Chapter 2

Better Access Initiative

Background to Better Access

2.1 The Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Scheme initiative (Better Access) is a central part of the Australian Government's contribution to COAG's National Action Plan on Mental Health (2006–11).

2.2 The purpose of Better Access is to integrate allied health and GP services to improve the treatment and management of mental health, by expanding the services that attract a rebate under the Medicare Benefits Schedule (MBS). The expansion of such services was designed to encourage patient referrals between GPs, psychologists, clinical psychologists, social workers and occupational therapists, and to promote mental health education and training for health professionals.[1] The initiative commenced on 1 November 2006. Changes were made in 2009 that enabled GPs with specific mental health training to claim higher rebates.

2.3 Under Better Access, new (rebatable) Medicare items were introduced that enable:

GPs to provide mental health assessments and to develop and implement treatment plans;
Clinical psychologists to provide therapy;
Psychologists, social workers, GPs and occupational therapists to provide focussed psychological strategies services; and
Psychiatrists to see new patients for an initial consultation.[2]

2.4 Such items may be provided to eligible patients for up to 12 individual and 12 group sessions per year (plus an additional 6 sessions in exceptional circumstances).[3]

Evaluation of Better Access

2.5 In 2009, the Department of Health and Ageing tendered for consultants to evaluate seven components of the Better Access program. The evaluation was undertaken by researchers from the University of Melbourne (components A, A.2, B and E), Flinders University (component C), KPMG (component D), and the Department (component F). A summative evaluation, undertaken by a consortium of researchers from the University of Melbourne and the University of Queensland, was released in mid-February 2011.[4] The evaluation was overseen by a Project Steering Committee convened by the Department, comprising nine members with 'specific experience, expertise and knowledge in relation to program evaluation and the delivery of mental health services'.[5]

2.6 The evaluation synthesised data from twenty sources to provide responses to three key questions:

Has Better Access improved access to mental health care?
Is Better Access an effective (and cost-effective) model of service delivery?
Has Better Access had an impact on the profile and operation of Australia’s mental health workforce?[6]

2.7 The evaluation concluded that the initiative has improved access to mental health care, and the Better Access model has had a generally positive impact on service delivery and the mental health workforce.[7] More detailed findings relevant to the inquiry included:

Since the introduction of Better Access, more people have accessed mental health services. The uptake of the rebatable sessions has been high and increasing: 2.7 million, 3.8 million and 4.6 million Better Access services were delivered in 2007, 2008 and 2009 respectively.
Many Better Access consumers are suffering from anxiety or depression, and are experiencing significant psychological distress, that is, moderate to severe rather than mild symptoms.
Better Access has gone some way to providing services to people on low incomes, living in regional areas or for other reasons not previously accessing Medicare services.
Of the consumers who accessed services, most accessed between one and six consultations (72.7 per cent).
According to the evaluation, Better Access services appear to deliver better health outcomes in a cost-effective manner.[8]

2.8 These findings were qualified by the suggestion, repeated several times throughout the summative evaluation, that limitations in available data prevented the authors from drawing comprehensive conclusions about the effectiveness of any aspect of the program.[9]

2.9 A list of the strengths and weaknesses of each data source was presented in Table 1 in the report. The strengths listed in relation to many of the data sources include: large and representative sampling; use of MBS to provide useful data; and the unique nature of the data collected. Common weaknesses were identified as: selection bias or reliance on self-reporting; a lack of potential to track any change or improvement over time; and difficulties in inferring conclusive information about Better Access from the data.[10]

2.10 Several submitters commented on what they considered weak aspects of the methodology or limitations of the data.[11] The methodology of the study was the target of particular criticism:

The recent evaluation of BA did not proceed according to scientifically accepted methods, the latter crucial for establishing the most accurate results. We believe the conclusions drawn are readily disputed based on the very poor methodology of the evaluation and therefore of limited value as a basis for decision-making going forward.[12]

2.11 As well as the methodology, the findings of the study are also open to interpretation. For example, some commentators welcomed the evidence that Better Access increased mental health services in rural areas, as well as its significant uptake rate overall. Other commentators were concerned that mental health services in rural areas remain less accessible than in metropolitan areas, and that the significant uptake of Better Access overall has been very expensive. The Government made significant changes to its mental health spending in the 2011–12 Federal Budget, and used findings of the evaluation demonstrating the significant expense of Better Access to support its rationalisation of the initiative.[13]

Changes to Better Access in the 2011–12 Federal Budget

2.12 In its 2011–12 Budget statement, the Government stated that Better Access is an increasingly costly program, and that it has not been fully effective in addressing the mental health needs of all target groups.[14] To address this cost issue, and increase access to mental health care to groups such as Indigenous people, people in regional Australia and people on low incomes, the Government redirected funding from Better Access towards other programs.[15] Savings from Better Access will fund a quarter of the mental health package over the forward estimates period.[16] Programs awarded significant funding increases include Access to Allied Psychological Services (ATAPS), headspace, and Early Psychosis Prevention and Intervention Centres (EPPIC), which are discussed in chapters 3–4.

2.13 The savings are gained from two major changes to Better Access:

The rationalisation of services provided by GPs by introducing time-dependent rebates (allocating separate Medicare items to consultations taking between 20 and 39 minutes, and those taking 40 minutes or more); and
The rationalisation of MBS rebatable allied health services sessions—from 12 individual and 12 group sessions, plus an additional 6 sessions in exceptional circumstances—to a maximum of 10 with no provision for exceptional circumstances.[17]

2.14 The following section discusses each of these changes, and the arguments in support of and against the changes that were made in the course of the inquiry.

Rationalisation of GP mental health services—new time dependent rebates

2.15 The budget measures lower the fees charged and rebates applicable to all mental health items provided by GPs, introducing a timed rebate system. In making these amendments, the Government has sought to align mental health consultation rebates more closely with standard consultation rebates; GPs will receive the same rebate for a mental health consultation as they would for a standard Level C or D consultation of the same length.[18] However, a relatively higher rebate will be available to GPs who have undertaken specific mental health training.[19] The two-tier rebate system refers to the standard rebate available to GPs who have completed the mental health skills training—tier one—in comparison with that available to those who have not—tier two.

2.16 A comparison between the current charges for mental health consultations and the new timed charges is presented below. It should be noted that these figures represent the total fees charged by GPs, not the total amount charged to the patient; the Medicare rebate is 75 per cent of the total cost for items 2702, 2710 and 2712 and 100 per cent of the cost of item 2913.[20]

Item	Current untimed total fee charged by GPs who have not completed mental health skills training	Current untimed total fee charged by GPs who have completed mental health skills training	New timed total fee charged by GPs who have not completed mental health skills training	New timed total fee charged by GPs who have completed mental health skills training
2702: GP Mental Health Treatment Plan taking 20 to 39 minutes[21]	$128.20	$163.35	$67.65 (-$60.55)	$85.92 (-$77.43)
2710: GP Mental Health Treatment Plan taking 40 minutes or longer[22]	$128.20	$163.35	$99.55 (-$28.65)	$126.43 (-$36.92)
2712: GP Mental Health Review[23]	$108.90	$108.90	$67.65 (-$41.25)	$67.65 (-$41.25)
2913: GP Mental Health Consultation[24]	$71.85	$71.85	$67.65 (-$4.20)	$67.65 (-$4.20)

Use of BEACH data

2.17 The Government has made these changes noting the Bettering the Evaluation and Care of Health (BEACH) report, which was one of the twenty data sources used to compile the summative evaluation of Better Access (detailed earlier). The BEACH report indicated that over 80 per cent of GP mental health treatment plans were being completed in less than 40 minutes, with an average time of 28 minutes.[25]

2.18 The Australian Medical Association (AMA) was concerned that the BEACH data referred to above does not accurately reflect the total time spent by GPs on mental health treatment plans, just the face-to-face time spent with a patient.[26] The AMA, and other GP representative groups such as the Royal Australian College of General Practitioners claim that the Government has misinterpreted the BEACH data and that the changes devalue mental health care.[27] Further, a survey undertaken by the AMA itself indicates that the average time spent by GPs developing mental health plans is closer to 35 minutes with the patient as well as an additional 17 minutes spent developing the plan, co-ordinating patient care and other related work.[28]

2.19 The Department of Health and Ageing (DoHA) responded to the suggestion that the data had been misinterpreted. Mr Bartlett from DoHA said:

All BEACH data is face-to-face time. None of it includes non-face-to-face time. All consultations include a non-face-to-face element. There is debate about how much that is. The AMA over a period of time has suggested that you can split it up 75 face-to-face, 25 non-face-to-face. As I said earlier, when you work through that there is a difference between a level C consultation as an example and a mental health treatment plan in terms of non-face-to-face if you accept the AMA's 18-minute response from the survey, but the difference is considerably smaller than something or nothing. So I think that the use of BEACH data in that way is not invalid.[29]

Workforce implications

2.20 headspace, amongst other submitters, objected to the changes on the basis that they might exacerbate workforce difficulties. headspace's submission explained that it is very difficult to attract GPs into youth mental health care, and that reducing the rebate rate, by up to 47 per cent, would act as a further disincentive for GPs to work within the headspace mental health care model.[30]

2.21 Similarly, the Rural Doctors Association of Australia (RDAA) was concerned about the rationalisation of GP services under Better Access because of the lack of specialist services in rural and remote areas, and the reliance on GPs with advanced skills.[31] The RDAA considered that a rural pathway for GPs is more likely to be favoured where there is scope to perform higher level clinical work, and that reducing MBS rebates will act as a disincentive, exacerbating the health services in rural areas.[32]

2.22 However, the committee did receive submissions supportive of the budget changes to Better Access. Beyondblue supported the introduction of timed rebates for GP mental health items, as well as the continued higher rebate for GPs who have completed mental health training.[33] Other submitters expressed general support for the rationalisation of Better Access on the basis that funds would be better diverted to improving services to target groups identified in the Budget.[34]

Mental health consultations compared to standard consultations

2.23 Standard MBS rebates for GPs are based on the amount of time spent with the patient, the complexity of assessment and treatment and other matters such the location where the consultation takes place. GP consultations at the GP's consulting rooms are divided into Levels A, B, C and D. Level A is intended for short, straightforward appointments. Progressively higher rebates are claimable when GPs treat more complex issues that require more time: less than twenty minutes (Level B); at least twenty minutes (Level C); and at least forty minutes (Level D).[35] A Level D consultation is described as a:

Professional attendance by a general practitioner (not being a service to which any other item in this table applies) lasting at least 40 minutes, including any of the following that are clinically relevant:

(a) Taking a detailed patient history;

(b) Performing a clinical examination;

(d) Implementing a management plan;

(e) Providing appropriate preventative health care;

in relation to one or more health-related issues, with appropriate documentation.[36]

2.24 The process for preparing a Mental Health Treatment Plan includes an assessment of the patient and the preparation of a plan. According to the MBS both steps must include the following:

Assessment

recording the patient’s agreement for the GP Mental Health Treatment Plan service;
taking relevant history (biological, psychological, social) including the presenting complaint;
conducting a mental state examination;
assessing associated risk and any co-morbidity;
making a diagnosis and/or formulation; and
administering an outcome measurement tool, except where it is considered clinically inappropriate.

Plan

discussing the assessment with the patient, including the mental health formulation and diagnosis or provisional diagnosis;
identifying and discussing referral and treatment options with the patient, including appropriate support services;
agreeing goals with the patient – what should be achieved by the treatment - and any actions the patient will take;
provision of psycho-education;
a plan for crisis intervention and/or for relapse prevention, if appropriate at this stage;
making arrangements for required referrals, treatment, appropriate support services, review and follow-up; and
documenting this (results of assessment, patient needs, goals and actions, referrals and required treatment/services, and review date) in the patient’s GP Mental Health Treatment Plan.[37]

2.25 The committee explored the issue of comparing a mental health treatment plan with a standard Level C or D consultation which incorporates preparation of a management plan. DoHA responded that:

...there is not a stark distinction between what is done with a mental health treatment plan and what can be and is done under a level C consultation. There is a comparability there...If you go back and accept what the [AMA] said—that the relative value study reflects what you would expect for a level C consultation—you are looking at something like eight to 10 minutes non-face-to-face time for a standard level C consultation. There is a difference, but again there is also a difference in rebate.[38]

2.26 The committee heard that GPs providing mental health consultations are concerned that such consultations require a time commitment beyond face-to-face time and as such should be recognised with a higher rebate. However, the committee also notes that it did not seek evidence in relation to GPs who receive standard Level C or D rebates and who may also provide additional services outside the appointment time for patients with other severe or persistent illnesses.

2.27 While the inquiry has not received evidence about preparatory or follow-up work undertaken by GPs treating a range of severe illnesses, the above guidelines for Level B, C and D consultations recognise that additional time beyond that spent face-to-face with the patient is necessary for many health issues, not just mental health care.

2.28 In addition, as mentioned above, the committee notes that the premium will be retained for GPs who have completed mental health training. It is hoped that this incentive for GPs to undertake training will encourage continued quality care.[39] DoHA explained to the committee that 72 per cent of GPs have completed the mental health training, and therefore will be eligible for the higher rebate.[40] As such, most GPs will continue to receive higher rebates for mental health consultations than they do for standard consultations.

Rationalisation of allied health treatment sessions—10 session entitlement

2.29 The number of rebatable allied health treatment sessions will be capped at 10 individual and 10 group sessions—a course of six sessions plus four additional sessions following a review. The previous maximum for both individual and group sessions was 18—two courses of six sessions plus an additional six sessions in exceptional circumstances.[41]

2.30 This change is made in the context of data indicating that 87 per cent of consumers access between one and ten sessions, and the argument that individuals requiring more than 10 sessions may be better suited to other specialist services such as psychiatrist consultations.[42] However, as mentioned earlier in this chapter, the limitations of the available data about the Better Access program have been acknowledged.

Feedback about the sufficiency of 10 sessions from psychologists

2.31 Much of the concern expressed about the rationalisation of rebatable sessions under Better Access from a maximum of 18 to 10 was from psychologists. A significant number of submissions received from psychologists expressed strong views on this issue suggesting broad agreement across the discipline that severe and persistent mental illness requires longer-term treatment than 10 sessions.[43] Others submissions discussed a delineation of severity of mental illness, such as via the multi-axial system, noting that people with some Axis 1 disorders also require more than 10 sessions of treatment.[44]

2.32 The Australian Association of Psychologists inc (AAPi) suggested that 18 sessions is 'sufficient and not oversufficient...[to]...allow a person to overcome a substantial life difficulty':

I would suggest that almost all people who come to a psychologist with a substantial emotional difficulty, a depressive situation, an anxiety situation, a traumatic occurrence, would require 18 sessions. Brief psychological therapy exceeds 10 and goes up to 20. That is considered brief psychological therapy for a person who is undergoing a severe life difficulty. They are not the chronic people. The chronic people come after that and require weekly or fortnightly monitoring lifelong. I would say psychology desperately requires the 18 sessions to do its job.[45]

2.33 Carers NSW cited data indicating that many people with a mental illness are from low-income backgrounds.[46] Carers NSW was concerned that some of these people may not be eligible for ATAPS and rely on Better Access for mental health care. It argued that after the 10 MBS rebatable sessions are exhausted, people with limited means will not be able to afford the full cost of extra sessions.[47] Carers NSW also asserted that many carers rely on GPs for the provision of mental health care, for reasons such as the perceived stigma associated with visiting other specialists, or the additional costs of such appointments.[48]

2.34 The Federation of Ethnic Communities Councils of Australia (FECCA) stated in its submission that capping Better Access sessions to 10 may disadvantage people from a non-English speaking backgrounds, who may require additional sessions in order to build trust, explain the problem or find and build rapport with an interpreter.[49]

2.35 ACON (formerly known as the AIDS Council of NSW) was concerned that recovery from mental health illness may be delayed if limited sessions are available, and that there should be exemptions for people with co-morbidities or complex needs.[50] This suggestion that discretion will be required if sessions are rationalised was echoed by the Australian Counselling Association.[51]

2.36 Many people who have first-hand consumer experience of psychiatrist sessions under Better Access provided the committee with submissions asserting that the 18 session maximum should be retained. Several individual submitters explained that management of and recovery from their mental illness would not have been possible without access to the full 18 sessions.[52]

2.37 The arguments above in favour of retaining the 18 session maximum rely on the assumption that Medicare rebatable sessions under Better Access are appropriate to treat people with a severe mental illness. This was debated amongst submitters; some considered that Better Access was not designed to treat people with a severe mental illness, while others contended that it was. The opinion was also expressed that whether or not Better Access was originally intended to treat people with a severe mental illness, viable alternatives do not presently exist and therefore Better Access should be funded to fill the gap.

Targeting hard to reach groups

2.38 The Better Access evaluation and the various ATAPS evaluations discussed in Chapter 3 of this report indicate that Better Access either does not meet the needs of hard to reach groups, or that the ATAPS model is more suited to the task. However some witnesses questioned these conclusions. The Royal Australian College of General Practitioners (RCAGP) for example disputed DoHA's assertion that Better Access is not reaching rural and remote areas. The RACGP suggested that it is workforce shortages, that contribute to fewer services being delivered outside metropolitan areas, and that Better Access has actually had the opposite effect:

The Better Access Evaluation Report actually concludes that while some groups have had greater levels of uptake of Better Access than others, Better Access has reached all groups and increased most dramatically for those who have been the most disadvantaged in the past, including people aged 0–14, rural areas, and the most socio-economically disadvantaged areas.[53]

2.39 The AMA also emphasised the increase of Better Access service delivery to hard to reach groups:

The criticisms of it are that it is not reaching the target groups. The greatest growth in this program is actually in those target groups, so, if you like, it is coming to maturity just now. The greatest growth was actually in the young people getting access to this program. The next greatest growth was in the lowest sociodemographic, where over 150,000 people were being treated, but the growth rate in that area was the greatest. [54]

2.40 DoHA accepted RCAGP's point that there was some improvement in the Better Access performance in terms of reaching disadvantaged groups, however it maintained that ATAPS is the more appropriate service delivery for these groups:

The [Better Access] evaluation showed that access for hard-to-reach populations has, to some extent, improved. But, as Ms Huxtable has just said, those groups traditionally less well served by Medicare continue to miss out on mental health services that they need and that is a feature of any universal fee-for-service rebate type scheme. In particular, we know that Better Access continues to struggle to adequately service hard-to-reach and vulnerable groups such as young people, men, people living in rural and remote regions, Indigenous Australians and people living in areas of high socio-economic disadvantage. The evaluation also confirmed that the usage and distribution of services across the community is relatively poor. In rural and remote Australia service levels drop off dramatically. So, for example, the use of services is approximately 12 per cent lower for people in rural areas and approximately 60 per cent lower for people in remote areas compared to that for people living in capital cities. The evaluation data also showed a clear difference in access according to socioeconomic status, with use of Better Access services approximately 10 per cent lower for the people living in the most socioeconomically disadvantaged areas. [55]

2.41 The department also noted a significant disparity in uptake of Better Access services between socio-economic groups:

The use of Better Access services was approximately 10 per cent lower for people living in the most socio-economically disadvantaged areas. In 2009, the richest quintile of Australians accessed 2½ times the number of services and received three times the Medicare rebates, compared to the poorest quintile.[56]

Better Access as a means of treating people with a severe mental illness

2.42 The summary of Better Access on the Department of Health and Ageing's Mental Health website explains that the initiative is designed to assist:

Individuals with a clinically diagnosed mental disorder who would benefit from a structured approach to the management of their mental care needs, using the short to medium term treatment available under the Better Access initiative.[57]

2.43 This suggests that the program might be targeted towards people with less severe mental illnesses who would benefit from 'short to medium term treatment'. It is also clear from a number of sources that the Better Access initiative was envisaged to treat high prevalence mental illnesses, for example, the Summative Evaluation of the Better Access scheme states:

The Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule (Better Access) initiative was introduced in November 2006 in response to low treatment rates for common mental disorders (e.g., anxiety, depression and substance use disorders). Its ultimate aim is to improve outcomes for people with these disorders by encouraging a multi-disciplinary approach to their care.[58]

2.44 The Department of Health and Ageing's budget publication dating from the inception of Better Access in 2006 indicated that the program would include treatment by psychiatrists of an 'estimated 35,000 additional individuals with a severe mental illness' by 2010–11, suggesting that some people with severe high-prevalence disorders were expected to access the initiative. This is consistent with the COAG National Action Plan on Mental Health 2006 – 2011, introduced around the same time that Better Access was introduced. It stated that the treatment of severe mental health disorders would occur at least in part through the primary health care system through practitioners who are included in the scope of Better Access including:

...psychiatrists in the community and a primary health care sector of GPs, psychologists, mental health nurses, and other allied health workers that provide clinical services to people with mild, moderate and severe mental illness including early identification, assessment, continuous care and case management.[59]

2.45 Better Access was designed to encourage mental health professionals to work together to ensure people's care needs were met in the most appropriate way:

Reforms will be made to...allow private psychiatrists to see more new patients and refer on those patients who could be more effectively treated by appropriately trained psychologists and GPs.[60]

2.46 However, it is likely that policy makers in 2006 did not anticipate the extent to which Better Access sessions would be utilised in the following years, nor the extent to which people accessing the program would be experiencing severe or very severe symptoms. It is also the case that state and territory governments provide most services for people experiencing severe mental illness, a role Better Access was never intended to supplant.

2.47 Professor Hickie of the Brain and Mind Research Institute, University of Sydney, considered that Better Access is not the appropriate program to be providing long-term assistance to people with a severe mental illness. He explained to the committee that rationalising Better Access sessions could actually assist more people to receive care:

There will be no reduction in psychological services. With a reduction in number of sessions, more people will get into Better Access and, with an increased investment in ATAPS, more people will receive the various levels of ATAPS services.[61]

2.48 The Department of Health and Ageing agreed that primary care programs like Better Access or Tier 1 of the ATAPS program are not the most appropriate programs for people with severe mental illness:

While some people with more complex or intensive care needs may benefit from interventions under Better Access, it was never intended to provide intensive, ongoing therapy for people with severe ongoing illness.

People in this group are generally clients of state and territory government specialist mental health services.

It is important that people get the right care for their needs. As indicated on the Medicare Australia web site, people who currently receive more than ten allied mental health services per calendar year under Better Access are likely to be patients with more complex needs and would be better suited for referral to more appropriate mental health services. This may include the following:

People with severe and persistent mental disorders who require over ten allied mental health services are still eligible for up to 50 Medicare subsidised consultant psychiatrist services; and

The specialised mental health system in each state or territory.[62]

2.49 The Department stated that, in the long term, the current approach was able to deliver appropriate levels of mental health care for those suffering severe mental illness. They also noted that some gaps in service delivery do exist:

...as I say, we are looking at the package as a whole: a balanced package of services to start to reform the mental health system and close some of the gaps that we know exist. We are working very closely with the states and territories and will be seeking investment from the states and territories, in respect of the national partnership agreement, for example. And as the government has clearly said through this budget package, they know it is just the start.[63]

2.50 The committee received some submissions that concured with Professor Hickie and the Department's view. The Mental Health Council of Tasmania as well as the Consumers Health Forum of Australia supported the savings generated by the rationalisation of Better Access sessions and considered that ATAPS is targeted towards assisting people with a severe and persistent mental illness.[64] The Consumers Health Forum, however, qualifies its support for the rationalisation by suggesting that a review and further evaluation of Better Access take place to measure any impact that the changes may have on consumer outcomes.[65]

2.51 Conversely, other submitters considered that Better Access is an appropriate measure, or the best available measure, to treat people with severe mental illness, and that it is working effectively. For example, some witnesses to the inquiry considered that Better Access is needed to support people with eating disorders, for which the committee heard at least 18–20 sessions are required.[66]

2.52 The Private Mental Health Consumer Carer Network was also concerned that a reduction in GP mental health sessions would disadvantage people with severe mental illness for whom psychiatrists may be less accessible.[67] The Network considered that GPs play an integral role in the provision of mental health care and that a reduction in rebatable sessions would have a negative effect on the long-term health of people with mental illness.[68]

2.53 Regardless of the original intent of the initiative, evidence from the Australian Psychological Society suggested that the majority of people accessing mental health treatment under Better Access are experiencing severe symptoms. A 2010 APS survey indicated that 81 per cent of Better Access clients requiring more than 10 sessions had depression and/or anxiety disorders; that is, high prevalence, severe disorders.[69]

Committee view

2.54 The rationalisation of rebatable Medicare items for mental health consultations should align more closely with standard timed consultations. In addition, the relatively higher rebates should continue to be made available to GPs who have undertaken mental health skills training.

2.55 Aligning rebates for mental health consultations with standard Level C and D consultations would be appropriate, as a range of presentations of severe or complex illnesses require follow-up work by GPs. In order to justify a continued higher rebate for GPs providing mental health consultations without specific training, the case would have to be made very strongly that mental health plans take significantly more time to develop than do the follow-up tasks required to treat all other severe and persistent illnesses.

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