Chapter 3

Access to Allied Psychological Services program

Introduction

3.1        The Government's 2011–12 Federal Budget National Mental Health Reform package is designed to address service gaps in the mental health system to ensure that early and consistent rather than crisis-driven care is provided to people who need it.[1] In addition, the reform is focused on addressing the needs of people identified as not always receiving adequate mental health services (see Chapter 1).[2] The Access to Allied Psychological Services program is seen as one way of meeting these challenges.

Access to Allied Psychological Services (ATAPS)

3.2        The ATAPS program has been in existence since 2002 and was designed to fund 'short term psychology services for people with mental health disorders through fundholding arrangements delivered through Divisions of General Practice'.[3]  The ATAPS projects enable GPs to refer patients with high prevalence disorders such as depression and anxiety to allied health professionals (predominantly psychologists).[4]

3.3         Since 2003 there have been a number of policy developments which have impacted on the original design of the program.  The most significant of these was the introduction of the Better Access program in 2006 which serves a similar client group, but through the Medicare Benefits Schedule rather than a fundholding arrangement.

3.4        The ATAPS program has been evaluated regularly since its inception with the University of Melbourne's Centre for Health Policy, Programs and Economics producing 16 interim evaluations since 2003.  A review of the program was also ordered by the Minister for Health and Ageing in April 2008, and this was completed in February 2010.  The purpose of the review was to refocus the program to "better complement Better Access and to target service gaps for people who cannot easily access Medicare based programs."[5] The review was overseen by an Expert Advisory Committee comprising representatives of many of the key stakeholders in the mental health field. [6]  

3.5        Figures produced by the review of the program show that since 2003 it has provided over 600,000 mental health sessions of care, achieving improved consumer outcomes in 86 percent of cases.[7]  The last evaluation report, which looked at data from January 2006 to June 2010, found that there had been 150,954 referrals made in that period, with 113,107 patients receiving at least one episode of care.[8] The figures are small compared to the 11.1 million Better Access services that were delivered from 2007 to 2009. However a number of recent government health publications have foreshadowed the expansion of the program announced in the budget.

Broader Policy Context

3.6        In 2009 the National Health and Hospital Reform Commission (NHHRC) published a report called A Healthier Future for All Australians. This report included a number of recommendations intent on improving access and equity to better care for people with serious mental illness.  Many of these recommendations focus on providing a more holistic approach to mental health care outside of the hospital sector, as well as specifically proposing a national mental and sexual health service aimed at young people and the expansion of early intervention programs for this group.  In the broader context the report also recommends the establishment of Primary Health Care Organisations (Medicare Locals) that will evolve from or replace existing Divisions of General Practice.[9]

3.7        The Department of Health and Ageing's Building a 21^st Century Primary Care System–National Primary Health Care Strategy (2010) report has a number of key priorities for the delivery of mental health services. Some of the policies outlined include:

• Access to core services supported by universal access to a Medicare rebate will be retained but will be supplemented by targeted local programs and collaborations across the service system;
• Address current variability in access and outcomes, including for after-hours access, traditionally under-serviced groups, and for patients in transition across the service system;
• Service delivery will proactively respond to the needs of those Australians who find it difficult to access mainstream services, or who have specific health care needs whether because of their location or demographic characteristics or health status or because of the circumstances under which they need to access care. At the same time, mainstream services will be more responsive to the needs of different groups; and
• Service delivery and funding arrangements will support flexible service delivery models, promote effective and cost-effective use of technology and drive innovation by supporting information flows and workforce education and training.[10]

3.8        The Fourth National Mental Health Plan was endorsed by the Australian Health Ministers Conference in 2008.  The Plan commits to supporting better access to primary mental health services, particularly to those consumers unable to access Medicare Services. It also cites ATAPS as an example of a flexible delivery model at a local level that can provide targeted services that address service gaps.[11]

3.9        The ATAPS review report summarised the common themes across all of the these reports as—

• The Australian Government has an important role in primary health care including primary mental health care;
• There is a continuing need to ensure Medicare based universal services are provided in addition to blended funding models which utilise fundholding arrangements to target services to particular local and population needs, including episodic care;
• Service gaps need to be better identified and targeted through planned and coordinated approaches;
• Key groups within the community such as children and youth and Aboriginal and Torres Strait Islander people, remain a significant priority and require care sensitive to their needs and which they are more likely to access;
• Collaborative partnerships engaging non‐government organisations can play an important local and regional role in providing integrated treatment; and
• There is potential to better utilise new technology including web based modes of care in the provision of health services.[12]

ATAPS – performance to date

3.10      As mentioned above, ATAPS has provided over 600,000 mental health services from 2003 to 2009 with a total spend in that period of $80.7m.  These services were provided by 10,296 GPs (5,914 urban; 4,382 rural) who referred consumers to 3,527 allied health professionals (2,548 urban; 979 rural). The numbers steadily rose between 2003 and 2006 until Better Access was introduced in 2006.  To put these figures in context there are currently 24,000 GPs, 16,450 allied health professionals and 1,700 psychiatrists using Medicare items under Better Access.[13] Over 90 percent of the allied health professionals under both programs are psychologists. Following the introduction of the Better Access program the number of people referred by GPs to allied health professionals declined for around a year before rising steadily again.  Figures show that the impact of Better Access on ATAPS participation has been much less pronounced in rural areas.[14]

3.11      Over 70 percent of consumers using the ATAPS program are women with an average age of 39.  Around 2 percent are Aboriginal or Torres Strait Islanders.  Most people accessing the program present with high prevalence disorders such as anxiety and depression and between 2 percent and 6 percent of referrals include a diagnosis of severe mental illness.[15] The breakdown of figures for ATAPS does appear to support the premise that the program has the potential to be able reach marginal groups with 68 percent of all services delivered through ATAPS being accessed by people on a low income, and 45 percent delivered in rural areas.[16] In contrast, 25 percent of Better Access services are delivered in rural areas.

3.12      The treatment profile of those who received treatment through ATAPS is almost identical to that of Better Access patients with approximately 5 services provided per consumer.[17]  Discussion of the relationship between the treatment variables and the clinical outcomes in the sixteenth interim evaluation report of ATAPS suggests that six sessions of care 'are not only sufficient, but perhaps optimal in many cases', and that 'greater numbers of sessions are associated with poorer outcomes'.[18]

3.13      Around 75 percent of ATAPS services did not include a co-payment, and where it did it was more common in urban areas than rural.  The costs of each service ranged hugely from $57 to $631.  The review suggests that care be taken with interpreting these costs as they are affected by other factors such as the delivery of services to remote areas, or targeting hard to reach groups.   

Australian National Audit Office Report

3.14      The Australian National Audit Office (ANAO) undertook an independent audit of the ATAPS program in 2010-11, reporting to Parliament on 21 June 2011. The comprehensive report considered the design of the program; delivery aspects; the use of ATAPS in the response to recent natural disasters; and the monitoring and evaluation program for the program.[19]

3.15      The ANAO report highlighted positive features of the ATAPS program, as well as drawing attention to the challenging aspects of administering the scheme.  The positive aspects of the program discussed in the report included its capacity to respond quickly and with agility as illustrated during the Victorian bushfires and Queensland floods, and its ability to be used as a platform for new and innovative service delivery, targeting particularly hard to reach groups such as rural and remote consumers and young people.[20]

3.16      The administration of the scheme requires attention if the program is to meet the aims of the recent budget changes.  The ANAO report cites problems with the design and subsequent administration of the program to date:

...the administrative arrangements established by DoHA have not consistently supported the achievement of program objectives. In particular, there has been variable administrative performance, over the relatively long life of the program, in relation to a number of important program elements including: the allocation of program funding on the basis of identified need; monitoring compliance with program requirements; and the administration of new ATAPS initiatives.[21]

3.17      Aspects of the funding system in particular drew comment in the report.  The funding model of the program was initially population based, but has not correlated consistently with the gradual policy transition to a more needs-based targeted approach.  This aspect, tied with the lack of regular assessment of health care needs within GP Divisions, has resulted in 'some communities not receiving an equitable share'.[22]

3.18      The report found that the risk management of the program was also not designed to ensure that the limited resources available had the greatest chance of reaching those most in need.  The report suggested:

A risk‐based approach to monitoring compliance would enable the department to more effectively deploy its limited resources and to better identify, and if necessary treat, the risk of ATAPS not being used as specified in the program guidelines.[23]

3.19      The report had five recommendations, all of which were agreed to by the Department of Health and Ageing.  These were:

• To support the effective targeting of program funding, the ANAO recommends that DoHA provide options, for Ministerial consideration, that would allow the ATAPS program to transition to an appropriate needs based funding model.
• To strengthen management of the ATAPS program, the ANAO recommends that DoHA enhance support for program administrators through the provision of:

(a) induction and training tailored to the administration of the ATAPS program;

(b) fit‐for‐purpose policy and procedural materials to guide administrators, support consistent administrative practice and retain corporate knowledge; and

(c) a central repository to provide administrators with ready access to key program decisions that they require to efficiently discharge their responsibilities.

• To support equitable access to treatment for eligible consumers experiencing a mental health disorder, the ANAO recommends that DoHA periodically review the demand management strategies employed by Divisions funded under the ATAPS program and provide additional assistance and guidance where necessary.
• In order for DoHA to effectively monitor progress and assess the success or otherwise of any future ATAPS initiatives, the ANAO recommends that the department:

(a) establish success indicators at the commencement of each initiative and use these indicators to inform ongoing monitoring and evaluation activities; and

(b) record key implementation and evaluation decisions to support accountable program delivery.

• In order to plan and coordinate its compliance activities, the ANAO recommends that DoHA establishes a risk‐based compliance strategy, promulgates the strategy to internal and external stakeholders, and periodically reviews the strategy.[24]

ATAPS—next steps

3.20      The Government signalled its commitment to expand access to mental health interventions for marginalised and disadvantaged groups through ATAPS with the commissioning of the review of ATAPS in 2008.  The review indentified four areas for ATAPS to focus on:

Better Addressing Service Gaps

• The review recommends that there needs to be increased service provision in areas where Medicare services are limited through geography or locality. 
• ATAPS should also be utilised to provide services for hard to reach groups including Aboriginal and Torres Strait Islander people, children and young people, services for parents of children with mental health problems, people at high risk of suicide, homeless people, and any other group that could benefit from a more flexible model of care.

Increasing Efficiency

• The review recommends a change to the funding structure of ATAPS through the introduction of a two tier funding model.  The first tier would continue to provide services to supplement Better Access in areas, or for groups with limited access to Better Access.  The second tier would be able to target funding to areas or groups with particular needs. 
• An option for services to be delivered by NGOs where GP Divisions cannot or do not want to administer ATAPS services was also proposed.

Encouraging Innovation

• The Tier 2 funding would be able to be used by Divisions with a track record of providing innovative services for hard to reach groups. 
• This tier of funding would also be used for special purposes which in the past have included perinatal depression, bushfire support and telephone based cognitive behaviour therapy.

Improving Quality

• The review proposes the introduction of a requirement for continual professional development for all those health practitioners involved in the delivery of ATAPS services.
• Information exchange, best practice and benchmarking initiatives should be incorporated into all ATAPS projects and programs.[25]

3.21      The Government has committed to the expansion of the ATAPS program to incorporate the recommendations of the review in the recent budget changes.  The funding for ATAPS will increase from $36.1m in 2010-11 to $108.7m in 2015-16.  This represents a total spend over the next five years of $432.7m. The aim is to provide services for an additional 185,000 people over five years, specifically targeting hard to reach groups.[26]  

The ATAPS service delivery model

3.22      As discussed at paragraph 3.2 the service delivery model of ATAPS is to fund short term psychology services for people with mental health disorders through fundholding arrangements delivered through Divisions of General Practice, or Medicare Locals as they come on stream.  The delivery of these services is more likely to involve the input and collaboration of a number of health practitioners rather than a GP and a psychologist as is typical under Better Access.  It is this flexibility in service delivery which the various reports and evaluations have identified as being the strength of the program, but it also presents challenges around areas such as workforce management. 

3.23      The Australian General Practice Network (AGPN) have been instrumental in designing how ATAPS will function following the budget changes, but also in the context of the introduction of Medicare Locals.  They have been funded to develop a 'clinical governance framework for ATAPS that can be implemented in the Medicare Local environment and also to do a systematic workforce mapping exercise to better understand the status, skills and qualifications of the ATAPS workforce.'[27]  

3.24      AGPN gave evidence that suggests the potential for ATAPS is significant but there are barriers to its realisation:

ATAPS and related programs make for an opportunity to really embed a robust primary mental health care system. But this also means investment in those functions over and above what you could describe as straight program administration. I am talking about functions such as service planning; service development; partnership and linkage development with other providers[28]

3.25      They also refer to challenges presented by ATAPS being a capped program, rather than being funded through the MBS:

...while these service models have injected much-needed new services that are complementary to MBS funded services, these are capped programs and it has not been uncommon to see demand outstrip supply.[29]   

3.26      AGPN's concerns about the type of infrastructure required for ATAPS to be successful are supported by the Australian Association of Psychologists inc. (AAPi) who said:

Our opinion is that the ATAPS funding is targeted towards a client group which requires case management as its primary service. Multidisciplinary teams operate to help people who are homeless and need housing and who are alcohol intoxicated and need detox. A whole range of services can be only provided by case managers and not psychologists. Psychologists are not the right people to be doing that. That money will go into services within offices that last 50 minutes. What is needed is for ATAPS to be directed more to community services like community health centres, community mental health centres, social workers, nurses and welfare officers.[30] 

3.27      The Public Health Association of Australia also recognised that the ATAPS program requires the involvement of many health practitioners:

The Budget’s extension of access to the ATAPS program will help to promote collaborative care.[31]

3.28      An example of the diversity of an ATAPS program was provided in evidence by North East Health Wangaratta who told the committee:

We are mental health nurses, with a psychologist and a social worker. Given the work we are doing, I think we are doing it admirably.[32]

3.29      This is in contrast to evidence received from the Australian College of Mental Health Nurses who submitted:

Mental Health Nurses have informed the ACMHN that they have difficulty obtaining work under ATAPS. At least one former Division of General Practice which is now a Medicare Local has made a decision only to engage psychologists under ATAPS.[33] 

3.30      The AGPN confirmed this diversity in ATAPS teams, and the challenges involved in data collection around the issue:

In some cases some general practice networks employ a single discipline, in some other cases there are multidisciplinary staff... That is one of the things that we are about to try to look at to get some more substantial and significant information on exactly what the ATAPS workforce looks like because we have some of the workforce that is subcontracted and some that is employed. Many general practice networks find it extremely difficult to actually recruit an allied health workforce, particularly in the rural and remote areas.[34]

3.31      The Australian Counselling Association contributed to the debate on the diversity of the ATAPS workforce by describing mental illness as a continuum which could be treated by a variety of different health professionals depending on the stage of the illness:

[We] believe that we certainly meet the criteria for ATAPS. However, that sort of detracts a little bit from the perspective we are coming from in that we believe that mental health is in a continuum...the problem is the siloing of professions. Every profession wants the dollar for their profession and every peak body wants the money for their members—which is fine... Shouldn't it be based on consumer need? The consumer need is best looked after by ensuring that the person whom they are seeing is at the appropriate level—not over qualified or underqualified.[35]

3.32      The Australian Psychological Society (APS) also commented on the potential negative impacts. They said in evidence that one of their great worries was that under a capped ATAPS program funded through Medicare Locals or GP Divisions, consumers would be treated by inexperienced psychologists:

They try to find the psychologists they can get for the lowest possible salary...Because the money is much lower for the psychologists [than through Better Access] you do not tend to get the very experienced ones and because now it has become such a niche program to these hard-to-deal-with groups you want the most experienced psychologists there. You actually want people that have really good training in those niche areas. That is a worry.[36]

3.33      One of the consequences of the variety of delivery models with ATAPS is the proportion of the budget that goes into the administration of the program.  The AMA submission cites the ANAO report that says:

Originally about 85 percent of ATAPS funding was utilised by Divisions for service delivery and the remaining component was set aside for administration (15 percent). Over recent years, the proportion of funding quarantined by Divisions for administering the initiative has substantially increased. Now many Divisions use a ratio of 75 percent service delivery to 25 percent administration.[37] 

3.34      The AMA contrasted these ratios to those of the Better Access initiative in which they say 'every dollar allocated...goes directly to the delivery of clinical care.'[38]

3.35      The committee put these figures to the AGPN at its public hearing in Melbourne on 19 August. The AGPN provided an expansive answer on what additional administration costs may cover:

We have made it clear in our submission that we think the 85:15 ratio is inadequate. Our key point in making that statement, though, is that we would draw a distinction in relation to the sorts of activities that that 15 per cent would cover by way of administering a program, managing a contract with government, entering data into a minimum dataset, which are some of the program administration types of activities that divisions do as a routine undertaking in managing ATAPS. Where we think there needs to be additional capacity is for something that you would not necessarily categorise as administration but it is a legitimate function of service delivery and service design, and that is to have capacity to do the local consultation and work with local hospital networks and state funded services about how this new expansionary funding into ATAPS can be best mobilised on the ground. It is meant to be a targeted program, so you would not want a division to just replicate a state funded service in the region; you would want it to integrate and to target elsewhere. They are quite sophisticated service development and planning functions that you cannot buy with a 15 per cent admin vote.[39]

3.36      The APS also commented on the additional administration expenses associated with ATAPS:

I think ATAPS is quite expensive, in part for good reason. It is targeting niche groups which are quite difficult, such as homeless people, Indigenous people, people that are suicidal, et cetera. You do need to spend money sometimes on outreach. It is not all in the office and so forth. ATAPS is run through the divisions at the moment and Medicare Locals in the future that take a cut for administration. I personally do not see the need for that happen. I think it can be direct referral through the GPs like Better Access is.[40]

3.37      The ANAO report surveyed GP Divisions on the issue of administration cost for the ATAPS program, and the potential costs following the government's reforms: 

All Divisions interviewed by the ANAO commented on the adequacy of administration funding and the implications of the recent increased emphasis on targeting ‘hard to reach’ consumers through more flexible and innovative models of service delivery. Divisions considered that these developments, coupled with a heavy reporting and data collection workload, warranted a review of the current level of administration funding.[41]

Administration costs

3.38      The committee notes the expansion of ATAPS to hard to reach groups, and to better meet the mental health needs of consumers in an ongoing and holistic manner. It notes the expectation that this will entail higher administrative costs.  It also notes that the ATAPS program is not intended as an alternative to the Better Access initiative.  It may be able to provide a different type of care, and one of the ATAPS program's strengths is its flexibility to provide a broad care package to consumers.  However, it is expensive in comparison to Better Access,[42] and the substantial funding increases are not due to come on stream until after Better Access has been reduced.

3.39      The ATAPS service delivery model is also complex in nature and requires long-term planning and design, particularly around workforce issues, before it can begin to meet the anticipated needs of consumers. The committee notes that there has been 16.1 million allocated in the 2011–12 financial year, which has begun to be provided to GP divisions.[43] The committee hopes that the various reports, reviews and evaluations provide DoHA with a template to work from in the design and planning necessary for the implementation of an expanded ATAPS program.

Can ATAPS fill the gaps?

3.40      The key question that came up in the evidence before the committee was whether the newly designed program could meet the demands placed on it given the reduction in some aspects of the Better Access program.

Funding barriers

3.41      The ability of ATAPS to improve access for hard to reach groups more effectively than Better Access has been recognised in DoHA's 2010 review, as well as the ANAO report, as one of its potential strengths.  However while the emphasis on meeting the needs of key groups within the community such as Aboriginal and Torres Strait Islander people, or people in rural and remote areas is welcomed, the question remains of what happens to those consumers who require an extended level of care that will in future not be provided through the Better Access program.

3.42      The APS were quite forthright in their view that ATAPS is not ready to fill the gap:

The government has stated that people affected by the cuts can be seen under the Access to Allied Psychological Services, or ATAPS, program run through the divisions of general practice, but this is not a viable referral option under current arrangements. There is simply not enough funding in ATAPS to provide services for anything like the 87,000 people per annum.[44]

3.43       The issue of funding levels and administration requirements as barriers to using ATAPS came up frequently during the committee's public hearings.  The Royal Australian College of General Practitioners (RACGP) highlighted the difficulties faced by many GP Divisions in administering ATAPS:

If I refer a patient to ATAPS, as I did last week—and I work in an Aboriginal medical service—I am trying to access services where they are not going to be out of pocket, which is what ATAPS does. I have to be registered with the division myself. That takes time. It requires a meeting with someone from the division. I then have to get a reference number for my patient and I have to determine whether the psychologist I want to send them to also has a reference number. I have to conduct a specific tool that they want—the DASS21 tool—to assess their patient. We then have to complete all the ATAPS forms alongside our mental health plan form, which we do for Better Access anyway. It is an enormous amount of paperwork and the rebate is not there; it is basically the same.[45]

3.44      The RACGP also commented on the budgeting requirements for a capped program such as ATAPS:

...ATAPS has different rules and regulations across Australia. A lot of divisions spend their ATAPS funding six months into the 12 months and then there is nothing left. Also...often there are bureaucratic issues that have to be gone through to finally access the service. Often in mental health emergencies timing is everything. If you have someone who is suicidal or in acute personal crisis, you want to link them with services quickly. So, from my perspective, nationally those are the three issues that most concern our members about ATAPS.[46]

3.45      On this specific issue the committee also heard from Northeast Health Wangaratta who provided information on how they budget within the ATAPS framework:

We budget ours and because it is an employment model we employ the EFT that we can with that funding. I have heard of other divisions where their money has run out three months into the year. Because we have an employment model it is balanced across the year. It means that there is less during the year but it is spread.[47]

3.46      However, Northeast Health Wangaratta added the following points regarding their funding arrangements:

For the last five years, base funding to the ATAPS program for tier 1 services has remained constant, with no consideration of increases in clinician wages or increased travel costs relating to fuel price increases. This has been highlighted to the department repeatedly as an issue for this service in annual plans and reports. The increase in wages for clinicians and associated service provision costs has meant a 15 per cent reduction in clinician hours for this coming financial year. This is in stark contrast with the state funding for the area mental health services, which is recurrent and indexed.[48]

Clinical need

3.47      Despite the high participation rate of Better Access, there remains a significant number of people in need of more expert care than Better Access, in its current form, can provide.  In evidence to the committee Professor McGorry described the types of disorders this group may be experiencing:

They suffer from a variable mix of persistent mood and anxiety disorders, eating disorders, post-traumatic stress, complex personality problems, substance abuse and psychotic disorders. This group of people need access to more specialised forms of care than the basic primary care approach can provide. This means we need a secondary model involving many different types of expertise running from clinical psychology, psychotherapy, psychiatry and addiction medicine through to social programs for housing, family support, further education and employment.[49]  

3.48      The question is whether ATAPS can fulfil the role of that 'secondary model'.  The Flexible Care Packages (FCPs) and the 'Tier 2' ATAPS funding initiatives have the potential to better meet the needs of consumers with persistent long-term disorders.  In its discussion paper on the Flexible Care Package aspect of ATAPS the Government had originally pledged $60 million of funding for the three years from 2011-12.  This funding was revised in the budget when the Government announced that the money earmarked for FCPs for the two years from 2012-13 would now be rolled into the Coordinated Care and flexible funding for people with severe, persistent mental illness and complex care needs.[50]

3.49      The purpose of the funding has presumably not changed.  The January 2011 Discussion paper provided a description of how the FCPs funding would deliver care to consumers:

The total number of ATAPS flexible care services provided to an individual (both clinical and case coordination) will depend on the individual’s particular needs. It is estimated that an average of 20 clinical services in a calendar year will be provided to each individual, although it is recognised that some clients may need more clinical services in a calendar year depending on the level of severity of their illness and associated disability. In addition nonclinical support will be available to the individual, subject to their needs and care plan.[51]

3.50      The Tier 2 ATAPS funding initiative is also an attempt to utilise the agile and flexible capacity of the ATAPS program.  The Tier 2 funding is described earlier in this chapter as funding that would be available to GP Divisions, or Medicare Locals for special purposes such as disaster relief or innovative projects to meet the needs of hard to reach groups.  Again this is an important initiative with the potential to enhance flexibility and reward innovation.  However the question as always remains whether the funding levels will be sufficient to meet the needs of consumers.

3.51      The committee agreed in principle with Professor Hickie's statement that the movement of consumers with complex needs from Better Access is not necessarily a bad thing as it will guide them towards a more appropriate care model provided through ATAPS.[52] 

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