consideration of the extension of the scope of practice of specific allied health professions with regard to prescription rights. This recommendation has been reiterated in the report of the National Health and Hospitals Reform Commission, and particularly identifies psychology as one of those health professions to which the extension of prescription rights might apply.
The relevance of psychology being included in prescription rights is particularly based on the benefits of the integration of psychopharmacological treatments with psychological interventions. Prescriptive authority of varying kinds currently exists for specifically trained psychologists in seven States of the US, one province of Canada (Alberta), and in the countries of Guam and South Africa.
Substantial postgraduate training and supervision as a foundation for prescribing rights is essential. A clear delineation of which types of medication would be appropriate for prescription by a psychologist also needs to be provided. Independent of the health reform agenda, a process has been underway within the APS since 2006 by a group of interested psychologists who are investigating prescribing rights for psychologists. Some preliminary surveys have been undertaken and guidelines for a training program are being established.
Primary health care centres
Collaborative and integrated team-based health care is the most appropriate approach for managing a range of chronic conditions to achieve the best health outcomes. Under a reformed primary care system, substantial service delivery should be provided through local multidisciplinary primary health care centres (PHCCs). The Government's GP Super Clinics that are currently being established around Australia are moving towards this model. The APS has made a number of recommendations for the nature of PHCCs which would ensure that they operate efficiently and effectively in delivering collaborative and integrated multidisciplinary care for the benefit of health consumers, as outlined below.
- Equitable governance arrangements
Governance arrangements for primary health care organisations overseeing the local PHCCs should provide equal representation of all health professionals in the planning, implementation and evaluation of services. Such equity in the governance of practices would encourage shared decision making and a greater commitment and sense of ‘ownership' of the health service by all involved, and would enhance high quality coordinated and integrated care.
- Co-location of a mix of health practitioners
Co-location of a core group of health professionals will enhance integrated health care. The nature of services provided by the PHCC will inform decisions regarding the most effective combination of primary health care providers. One of the main challenges will be to provide an appropriate model of chronic disease management given that this will be an increasing focus of care. A comprehensive approach to chronic conditions prevention and self-management requires a primary health care professional workforce that covers interventions across three areas of need: disease-related treatment; development of health behaviour change strategies; and psychosocial interventions (Lindner et al., 2003). The evidence-based application of this model has been supported by a large number of investigations into chronic conditions prevention and self-management.
- Assessment and referral through a triage arrangement
The use of a specific triaging arrangement to undertake assessment, screening and referral in PHCCs will be an important component of service provision to streamline access to the GP, identify health issues and refer to other health professionals as appropriate. A variety of preventative health and treatment issues could be identified, educational materials could be provided and the person could be directly referred to appropriately experienced allied health practitioners. Components of this could be undertaken online or over the phone prior to attending the PHCC.
- Supported case conferencing
An essential element of effective multidisciplinary care is support for regular case conferences between GPs and allied health practitioners to maximise collaborative, coordinated and efficient service delivery. To encourage health professionals to engage in collaborative care and to ensure that it is an integral element of service provision, there should be incentives for involvement in case conference discussions such as through funding arrangements.
- Electronic health records system
The increased number of professionals involved and the resulting paperwork for coordination requires efficient administration and follow-up is time consuming and administratively inefficient without appropriate levels of electronic file management. A shared electronic consumer record would be ideal in these circumstances and would assist in enhancing coordinated and collaborative care. Such electronic systems are already available but would need to be further developed to enable them to be utilised by a number of health practitioners and to comply with relevant privacy legislation.
- Funding arrangements
Blended funding systems would support flexibility for PHCCs in determining how best to meet the needs of the practice population. Such systems can also benefit workforce sustainability through flexible employment arrangements such as mixed salaried and private practice employment. Quality improvement payments can provide incentives to enhance quality care by a broad range of primary health care professionals. Funding through the Medicare system is particularly appropriate where episodic care is required. However, where there is a need for ongoing care in chronic disease management, packages of funding may be more appropriate.
The growing shortage of health professionals, including psychologists, is likely to worsen over the next decade with the ageing of Australia's population. Conceptual development and appropriate funding of training models to ensure the supply of psychologists in the health workforce is therefore an essential and central component of health reforms. Measures must urgently be put in place in order to ensure that Australia's workforce is able to deliver the specialist psychological skills which will be needed by the Australian community in the future. These issues are exacerbated in rural and remote areas of Australia by the relatively poor distribution of the workforce.
There is a continuing and serious decline in the availability of suitable clinical placement experiences for psychology trainees across Australia, heavily limiting the number of student places which can be offered in university entry-level professional psychology programs. This decline is the result of growing competition among health professions for shrinking numbers of largely unfunded allied health training placements. It will be essential to expand the future opportunities for placements in primary care given the likely structural reforms to the health system.
In addition, the Commonwealth funding provided to universities for entry-level professional psychology training programs is highly inadequate, creating a disincentive for universities to offer further places. Changes to the funding of postgraduate professional psychology education and training programs are urgently needed, specifically a re-alignment of all postgraduate psychology programs to the Higher Education funding cluster 7 (medicine/dentistry/veterinary science) in recognition of the high costs of postgraduate psychology training. While the issues surrounding the poor distribution of the workforce are complex, the extension of existing successful medical models such as the Rural Retention Program to include allied health providers should be considered to maintain the existing workforce and encourage new practitioners to work in these areas. This is of particular importance in areas where there is a high population of Indigenous people.
The recommendations for the reforms outlined above would in various ways contribute to increased community access to effective psychological interventions. The cost-efficiency of these interventions is well recognised, enabling psychology to make a significant contribution to addressing the challenges facing the Australian health system.