Chair's Additional Comments
Introduction
1.1
The Community Affairs References Committee strives to reach consensus in
inquiry reports. In this case, the committee has tabled a majority report that
it agrees outlines the evidence received during the course of the inquiry. However,
committee members were unable to agree on specific recommendations to address
the concerns raised by those who contributed to the inquiry. Therefore, Senators
from each party have tabled additional comments or dissenting reports. The Chair
has carefully considered all the material presented to the committee and
identified recommendations that she feels best reflect the breadth of the evidence
received. This report needs to be read in conjunction with the majority report
as it specifically addresses issues raised in the majority report.
Better Access
1.2
Given the conclusions reached in both the Better Access and ATAPS
evaluations, the Chair accepts the Government's conclusions that Better Access
has not reached lower socio-economic groups or rural or remote areas as well as
it has people in metropolitan areas. There is greater scope for ATAPS to meet
the needs of hard to reach groups than Better Access, in particular, ATAPS is
structured more appropriately to reach those groups.
1.3
Better Access began as an initiative aimed at high-prevalence disorders.
However, the initiative has been increasingly used by people experiencing
severe symptoms. The Government has not been sufficiently clear in
communicating whether its objective is to target particular mental illnesses,
particular levels of severity of condition, or conditions of a particular
duration (chronic versus short-term episodic). The Government needs to
communicate better to both professions and the public about what Better Access
is for, and what it is not for. It also needs to make clear, to those for whom
Better Access is not the right program, what existing service they should be
accessing.
1.4
In the case of severe conditions, such as eating disorders, the
committee heard that people have difficulty securing treatment. This echoes
evidence received over six years ago by the Select Committee on Mental Health.
The extended 18 sessions of Better Access have provided a way for professionals
to deliver a recognised treatment program for these disorders. The Government's
view may be that this was not the intention of Better Access, but at this point
there is no alternative. This situation will become worse under the
Government's proposed changes.
1.5
The rationalisation of MBS rebatable sessions under the Better Access
initiative is likely to, in the immediate term, exacerbate existing service
gaps for people with severe and persistent mental illness. The committee has
not received evidence that ATAPS will meet the needs of these people in the
short term. In theory the Better Access initiative was designed to address high
prevalence disorders that could be treated by 6–12 sessions. However, in the
absence of viable alternatives, this initiative has been utilised to provide
treatment to people with a severe mental illness who need the maximum 18
sessions. Until the Government provides an alternative, effective means to
address the needs of people with a severe mental illness, it cannot justify
excluding these people from accessing services under Better Access.
Recommendation 1
1.6
The Chair of the committee recommends that the rationalisation of the
number of rebatable allied health sessions under Better Access be delayed until
it can be demonstrated that other programs (such as ATAPS) are adequately
equipped to provide services to people with a severe or persistent mental
illness.
Recommendation 2
1.7
The Chair of the committee recommends that the Government consider
putting in place an interim program through the MBS that would allow access to
six additional sessions under Better Access for consumers who meet tightened
criteria based on the severity of their condition.
Recommendation 3
1.8
The Chair of the committee recommends that the Government continue to
evaluate Better Access and keep a watching brief on how the program is being
accessed nationwide with a particular focus on the take up of Better Access
services by hard to reach groups.
Access to Allied Psychological Services
1.9
The mental health workforce is key to the delivery of any mental health
policy initiative. The expansion of ATAPS, in conjunction with the introduction
of Medicare Locals, presents significant opportunities to embed mental health
services in primary care. However, the program faces significant challenges. The
composition of the workforce should be expanded more consistently, beyond GPs
and psychologists, to incorporate more mental health nurses, social workers and
counsellors. In addition, the design and planning of care initiatives through
interaction with hospital and NGO networks should be central to what the
program can deliver. The Northeast Health Wangaratta model is an excellent
example of this.
1.10
The Chair supports the Government's initiatives to broaden the ATAPS
program and provide the type of holistic care that is required by some
consumers. The effort to reward innovation through Tier 2 funding is also
encouraging.
1.11
ATAPS will not and is not designed to meet the needs of consumers in
crisis. For this reason it is not going to meet the needs of those
experiencing severe mental illness who are currently receiving treatment under
the 'exceptional circumstances' provision of the Better Access program.
1.12
In addition, ATAPS places a greater administrative burden on GPs than
the Better Access program does. The APS suggestion that referrals could be
carried out in a similar administrative manner to Better Access should be
explored.
1.13
Further, ATAPS is a capped funding model while Better Access is not. In
the context of specific funding arrangements, financial management will become
an important consideration for GP Divisions, Medicare Locals or NGOs. The
employment model used by Northeast Health Wangaratta is a useful model,
although in some cases this may not be appropriate.
1.14
While flexibility and the ability to design the program according to
local need is one of the positive elements of ATAPS, there is a danger that
this could result in patchy or inconsistent service delivery across the
country. The Government needs to develop guidance to assist in the rollout of
Medicare Locals and the expansion of ATAPS and advise practitioners on how to
achieve the full potential of ATAPS. This guidance should include advice on financial
management and the development of innovative programs targeting hard to reach
groups. Given that the timescale for the expansion of ATAPS is relatively
long, there is also scope to establish a comprehensive performance assessment
framework that could highlight examples of best practice in service delivery
that could be disseminated and adopted across the country.
Recommendation 4
1.15
The Chair of the committee recommends that the Government develop
guidance materials as quickly as possible to assist Medicare Locals and GP
Divisions in meeting the full potential of the expanded ATAPS program. This
material should include examples of nationwide best practice in areas such as financial
management and the development of innovative projects targeting hard to reach
groups.
Recommendation 5
1.16
The Chair of the committee recommends that a comprehensive performance
assessment framework be established as part of the ATAPS expansion. The data
gathered should be used to develop benchmarking tools to compare ATAPS service
delivery across Medicare Locals and GP Divisions with similar geographic and
demographic indicators.
1.17
The expansion of ATAPS is an appropriate recognition of the complex
challenges which face mental health delivery nationwide. The diversity
possible within the program, ranging across the traditional Tier 1 funding,
through Tier 2, to the Funding Care Packages and Coordinated care model, is an
encouraging first step in what needs be a long term policy commitment by Government
to bring mental health to the same stage as physical health care. However
while the committee did not hear any evidence that opposed the expansion of the
ATAPS program, it has also not heard any evidence that supported a view that
the program will be substantially operational in its new form by November 2011.
Under the current proposals there will almost certainly be a substantial period
where Medicare Locals and GP Divisions will not be fully engaged with the ATAPS
program, and consequently will not be able to deliver appropriate mental health
care for consumers. The Chair is greatly troubled by this scenario.
Recommendation 6
1.18
The Chair of the committee urges the Government to revise its scheduling
for the 2011–12 Federal Budget changes to ensure continuity of care.
Youth Mental Health
1.19
There is widespread support for headspace, but also widespread concern
about whether all the policy settings are right to ensure the initiative
succeeds. The external evaluation identified a range of issues, and submitters
have added to those. The greatest concern appeared to be whether the funding
model would be effective in ensuring the ongoing participation of GPs.
1.20
Adequate remuneration for GPs will be needed if they are going to agree
to participate in headspace centres rather than working elsewhere.
However, as headspace pointed out, health professionals including GPs
working in the centres do not have to be self-funded through the MBS. They can
also be paid as employees of the centres.
1.21
The Government is increasing the level of funding for each centre, not
only expanding the number of centres. Accordingly, one of the options available
is for the headspace consortia to seek to make use of this money to employ GPs
directly, ensuring a guaranteed funding base that provides a buffer against the
time pressures and other issues that submitters identified as discouraging some
GPs from working in this field.
1.22
The Chair is concerned about the transitional issues. Fundamentally, an
approach that cuts funding for one program now, with the expansion of funding
of other programs only coming later, cannot be supported. Funding shifts should
be closely matched. Changes to Better Access should take place, for example,
only as expansion measures such as additional headspace centres come
online. As the evaluation report noted, this will be 9–12 months after there is
agreement to fund them, to which must be added the lead times involved in the
competitive bid process.
Recommendation 7
1.23
The Chair of the committee recommends that any tightening of eligibility
for Better Access be delayed until the youth mental health initiatives funded
in the 2011–12 Federal Budget are fully expanded and operational.
National Mental Health Commission
Recommendation 8
1.24
The Chair of the committee considers that consumers must have a central
role in any mental health advisory body, and that Aboriginal and Torres Strait
Islander people should be represented. The National Mental Health Commission,
which will have nine Commissioners and a Chair, should include at least one
commissioner who is a consumer, one who is a carer and one who has Aboriginal
or Torres Strait Islander heritage.
Recommendation 9
1.25
The Chair of the committee recommends that the Government review the
operation and structure of the National Mental Health Commission after two
years with a view to placing it on a statutory basis.
Two-tier rebate for psychologists
1.26
The evidence does not provide adequately compelling arguments to change
the current arrangements. Out of nine areas of practice endorsement that
generally require higher levels of study, only one attracts a higher Medicare
rebate. The Chair recognises, however, the value of the services provided
across the range of practice areas. In these circumstances, the Government
should undertake ongoing monitoring of any effects of the two-tier Medicare
rebate for psychologists on workforce composition.
Recommendation 10
1.27
The Chair of the committee believes that the new Mental Health
Commission should undertake ongoing monitoring of the two-tier Medicare rebate
for psychologists to ensure that patients have access to the most appropriate
practitioners and that workforce balance across the mental health sector is
maintained.
Senator Rachel
Siewert Senator Penny Wright
Chair Australian
Greens, South Australia
Australian Greens, Western Australia
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