Dissenting Report by Coalition Senators

Chair’s Report

1.1 Coalition Senators note that the Chair's report was to only have reported the evidence given at the hearing or extracts from submissions. This was the agreement reached at the meeting of the Community Affairs Committee on 28 October. Instead, the Chair's report includes commentary about the evidence.

1.2 The Coalition's comments herein are intended to comment solely on the evidence received and our conclusions drawn from the same.

Better Access Initiative

1.3 The Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Scheme initiative (Better Access) was a central part of the Howard Government's contribution to COAG's National Action Plan on Mental Health (2006–11). The agreement by COAG in July 2006 was:

based on a recognition that, after a decade of national reform, renewed government effort was needed to give greater impetus to the reform process. The Action Plan represented a landmark in the history of mental health services in Australia. For the first time, leaders of all governments focused on the issue of mental health and agreed to a plan to reform mental health services that addressed not only health needs, but made commitments to activities in other key areas of housing, employment, education and correctional services, all of which have an essential part to play in improving the mental health of Australians.[1]

1.4 The intention of the Coalition’s historic 2006 investment of $1.9 billion in mental health and its centrepiece Better Access was 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. The initiative commenced on 1 November 2006.

1.5 The joint media release by then Minister Abbott and Pyne of 9 May 2006, outlines the objective of the COAG mental health announcement:

The 2006-07 Budget delivers on the Government’s commitment of $1.9 billion to improve services for people with a mental illness, their families and carers. These measures are the Commonwealth Government’s contribution to the COAG Mental Health package, as announced by the Prime Minister on 5 April 2006.

These practical measures will provide families, schools and health professionals with more support in recognising and addressing mental illness and new assistance to people who are living with mental illness and their families.

A national information campaign will raise awareness of the links between illicit drug use and mental illness.[2]

1.6 Under Better access to psychiatrists, psychologists and general practitioners through the Medicare Benefits Scheme new rebatable Medicare items were introduced:

New Medicare rebates will be introduced for people with mental illnesses to access improved services from appropriately trained GPs and psychiatrists and, on referral, from clinical psychologists.

It is expected that, in the fifth year of the initiative, an additional 35,000 people with severe mental illness will be able to obtain access to a psychiatrist. Also in the fifth year, approximately 400,000 Medicare-funded services will be provided by clinical psychologists.

It will encourage team-based mental health care in the community with psychologists working alongside GPs, psychiatrists, mental health nurses and other allied mental health professionals. G Ps will be provided with training to improve their detection of mental illness and quality of services.[3]

1.7 It is clear from the Ministers' press release and comments such as the following from then Prime Minister Howard, that the focus was on mental illness, with no differentiation between mild to moderate or severe:

The package I am announcing today comprehensively addresses the key shortcomings in mental health services in those areas for which the Australian Government has responsibility.

...

We are providing:

A major increase in clinical and health services available in the community and new team work arrangements for psychiatrists, GPs, psychologists and mental health nurses;

New non-clinical and respite services for people with mental illness and their families and carers;

An increase in the mental health workforce; and

New programmes for community awareness.[4]

1.8 Eligible patients were able to receive up to 12 individual and 12 group sessions per year (plus an additional 6 sessions in exceptional circumstances).[5] Changes were made in 2009 that enabled GPs with specific mental health training to claim higher rebates.

Evaluation of Better Access

1.9 In 2009, the Department of Health and Ageing tendered for consultants to evaluate seven components of the Better Access program. The evaluation was not released until mid-February 2011.

1.10 Criticism of the evaluation included the lack of measurement of key objectives of the Better Access program and how performance over the time of the program had been measured. For example, one of the initial objects was better co-ordination of services between mental health professionals. The evaluation did not measure this and other objectives.

1.11 The evaluation showed positive results including that since the introduction of Better Access, more people have accessed mental health services and the uptake of the rebatable sessions has been high and increasing with 2.7 million, 3.8 million and 4.6 million Better Access services being delivered in 2007, 2008 and 2009 respectively.

1.12 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. Indeed, there were real criticisms levelled at the evaluation, including from the Mental Health Council of Australia.

1.13 The Government is spending about $10 million a week on this program but only about $1 million on this evaluation. Since 2007 over 2 million people had received more than 11.1 mental services, yet only about 1,350 consumers were assessed despite the 2 year long evaluation. Uptake rates of treatment were 10% lower for people in the most disadvantaged areas and there was no evaluation at all of those traditionally disadvantaged, those from culturally and linguistically diverse backgrounds and Aboriginal and Torres Strait Islander people. This evaluation raised more questions than it answered.

1.14 The Coalition raised questions at past Estimates about the evaluation including about the tender process. As indicated, Better Access has assisted about two million people but the evaluation only surveyed about 1,350 consumers; or about 0.07%. It is questionable whether the sample used was an effective one, in order to achieve statistically and clinically significant results and whether the Government adequately consulted on what such an effective sample might have been to achieve statistically and clinically significant results.

1.15 The Coalition also raised questions about who determined the consumers to be surveyed in that it appeared that the very providers who were providing the services chose the consumers to be surveyed.

1.16 As indicated above in the Abbott/Pyne media release of 9 May 2006, one of the explicit founding objectives of this program is to encourage collaborative care, the Coalition is concerned that this was not properly assessed. The evaluation reports that there have been some 16 million mental health sessions under the program and it was unclear from the evaluation what therapies were being provided and whether they were evidence based care like cognitive behavioural therapy or just non-specific counselling.

1.17 At previous Estimates, evidence was provided about the overall proportion of new customers to repeat customers. Answers provided on notice indicate that in 2008, 68% of better Access clients were new customers. In 2009, this percentage had dropped to 57%. This would indicate that the program was designed for short sharp (cognitive behavioural therapy) CBT-based interventions were being used to provide ongoing or continual mental health services to the same clients.

1.18 Table 1 in the evaluation report purports to list the strengths and weaknesses of each data source. The strengths listed in relation to many of the data sources includes supposedly large and representative sampling which is questionable given that only 1,350 consumers were assessed. The common weaknesses identified were 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.

1.19 Several submitters commented on what they considered weak aspects of the methodology or limitations of the data set. The methodology of the study was the target of particular criticism in that it did not proceed according to scientifically accepted methods, the latter crucial for establishing the most accurate results. For example, the Australian Psychological Society College of Clinical Psychologists drew the committee's attention to:

...significant research methodological flaws within the Better Access study, which cautions us as to the credibility of the study and to any unintended simplistic equating of its findings to “proof” or “fact” to a level of evidence that would inform thinking around service planning and workforce issues. The level of evidence attributable to a single study with such a research design is not sufficient for such purposes.[6]

1.20 The Coalition shares the concerns of various submitters and believes 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.

1.21 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 comparative to metropolitan areas, and that the significant uptake of Better Access overall has been very expensive. The Government asserts it has made significant changes to its mental health spending in the 2011–12 Federal Budget and has used findings of the evaluation demonstrating the significant expense of Better Access to support its rationalisation of the initiative.

1.22 In short, it is arguable that the Better Access evaluation, with all its methodology and data set faults was set up to fail in order to enable the Government to take the money out of the program in order to recycle money back into the sector to give the appearance of "mental health reform" at a time when the Government has no real money available to spend on mental health.

1.23 There appears to be little evidence in the evaluation that justifies changing the GP rebate or the number of psychology sessions.

Changes to the Better Access Initiative

1.24 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. 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 wants to redirect funding from Better Access towards other programs such as Access to Allied Psychological Services (ATAPS), headspace, and Early Psychosis Prevention and Intervention Centres (EPPIC).

1.25 Rather than reforming mental health, it appears that the Government here is robbing Peter to pay Paul! By rationalising services, the Government is redirecting funds from one program to another.

1.26 In so doing, it is unclear whether the Government has any plan to monitor any impact on the quality of care available to people as a result of the changes.

1.27 Criticism has also been levelled at the Government at the lack of transparency leading up to the decision to cut the Better Access program. In 2008

General views on the budget announcements

1.28 There was a mixed reaction for the budget announcements with some initial support for what appeared to be overall increase in the mental health budget, qualified by some stakeholders who objected to aspects of the detailed proposals.

1.29 The Mental Health Council of Australia expressed the view that the announcements were:

...an important step towards improving the mental health system and the mental health of all Australians. They reflect a commitment by the Government to improving mental health and increasing the availability of mental health services in Australia.[7]

1.30 The Consumer Health Forum commented:

The Federal Government's 2011-12 Budget promised a range of new initiatives for mental health services that will result in improved outcomes for many Australians.[8]

1.31 However, the Australian Medical Association, the Royal Australian College of General Practitioners, as well as the Australian Psychologists Society all expressed concerns about the impact of the changes to the Better Access initiative. The AMA requested that the committee:

...recommend that the Government reverse its 2011/12 Federal Budget decision to cut Medicare funding for mental health services delivered by GPs and psychologists under the Better Access Program.[9]

1.32 The Australian Psychological Society urged the committee to:

...focus its attention on the Federal Budget cuts to the Better Access initiative as these are due to come into effect on 1 November 2011 and will deny effective psychological treatment to an estimated 87,000 people per annum from this date.[10]

1.33 While the Royal Australian College of General Practitioners said that:

The College is gravely concerned regarding the proposed cuts to the Better Access program and the subsequent impact on mental health delivery for every patient age group, demographic, and geography throughout Australia.[11]

Consultation on mental health spending

1.34 In 2008, the Government established the National Advisory Council on Mental Health (NACMH) with the objective to:

...provide[s] a formal mechanism for the Australian Government to gain independent advice from a wide range of experts to inform national mental health reform.[12]

1.35 Professor John Mendoza was appointed the Chairman but in June 2010, he resigned criticising the Rudd government for its lack of action on mental health. In an interview on PM on 21 June 2010 gave his reasons for his resignation:

Well it’s a frustration rather than anger. When I took this role on I genuinely believed that the Government was going to take a different approach to mental health reform. They’d certainly made clear in opposition that they were determined to address the long standing problems in this area.

They had commented on many aspects of the Howard government’s response in this area as being inadequate and wanting to do a lot better and, in fact, the formation of the council was specifically in response to, I guess, the lack of progress from the reform policy agenda that had been in place for some time.

So after two years, however, it was pretty clear we were getting nowhere.[13]

1.36 The chairmanship remained vacant until December 2010 when the Minister for Ageing and Mental, the Hon. Mark Butler appointed himself as the chairman of the NACMH. Either Mr Butler could not find anyone to replace Professor John Mendoza who quit the council in disgust in June or he wants to take a ‘hands-on’ approach and steer the council on the government’s path which appears to be to do very little. South Australia’s Social Inclusion Commissioner, Monsignor David Cappo, was appointed as deputy chair. At the time there was criticism about lack of transparency and objectivity – how can you have an advisory council to the minister chaired by the minister himself?

1.37 Despite the existence of the NACMH, in December 2010, the Mental Health Expert Working Group was established by Minister Butler specifically to provide advice on mental health reform in the lead-up to the 2011–12 Federal Budget. Membership of this group comprised:

Dr Christine Bennett; Monsignor David Cappo AO; Dr Pat Dudgeon; Mr Anthony Falker; Mr Toby Hall; Professor Ian Hickie AM; Professor Lyn Littlefield OAM; Ms Janet Maher; Dr Christine McAuliffe; Professor Patrick McGorry; Professor Frank Oberklaid; Ms Sally Sinclair.[14]

1.38 The Terms of Reference for the expert group were determined as follows:

The Mental Health Expert Working Group (MHEWG) is being established as a time-limited working group to provide confidential, strategic and practical advice to the Australian Government to inform mental health reform directions and decisions.

The MHEWG will provide significant input to the Australian Government about how to achieve well coordinated, cost-effective and lasting reforms to mental health care across a broad range of clinical and non clinical service systems with the aim of developing a strong, sustainable system now and into the future.[15]

1.39 Questions were asked by some submitters during the inquiry as to why it was necessary to establish a new group to provide advice on the above matters rather than consult the NACMH. However, other submitters were dissatisfied with its composition:

This submission refutes the defence that this group are independent and impartial including proffered explanation that the group are picked from a small academic mental health sector. There are nearly forty Australian Universities who could make solid contribution to a mental health policy expert panel...

This issue is considerably more significant than concerns about conflict of interest. The mental health reform agenda is intrinsically based in closed, non-consultative and exclusive process which is part of the larger imposed shift of health reform.... [16]

1.40 The Australian Clinical Psychology Association (ACPA) commented:

While this group includes eminent mental health professionals whose knowledge and direction may be generally useful in determining policy, the group was dominated by public sector interests, and under-represented by those working within the Better Access Initiative, which was the program most affected by the changes made. The recent resignation of Dr Christine McAuliffe, who represented GPs within this group, is of considerable concern.[17]

1.41 The Association of Counselling Psychologists (ACP)also expressed disquiet about the group:

The ACP questions the independence of the Mental Health Expert Working Group, on the basis that a significant number of the members of that group have a longstanding bias against Better Access and a conflict of interest towards funding their own projects.[18]

1.42 The Coalition is concerned that there was confusion about the consultation processes that this expert group undertook. In Estimates evidence was given that this group did consider the Better Access evaluation. Indeed, there is a real issue as the precisely why this expert group was established, and having been established, why it failed to contain with its ranks key representatives of the affected groups, including consumers.

1.43 The process was not handled as well as it could have been, and appears to have raised doubts amongst some stakeholders about the effectiveness of the National Advisory Council on Mental Health. It not only reinforces the earlier point about the credibility of an advisory body set up to give advice to the minister but chaired by the minister himself, but raises real questions about transparency and objectivity of its deliberations. .

Rationalisation of GP mental health services—new time dependent rebates

1.44 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 argues it has sought to align mental health consultation rebates more closely with standard consultation rebates and that 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. However, a relatively higher rebate will be available to GPs who have undertaken specific mental health training. 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.

1.45 The Royal Australian College of General Practitioners (RACGP) have 27,000 GPs on their vocational register.[19] Figures from 2006/07 show that 31% of these GPs worked in areas outside major cities.[20] In the first full year of the Better Access program in 2007, GPs provided services to 618,867 people through the Better Access Initiative, rising to 971,836 in 2009.[21] In 2010 an estimated 72% of GPs using Better Access have completed mental health skills training and are eligible to claim the higher rebates for consultations.[22]

1.46 The Government asserts it has made these changes noting the Bettering the Evaluation and Care of Health (BEACH) report, which was one of the data sources used to compile the evaluation. The BEACH report indicated that over 80% of GP mental health treatment plans were being completed in less than 40 minutes, with an average time of 28 minutes. Criticism was levelled at the use of BEACH data because it does not take into account the total time spent by GPs in preparing plans.

1.47 The Australian Medical Association (AMA) was concerned that the BEACH data only refers to face-to-face time between GPs and patients and as such does not accurately reflect the total time spent by GPs on mental health treatment plans. In evidence at the hearing 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.[23]

1.48 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.[24] Professor Claire Jackson, President, Royal Australian College of General Practitioners (RACGP) summarised these concerns for the committee:

The cuts to the Better Access program announced in the recent federal budget will jeopardise the mental health care of an estimated one million patients per annum, risking the current high patient access levels, quality of patient care, excellent clinical outcomes and our mental health workforce capacity.[25]

1.49 Moreover, the changes fail to take into account 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%, would act as a further disincentive for GPs to work within the headspace mental health care model.[26]

1.50 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 and 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.[27] It is clear that the major provider submitters were very concerned about these changes.

1.51 GPs providing mental health consultations are concerned that those consultations require a time commitment beyond face-to-face time and as such advocate they be recognised with a higher rebate. However, in acknowledging this view, the Coalition notes that there was no specific 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. In this sense, it would have been preferable for consultations to occur with key providers and stakeholders to canvass the effect of these changes and other options available. This was not done. Accordingly, in the absence of clear evidence about this, the Government cannot draw this conclusion as the Department sought to do in evidence.

1.52 In addition, the Coalition notes that the higher rebate will be retained for GPs who have completed mental health training but it is unclear whether this incentive for GPs to undertake training will encourage continued quality care. At the hearing, the Department of Health and Ageing (DoHA) explained to the committee that 72% of GPs have completed the mental health training, and therefore will be eligible for the higher rebate. It can be inferred (although there is no evidence of this) that most GPs will continue to receive higher rebates for mental health consultations than they do for standard consultations.

1.53 The Coalition believes that any rationalisation of rebatable Medicare items for mental health consultations to align more closely with standard timed consultations ought to have been discussed and fully canvassed with key provider groups and stakeholders before being arbitrarily inserted into the budget purely as a cost saving measure.

Rationalisation of allied health treatment sessions—10 session entitlement

1.54 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. This change has been made as a savings measure based on an evaluation which at the very least has limitations of the available data about the Better Access program and at worst, asks more questions than it provides answers. It is clear from the evidence at the hearing that the impact on patients was not fully canvassed.

1.55 Concerns have been expressed about the rationalisation of rebatable sessions under Better Access from a maximum of 18 to 10 mostly by psychologists. Understandably, many of their patients would feel reticent about providing submissions about this change, although the committee is grateful to those patients who have made such submissions.

1.56 The arguments above in favour of retaining the 18 session maximum relies on the assumption those Medicare rebatable sessions under Better Access should be used 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.

1.57 This goes back to the objectives of the original program. It is the basis of the Coalition's criticism of the Better Access evaluation in that it did not measure whether the program actually achieved what it set out to do.

Targeting hard to reach groups

1.58 The Better Access evaluation and the various ATAPS evaluations discussed in the Chair’s report appear to suggest 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. RCAGP for example disputed DoHA's assertion that Better Access is not reaching rural and remote areas.

1.59 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 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.[28]

1.60 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 socio demographic, where over 150,000 people were being treated, but the growth rate in that area was the greatest. [29]

1.61 The Coalition recognises the conclusions reached in both the Better Access and ATAPS evaluations but also notes that these, most particularly the Better Access evaluation, have been criticised. Despite the increased access to services afforded by Better Access, there remain issues about access by lower socio-economic groups, those living in rural or remote areas as well as people in metropolitan areas.

1.62 Whilst there may be greater scope for ATAPS to meet the needs of hard to reach groups than Better Access, there is a real issue as to whether ATAPS is structurally able to do so. In the absence of this assessment, the Coalition is concerned that denying access under Better Access, in the absence of a clear, viable and properly structured alternative, is not in the best interests of patients.

1.63 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, the extent of the dormant demand in the community, 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.

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

1.64 DoHA maintains 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. DoHA also maintained that in the long term the current approach was able to deliver appropriate levels of mental health care for those suffering severe mental illness. However they did concede that some gaps in service delivery do exist:

...these are people who should not necessarily be treated in the kind of primary care program like Better Access or, indeed, ATAPS. We would be encouraging states and territories, through their specialist mental health systems, to be lifting their game and closing service gaps that we all know exist in those kinds of areas—the pointy end of service delivery.[30]

1.65 Coalition notes that some submissions support the savings generated by the rationalisation of Better Access sessions and consider that ATAPS is targeted towards assisting people with a severe and persistent mental illness.

1.66 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.

1.67 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.

1.68 The RACGP commented:

The budget cuts have been formulated despite the proven benefit of the Better Access program, including improved overall treatment rates for patients...[31]

1.69 The Australian Psychology Association (APS) conducted research on the types of conditions that were treated through Better Access:

The research conducted on a large sample of 9,900 people who received between 11 and 18 sessions of treatment from psychologists under the Better Access initiative last year shows that these people are overwhelmingly those with severe depression or anxiety disorders...These people would be denied the additional sessions of psychological care required for effective treatment through the Better Access initiative under the 2011 budget funding cuts.[32]

1.70 It is very clear that there is a real difference of opinion as to whether Better Access or ATAPS is the more appropriate service delivery for these groups. The existence of this disparity of views is further testimony that the Government has failed to undertake proper consultation on the most appropriate way forward.

1.71 The Coalition is concerned that 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. We are further concerned that the committee has not received evidence that ATAPS will meet the needs of these people in the short term.

1.72 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.

1.73 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.

Access to Allied Psychological Services (ATAPS)

1.74 The Government's asserts that its 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 and that its reform is supposedly focused on addressing the needs of people identified as not always receiving adequate mental health services. The Government believes that the Access to Allied Psychological Services (ATAPS) program is seen as one way of meeting these challenges.

1.75 The ATAPS program was established by the Coalition in 2002 with the objective of funding 'short term psychology services for people with mental health disorders through fund-holding arrangements delivered through Divisions of General Practice'. The ATAPS projects enable GPs to refer patients with high prevalence disorders such as depression and anxiety to allied health professionals (predominantly psychologists).

1.76 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 fund-holding arrangement.

1.77 The ATAPS program has been evaluated regularly since its inception. Since 2003 it has provided over 600,000 mental health sessions of care, achieving improved consumer outcomes in 86%. 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.[33] Certainly, the 150,954 referrals made from January 2006 to June 2010 are relatively small compared to the 11.1 million Better Access services that were delivered from 2007 to 2009.

1.78 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.[34] Over 90% of the allied health professionals under both programs are psychologists. Following the introduction of the Better Access program the numbers for referring both GPs and 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.[35]

1.79 Over 70% of consumers using the ATAPS program are women with an average age of 39. Around 2% are Aboriginal or Torres Strait Islanders. Most people accessing the program present with high prevalence disorders such as anxiety and depression and between 2% and 6% of referrals include a diagnosis of severe mental illness. [36]

1.80 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% of all services delivered through ATAPS being accessed by people on a low income, and 45% delivered in rural areas. In contrast, 25% of Better Access services are delivered in rural areas.

1.81 The Australian National Audit Office (ANAO) undertook an independent audit of the ATAPS program in 2010-11, reporting to Parliament on 21 June 2011. Whilst the ANAO report highlighted positive features of the ATAPS program, it did draw 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.

1.82 However, the ANAO report cited 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. [37]

1.83 Aspects of the funding system in particular drew comment in the ANAO 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'.

1.84 The ANAO report also considers 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 ANAO report made certain recommendations noted in the Chair’s report and the areas identified for ATAPS to focus on namely: better addressing service gaps, increasing efficiency, encouraging innovation and improving quality.

1.85 The Government asserts that it has committed to the expansion of the ATAPS program to incorporate the recommendations of the review in the recent budget changes with funding for ATAPS to increase from $36.1 million in 2010-11 to $108.7 million in 2015-16 ($432.7 million over 5 years) with the aim being to provide services for an additional 185,000 people over five years, specifically targeting hard to reach groups.

1.86 As indicated earlier, the service delivery model of ATAPS is to fund short term psychology services for people with mental health disorders through fund-holding arrangements delivered through Divisions of General Practice, or Medicare Locals as they come on stream. The Coalition has been critical of Medicare Locals and has stated its objective of abolishing them.

1.87 The Coalition notes evidence that the Australian General Practice Network (AGPN) 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.' However, that evidence suggests that whilst the potential for ATAPS is significant, 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. [38]

1.88 The Coalition points to evidence in the hearing about the challenges presented by ATAPS being a capped program rather than being funded through the MBS including:

a.      reports by Divisions that demand far outstrips supply and funds are running out well and truly before the end of the year;

b.      the funding is targeted towards a client group which requires case management as its primary service with multidisciplinary teams and the involvement of many health practitioners;

c.      concerns that only psychologists are providing services and other allied mental health professionals are being excluded;

d.      the capped funding means that in some cases, Divisions may be forced to employ less experienced psychologists to make funding go further; and

e.      the proportion of the budget that goes into the administration of the program (with the ANAO report stating that originally 85:15 ratio of service delivery to administration has now become 75:25.

1.89 The Coalition notes that the AMA’s submission contrasted these ratios to those of the Better Access initiative where 'every dollar allocated...goes directly to the delivery of clinical care.'[39]

1.90 At the hearing, the AGPN stated the 85:15 ratio is inadequate and advocated for an additional capacity for service development and planning functions that you cannot buy with the current 15% administration vote.

1.91 The Coalition is concerned that there has been lack of consultation about the impact on the mental health workforce of the shift from Better Access to ATAPS. Given our criticism of Medical Locals, the proposed expansion of ATAPS does present challenges that have not been properly considered. The Government has failed to consult key stakeholder providers.

1.92 It is also unclear whether the Government proposes ATAPS as an alternative to the Better Access initiative. Whilst it is arguable that ATAPS 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, it is expensive in comparison to Better Access, and the substantial funding increases are not due to come on stream until after Better Access has been reduced.

1.93 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 Coalition cannot see how the necessary foundations will be in place by November 2011.

1.94 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.

1.95 Whilst it has been argued that ATAPS can improve access for hard to reach groups more effectively than Better Access, the Coalition is concerned as to what happens to those consumers who require an extended level of care that will in future not be provided through the Better Access program.

1.96 The Australian Psychological Society (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.[40]

1.97 The issue of funding levels and administration requirements as barriers to using ATAPS came up frequently during the committee's public hearings. RACGP highlighted the difficulties faced by many GP Divisions in administering ATAPS paperwork in the absence of any rebate, including:

(a) accessing services where the patient will not be out of pocket;

(b) ensuring the GP and any psychologist referred to also has requisite reference number;

(d) complete ATAPS forms and any mental health plans;

(e) other general administrative requirements.[41]

1.98 The RACGP also commented on the budgeting requirements for a capped program such as ATAPS and pointed to the following three issues of concern:

(a) ATAPS has different rules and regulations across Australia;

(b) a lot of divisions spend their ATAPS funding six months into the 12 months and then there is nothing left; and

(c) often there are bureaucratic issues that have to be negotiated to access the service and these are especially challenging in cases of mental health emergencies where timing and the need to access services quickly is critical (for example where patients are suicidal or facing an acute personal crisis and therefore need to be linked with services quickly).[42]

1.99 Whilst the Coalition appreciates the flexibility of ATAPS, there are concerns that this could result in patchy or inconsistent service delivery across the country. We are concerned that the shift from Better Access to the ATAPS structure is not adequate to meet the challenges of the added requirements placed on the ATAPS program. As a consequence, we share the concerns of those submitters in relation to adequate service delivery.

1.100 The Coalition is concerned that the impact of the shift from Better Access to ATAPS has not been fully considered, especially given the complex challenges which face mental health delivery nationwide. The Government’s assertions of 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 have not been properly assessed with key stakeholders.

1.101 Clearly, there is no evidence that the program will be substantially operational in its new form by November 2011. The Coalition is concerned that 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 access appropriate mental health care for consumers.

Youth mental health

1.102 The Coalition supports headspace and Early Psychosis Prevention and Intervention Centres (EPPIC). The Coalition’s Real Action Plan for Better Mental Health will provide a nationwide network of staged care to assist young Australians to access quality mental health services and pursue productive and fulfilling lives. The Coalition’s announcement at the 2010 election includes:

(a) 20 Early Psychosis Intervention Centres;

(b) 800 mental health beds; and

headspace

1.103 The Coalition established headspace in 2006 with Commonwealth funding. headspace currently delivers services at 30 centres across all states and territories. headspace is a model of delivering integrated mental health services to young people by co-locating specialist and primary health services at headspace centres and its vision is: “To improve the mental and social wellbeing of young Australians through the provision of high quality early intervention services, that are welcoming, friendly and supportive.”

1.104 The Coalition shares the concerns of headspace that these changes will affect headspace services given that health professionals at the centres, including GPs, psychologists, social workers, mental health nurses and occupational therapists, are either directly employed through headspace core funding, or self-funded through MBS items or private billing.

1.105 headspace targets 12–25 year olds with a mild to moderate mental disorder, and seeks to assist them across four key areas: general health; mental health and counselling; alcohol and other drug services; and education, employment and other services. The Chair’s report outlines the history of headspace and various evaluations of its work which indicate that headspace has improved mental health services for young people, especially early-intervention services for people aged 12–17.

1.106 The report also suggests ways in which headspace could improve its timeframes for service delivery, the need to engage target groups and funding issues, all of which will be impacted by the Government’s proposed changes.

1.107 The Coalition notes that in advocating an expansion of the headspace centres, the Government is adopting the Coalition’s policy. Whilst the headspace's submission to the inquiry welcomed additional funding, it highlighted that the rationalisation of Better Access, particularly the changes to MBS mental health treatment items, is likely to add to existing workforce issues with respect to attracting GPs to headspace centres:

Attracting GPs is already a considerable challenge, particularly in areas of GP shortage. headspace, across its 30 centres, has a full time equivalent of only eight GPs. headspace centres are finding it increasingly difficult to recruit GPs as there are not sufficient incentives for GPs to work in youth mental health. We believe that with the current systems and initiatives in place, it is not financially viable for GPs to work with young people. Many GPs are not comfortable working with this client group in general, and financial disincentives exacerbate this reluctance.[43]

1.108 headspace CEO Chris Tanti expressed concern that GPs may reduce their availability to practice at headspace centres once the proposed cuts are implemented:

Mental health treatment plans are a core activity for GPs working in a headspace centre. For example, analysis of 28 out of our 30 centres showed that in the last financial year item No. 2710, for a 40-minute preparation of a mental health treatment plan, equated to over one quarter of the total GP revenue billed at headspace centres...

The majority of GPs who are working in our centres are very passionate about working with young people...So I suspect they will not leave entirely but they will reduce the amount of time they have available at headspace.[44]

1.109 Conversely, the Australian Medical Association (AMA) suggested that increased funding to headspace should not come at the expense of Better Access. AMA anticipated that the time likely to elapse before new headspace centres are operational would suggest continued support to other initiatives in the interim is justified.[45]

1.110 The Coalition is aware that there is widespread support for headspace, but also widespread concerns 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.

1.111 The Coalition is critical of the Government for not having undertaken the necessary consultations with key stakeholders about these changes to fully assess their impacts. Whilst the Government is increasing the level of funding for headspace, the Better Access changes may result in headspace centres being forced to use such additional funding to employ GPs directly, thereby countering the disincentives caused by changes to the Better Access Initiative.

Early Psychosis Prevention and Intervention Centre (EPPIC)

1.112 The Chair’s report traces the origins of EPPIC from the 1988 establishment of a ward in the Aubrey-Lewis Unit at Royal Park Hospital dedicated to the treatment of young people hospitalised after their first episode of psychosis.

1.113 Whilst the Coalition recognises some disquiet about EPPICs, the Coalition supports early psychosis intervention centres as an important frontline service in addressing mental health issues. Indeed, such disquiet is compounded by the fact that the Government is cutting Better Access to provide funding for headspace and EPPICs, a criticism levelled at it by various submitters.

1.114 As indicated above, the Coalition is committed to Commonwealth funding for 20 centres. This is in contrast with the Government’s less promising commitment to fund four additional EPPIC sites in partnership with interested states and territories. The 2011-12 budget changes commit the Government to engage the states and territories to share the cost of funding and supporting an additional 12 centres, bringing the total number of centres to 16.

1.115 The Coalition is concerned that if the States and Territories do not make a contribution, then it is questionable whether the Commonwealth will maintain its commitment. Despite repeated requests, the Commonwealth and its department have not been prepared to commit to full Commonwealth funding if the deal falls through with the States and Territories. Hence, there is no guarantee that the Government's commitment to EPPIC will be matched by state and territory funding, and therefore no guarantee that the government will be able to fully deliver its planned expansion to EPPIC.

1.116 The Coalition is also concerned about the transitional issues in that the Government is cutting funding for Better Access now, with the expansion of funding of other programs only coming later. Accordingly, the Coalition believes that any changes to Better Access need to be considered in the context of new headspace centres and EPPICs coming online.

National Mental Health Commission

1.117 In the 2011–12 Federal Budget the Government allocated $32 million over five years for the establishment and operation of the National Mental Health Commission (the Commission) which it asserts will comprise nine commissioners, raise the profile of mental health issues, and provide independent advice to improve transparency and accountability in mental health policy.[46]

1.118 The Coalition supports the establishment of an independent National Mental Health Commission.

1.119 The Coalition has expressed grave reservations about the lack of transparency in appointments to the new National Mental Health Commission and most especially, about the appointment of Monsignor David Cappo as the first National Mental Health Commissioner.

1.120 Rather than being an independent body, the Government established a version of a NMHC as a unit in the Department of Prime Minister and Cabinet. Despite repeated questions, the Government has failed to outline what the selection process was for three appointments to the National Mental Health Commission.

1.121 In a Media Release on 1 June 2011, Minister for Ageing and Mental Health, the Hon Mark Butler promised greater accountability in mental health. He stated that:

More transparency and accountability in the mental health system will drive continuous improvement and innovation and help inform future investment in mental health...[47]

1.122 However, in a recent Estimates hearing, Mr Richard Eccles from the Department of Prime Minister and Cabinet, was not able to explain the selection process for the new CEO, Robyn Kruk, announced on 1 June 2011 or for the choice of Monsignor David Cappo as chair of the commission or of his replacement, Professor Allan Fels.

1.123 Monsignor Cappo had to step down barely a week after accepting this important role. In light of the media reports surrounding his appointment and various matters raised in the senate by Senator Xenophon, it was not surprising that Monsignor Cappo decided to step down for the position of Chair of the National Mental Health Commission.

1.124 The appointment of Monsignor Cappo had caused quiet concern in the sector as the role is seen as needing experience and the ability to deliver at the highest levels of government and the public sector. Mental Health is too important to be compromised in any way. His appointment lacked transparency and any semblance of a proper selection process. Indeed, the Coalition questioned the assertion by Minister Butler that Monsignor Cappo was the 'obvious choice', a position he maintained in the media release announcing Monsignor Cappo’s resignation.

1.125 There has been no consultation on any of the appointments and now no official explanation as to who made the choices or on what basis they were made. The Coalition has been critical of Minister Butler for failing to clarify how the appointments were made, how the nine new commissioners will be chosen and what the role and remuneration for all appointments will be.

1.126 Despite this criticism, Minister Butler persists in making assertions, such as the following in a Media Release of 7 September 2011:

This will drive greater transparency and accountability in our mental health system and deliver better outcomes for consumers and carers...[48]

1.127 The Chair’s report sets out the core function of the Commission namely to monitor, assess and report on how the system is performing and its impact on consumer and carer outcomes. The Commission will produce an Annual National Report Card on Mental Health and Suicide Prevention which will assess the relative effectiveness of a range of mental health programs and services, highlighting which services are actually delivering outcomes for people experiencing mental illness. The Chair’s report also indicates that the Government intends to establish the Commission as an executive agency, within the Department of Prime Minister and Cabinet, governed by a Chief Executive Officer. Under this model, the Commission will report to an agency minister within the Prime Minister's portfolio, who will also be responsible for appointing the nine commissioners.

1.128 Criticism has been levelled at the Government on two fronts about the Commission – about its limited scope and its lack of independence.

1.129 The Coalition shares the views of most submitters who commented on the Commission and supported the concept of an independent voice on mental health.[49] Several submitters suggested changing the format of the Commission, mostly to ensure its independence from to government, but also to improve its membership and representation, accountability and operation.

1.130 Under the Government's plan for the National Mental Health Commission, the commissioners will be appointed by the relevant agency minister, presently the Minister for Mental Health and Ageing. Given the lack of transparency of the process thus far, the Coalition shares the concerns of submitters about the selection of the commissioners and the need to ensure key stakeholders views are represented.

1.131 Some submitters queried whether or not the Commission, as an executive agency of the Department of Prime Minister and Cabinet, would be able to provide fully independent advice. However, it was clear from the evidence that the Commission's wider accountability and effective operation was also important.

1.132 As the body promoting accountability and transparency in mental health services, some submitters stressed that the Commission's own operation must be accountable and transparent. Submitters expressed concern that the parameters governing how the Commission will report on mental health services have not yet been determined and indeed, that the Commission should operate with clear guidelines around its roles and responsibilities, independence, and authority to implement changes.

1.133 Beyondblue commented that at this stage we really don't know what the Commission will look like:

it is a bit hard to respond...because no-one really knows just yet what it is going to look like... Our vision would be an entity that would be able to gather information and monitor the performance of mental health service delivery in Australia.^{^[50]}

1.134 Professor McGorry emphasised the importance of the Commission being independent:

I think the ideal is actually an independent commission—I think that is what we should aim for in due course; that is really the only way to guarantee independence...[51]

1.135 While the Mental Health Council of Australia also underlined the issue of independence and transparency:

We think there remain a number of questions to be answered, really, about how a national mental health commission will relate to similar or related bodies in the state jurisdictions and whether a mental health commission will in fact carry the independence and authority that are required.[52]

1.136 Whilst the Government explained that the rationale for positioning the Commission in the Department of Prime Minister and Cabinet was to ensure cross-portfolio coordination, this was not a rationale accepted by submitters who expressed doubts about whether the Commission could transcend portfolio and jurisdictional boundaries. Indeed, several submitters suggested that the Commission must be completely independent from government in order to deliver impartial advice and evaluate government spending.

Two-tiered Medicare rebate system for psychologists

1.137 The Chair’s report outlines the applicability and amounts of Medicare rebates for mental health services provided by GPs, psychologists, occupational therapists and social workers. The rebatable amount under Better Access for psychological services varies according to:

(a) the time spent providing services to the client;

(b) where such services are provided (in consulting rooms or otherwise); and

1.138 The 'two-tiered system' refers to the situation whereby services provided by clinical psychologists (tier one) attract a higher rebate than those provided by registered psychologists (tier two). The Chair’s report indicates that this has been the case since the implementation of the Better Access Initiative, and according to the Department of Health and Ageing, is based on advice from the psychology profession.

1.139 Medicare differentiates the services provided by psychologists from those provide by clinical psychologists. The Chair’s report examines the differing requirements for registration as a general psychologist, a clinical psychologist and an endorsed psychologist (in any of the nine practice areas) and then provides a summary of the arguments presented both for and against the two-tiered system.

1.140 The registration system is part of the National Registration and Accreditation Scheme for psychologists which replaced previous state and territory based registration arrangements on 1 July 2010. On the day of the commencement of the scheme, registration was transferred at equivalent level from state and territory boards to the Australian Psychology Board. Subsequent renewal applications (required on an annual basis) are made to the Board. The transition will be complete by 30 November 2011 at which time psychologists in all states and territories will be uniformly registered with the Board until 30 November 2012.

1.141 Submitters were divided as to whether the current scheme should remain unchanged (the argument primarily made by clinical psychologists) or should be changed to a single- or multi- tiered system (the argument primarily made by non-clinical psychologists). Aspects of this debate—alongside the rationalisation of rebatable sessions from a maximum of 18 to a maximum of 10 as discussed earlier—provided the impetus for more than a thousand psychologists to submit to the inquiry.

1.142 The Chair’s report traverses the arguments for and against the two-tiered system. The proposal was also made that the two-tiered system be abolished completely. Under the model proposed by some submitters, every registered psychologist would be eligible for the same Medicare rebate, regardless of any further qualification.

1.143 Whilst the committee received a very high volume of submissions from psychologists regarding the two-tiered rebate, the vast majority cited anecdotal evidence in support of their positions. However, it is clear that at a time when one in five Australians have some form of mental illness and the demand for mental health services is increasing, such a major difference of view amongst psychologist should be resolved, especially given the impact on workforce availability and on health outcomes for patients.

1.144 The Coalition suggests that consideration be given to referring the issue of the two-tiered system to the Australian Health Practitioner Regulation Agency (AHPRA) for further consideration as to whether current arrangements should be altered, including consideration of all the evidence provided to the inquiry. AHPRA was established on 1 July 2010 as part of the National Registration and Accreditation Scheme to regulate 10 health professions. The ten health professions regulated by AHPRA are: chiropractors; dental practitioners (including dentists, dental specialists, dental hygienists, dental prosthetists and dental therapists); medical practitioners; nurses and midwives; optometrists; osteopaths; pharmacists; physiotherapists; podiatrists; and psychologists. The AHPRA annual report for 2009–10 indicated that from July 2012, a further four health professions are planned to join the scheme: Aboriginal and Torres Strait Islander health practitioners; Chinese medicine practitioners; medical radiation practitioners; and occupational therapists.

1.145 In any case, the Coalition suggests that that the Government should undertake ongoing monitoring of any effects of the two tier Medicare rebate for psychologists on workforce composition.

Conclusion

1.146 In summary, the Coalition is critical of the Government for the way it has undertaken changes to Better Access. There has been scant consultation with key stakeholders to assess the impact of the changes, most especially on patients. Instead, the Government has relied heavily on the Better Access evaluation, which has been criticised on deficiencies in methodology and data sets.

1.147 The Coalition believes that until the EPPICs and additional headspace centres have been established and are operational, it will be difficult to fully assess the impact of these changes.

1.148 Furthermore, we are concerned that the consequences of the shift from Better Access to ATAPS have not been fully considered. This is particularly worrying given the challenges facing ATAPS which are highlighted in the ANAO report. Fundamentally, there is a real question as to whether the ATAPS structure is sufficient to meet this new demand. This is especially concerning given the estimates given at the hearing that there are potentially 87,000 people who are going to move from better Access to ATAPS. This is also complicated by the uncertainty of the move from the current system of Divisions of General Practice to Medicare Locals and how these changes will exacerbate already strained financial and structural issues.

1.149 In short, the Government has, like many other issues in Health and Ageing, taken action but failed to adequately assess the impact of its actions on key stakeholders and most importantly, on patients.

Senator Concetta Fierravanti-Wells Senator Judith Adams
LP, New South Wales LP, Western Australia

Senator Sue Boyce Senator Bridget McKenzie
LP, Queensland NATS, Victoria

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