Reforms in Lock-down

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Australia has done well to avoid the worst of the coronavirus. We move in fits and starts between times of lock-down, leaving people with a mix of relief and dread that we are all just one press conference away from putting our lives on hold again. Plans are shelved, some quietly forgotten about. Attention spans are limited to the immediate, most obvious problem, right in front of us. Anything more complex than that is parked. In therapy, my colleagues refer to this as “putting out spotfires”, but what happens when we do that at a nation wide policy-level?

Just over a year ago the Productivity Commission handed a report of the mental health system to the Australian Government (made public in November 2020). The recommended reforms were estimated to lead to gains of $21 billion per year to Australians at a cost of $4.2 billion, with close to 90% of those gains flowing from the identified priority reforms. When the Federal Budget came in May 2021 it became clear that the investment of funding was far too low and not focused on those priority reforms (see page 3). A significant emphasis of the Federal Budget was put on expanding the existing Headspace network to cover 164 locations and building similar Headspace-like centres for Adults. My concern is about what has happened to those priority reforms identified by the Productivity Commission? I hope the following examples show why these reforms are now more important than ever.

Expanded Telehealth
Mental health care practitioners who provide online consultations have been calling for better Medicare support for years – long before the pandemic. In March last year I gave a brief overview of the obstructive policies which prevented many people from accessing psychological care. At the time, eligibility to access therapy online was determined by whether one was bush-fire affected, living in a remote location with a specific region code, or being classified as vulnerable to COVID-19. Thankfully the red-tape around online services has been removed for the time being, however it is clear that MBS telehealth items are just temporary (it’s literally in the name of the item) and are due to expire on 31 December 2021. In mental health care, telehealth services have allowed much more flexible service delivery and have improved continuity of care in situations where a person might otherwise not be able to attend in person. It goes without saying that these services have been essential during periods of lock-down and have potentially reduced the transmission of the virus (and other infectious diseases) across the last year or so. As practitioners and the wider public have gained experience with telehealth some have become more familiar with this approach. From the way people have engaged with telehealth across this period, it would seem that there is a great potential to broaden public access to psychological care in Australia. Coming back to the Productivity Commission Inquiry, the 2020 report is clear that the Australian Government should enable “access to MBS-rebated psychological therapy and psychiatry via telehealth regardless of where people live” as a matter of priority (p. 29). It is unsettling that the Federal Budget for 2021 made no mention of that priority and there is no word from the Australian Government about what will happen when those temporary COVID-19 telehealth services lapse in a few months time.

Additional Sessions
Similarly, ten additional sessions of psychological care are currently available in Medicare as a temporary measure to address COVID-19 and due to expire in June 2022. As with the above telehealth items, initially these were restricted, in this case to people in lock-down. Thankfully those additional ten sessions are now available to all Australians who access the scheme, bringing the maximum number of sessions per year up to 20 appointments. For Australian psychologists (and others) that decision to increase the maximum cap on sessions brought a huge sense of relief. Those familiar with my work in advocacy will know how important this issue is. But how long will it last?

From my conversations with colleagues and friends in both Canada and the UK, I’m aware that they are facing similar dilemmas with policy restrictions and maximum session caps. For example, I’m aware that in Ontario there are moves by the government to cap access to psychotherapy at 24 sessions under OHIP (their equivalent of Medicare in Australia). That political agenda sparked a campaign pointing out that 24 hours (i.e., just one day) of therapy is often not enough and that policy makers don’t really know what is best for a person seeking care. Decisions like these are best left between the person seeking care and their mental health care provider. Similarly in the UK, I’m aware that access to psychological care via the IAPT scheme in the NHS offers prescribed psychological care up to the NICE-recommended number of sessions, usually at somewhere around the 15 to 20 session mark.

The point is there’s a natural policy trend towards setting an artificial upper limit on therapy, not for the sake of personalised care, or good research evidence, but rather, the perception that doing so will drive down costs. In reality, we know from decades of psychotherapy research that when we offer people access to as much therapy as they want, the average number of sessions remains low and people improve until their level of distress falls back down to the ‘normal’ range, whereupon they bring therapy to a close on their own (Barkham et al., 2006Baldwin et al., 2009Stiles et al., 2015Owen et al., 2015). Of course some will need more access to therapy than others, but we do not save money as a society by neglecting mental health care. On that note, the Productivity Commission report calls specifically for research trials to explore adding more sessions to Medicare-supported psychological care. Nobody seems to know anything about research of that kind being underway, which leads me to think that it probably isn’t happening.

Will we remember the Productivity Commission Inquiry into Mental Health when the pandemic is over? Can we really afford to wait until these temporary COVID-19 measures are phased out? Tell me what you think in the comments below.