The Better Access program, introduced by the Howard government in 2006 to improve access to treatments for common mental disorders, was controversial before it even began. A range of mental health experts and community advocates raised concerns before its launch that the Better Access model would not ensure equitable distribution of services or collaborative, quality care.
In 2009, the then chair of the National Advisory Council on Mental Health, John Mendoza, wrote to then-health minister Nicola Roxon urging reform of the program, stating that most of its members saw Better Access as a provider or supply-driven system.
“While there is a view that the huge demand and uptake of the services by consumers is evidence that Better Access is a successful initiative, this is not the broad view of the Council and (sic) that the program is in its current design unsustainable. Further, the majority view is that the program is not the “best buy” when compared with collaborative care models,” said the letter.
The release last year of an evaluation of the program served only to intensify the controversy surrounding Better Access. Pages of medical journals have since been filled with intense debates about whether it makes best and fairest use of public investment.
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One driver of the debate has been the ballooning cost; the program was projected to cost $442.5 million over the first four years, but actually cost $2.02 billion in the first five years (not including the often significant co-payments by patients). By contrast, there has been relatively little public debate about ongoing funding squeezes on the community mental health sector, which is largely funded through state governments with tightly capped budgets.
Associate professor Neil Cole, a consumer advocate and former member of the National Advisory Council on Mental Health, is quoted in one journal article by psychiatrist professor Ian Hickie and colleagues, as saying that Better Access costs so much 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 said.
This is all by way of putting some historical context to the claim this week by the Australian Psychological Society that Better Access has been “the most successful mental health initiative of the past 30 years”.
The statement followed the government’s announcement that it would put in place transition arrangements for patients requiring long-term treatment who had been adversely affected by the budget reforms to Better Access, until other service models are more developed. (This was also in the face of a Greens threat to block the reforms.)
The APS is right, in some respects at least, that Better Access has been successful — beyond any expectations. Uptake has been huge — one in every 19 Australians received at least one Better Access service in 2009, according to the evaluation — and it has been a billion-dollar booster to professional coffers.
It is also possible that the sheer scale of the uptake has helped reduce the stigma surrounding mental illness. But success in health policy should also be judged on equity and effectiveness. Better Access has not been a roaring success if judged by how much it has helped people who are poorer, disadvantaged or who live in areas not well served by psychologists. I haven’t heard too many grand statements about its impact upon indigenous health, for example.
Professor Helen Keleher, president of the Public Health Association of Australia, told Crikey the APS claim sounded like “hyperbole”, and suggests there is a risk that Better Access is contributing to increasing inequities: “Funding an expansion of community based public mental health services may be a better and more effective mechanism for providing accessible and affordable care for vulnerable groups.”
Barbara Hocking, executive director of SANE Australia, says that Better Access has been a really successful initiative — but not for everyone. “Many people who live in rural Australia or who are on a low income and can’t afford gap fees continue to miss out on good psychological treatment and we have to try other ways of helping them,” she said.
Sebastian Rosenberg, of the University of Sydney, adds: “Resources in mental health are incredibly valuable. We cannot afford to misdirect or waste them. We do not have enough data to verify whether the existing $10 million per week being spent on the Better Access program represents good value. Changes to the Better Access program are now more about professional bodies protecting industrial interests than about evidence on health outcomes.”
While the APS statement is a reminder that the primary role of professional groups is to represent members’ interests, this is also an issue for broad-based advocacy groups.
The National Rural Health Alliance, for example, initially welcomed the Better Access reforms, noting the program had been skewed towards the major cities. But the alliance has since been noticeably silent on the issue, presumably because its membership includes medical and psychology groups.
All of which is a reminder of the difficulty of ensuring public interest and equity considerations are put front and centre in policy making, when professional interests carry so much weight.