More or Less Spin?

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Since August last year we have waited for the Minister for Mental Health to talk with us about the impact of cuts to the Better Access to Mental Health Care initiative. So far our patience across those 8 months has not paid off. However tonight the Minister will be on ABC’s ‘Q&A’ program where many of us are hoping he will finally address the concerns of the public. To date, responses from the Minister about the cuts to psychological therapy in Medicare have followed a fairly predictable pattern. My hope is that the producers, the host, and the panelists on the ‘Q&A’ program have some understanding of the kind of spin that is going on around this serious issue. That’s why we will take a moment now to remind everybody what this issue is really about and how to address the usual spin. Our goal in doing so is to keep debate honest with a view to arriving at a proper resolution of the current problems in the system.

First off we need to appreciate the value of providing psychological care. This goes far beyond economic value of course, extending into areas like helping people live happier and more productive lives. Providing good mental health care is valuable to so many areas, but even if we did just look at Gross Domestic Product (GDP) the benfits of funding treatment are clear. Comprehensive estimates that been calculated showing that there is a five-fold return on investment to Australia’s GDP when directing funding to psychological care. This issue is very important to consider today, with the PM’s announcement of a $12 billion budget deficit. Clearly we need to be looking at how to add value to the system. Providing timely psychological care to our workforce clearly benefits our productivity as a nation.

The Minister has previously cited statistics which show that “the majority (87%) of current Better Access users receive between one and ten sessions, and will be unaffected by the new cap.” The problem is that the Minister can’t have it both ways. If so few people use more than ten sessions then cutting access to therapy wont save much money. Conversely, if the Minister argues that significant cost savings can be made then this only goes to show how many people rely on Medicare support for the treatment they need. Those who do rely on Medicare support to access psychological therapy are being cut off prematurely, which makes it much more difficult for disadvantaged populations to recover.

A broader issue is that the Minister relies on Medicare data to justify the cuts, which overlooks decades of controlled research about how many appointments people need. The evidence from research is that people need closer to 20 appointments for a lasting recovery. Many researchers and practitioners are wondering how the Minister can justify capping access to therapy at 10 sessions when he has endorsed clinical practice guidelines for the treatment of BPD (borderline personality disorder), the Beyondblue guidelines on anxiety and depression, and the ASCA guidelines for the treatment of trauma, which all recommend access to 20 sessions or more? To put this really simply, researchers and practitioners working in mental health care need our politicians to implement evidence-based policy rather than relying on popular opinions, fads, or ideology to drive mental health care.

The Minister has also often repeated the false claim that the Better Access initiative wasn’t intended to treat people with complex, chronic, or severe conditions. This seems to come up every time the cuts are challenged, but it is a completely false claim: a political construction. We know from documents still available today that the Better Access initiative was always intended to expand access to treatment for all groups, specifically including those with serious mental health issues. Page 11 of the Better Access manual lists the client eligibility criteria for the program, identifying chronic psychosis, schizophrenia, bipolar disorder, and other conditions, which are all frequently complex and severe in nature. For those who are interested in finding out more about this, we addressed these claims over a year ago in detail (here) but more recently we published a piece on this in the August 2012 edition of the journal Psychotherapy in Australia (which you can read here).

One of the big branding issues is that politicians want to be seen as helping the needy. When cuts to the Better Access program were announced the political discourse was all about the percentage of people seen in Medicare who are identified as being the most disadvantaged. It was claimed that other programs like ATAPS see a larger percentage of people from disadvantaged areas. What they neglected to mention was that the ATAPS program is accessed by far fewer people. When we look at the figures in terms of real human beings (rather than percentages) it turns out that Better Access provides psychological care to 75,000 people from the most disdvantaged areas every single year. This is close to 7 times the amount of disadvantaged people who receive the same care in the ATAPS program. Another way to look at it is in terms of value for money in delivering each session of care. From that standpoint, the Better Access program costs under $125 per appointment (in the majority of cases it is under $85 each session) whereas ATAPS costs an average of $167 per appointment each time. It just doesn’t make financial sense to cut funding from Better Access to fund ATAPS when both programs compliment each other. Both programs help us to reach disadvantaged people in the various settings where people seek help.

Nevertheless, what we often hear from those in favour of the cuts is that the Better Access initiative does not specifically target disadvantaged populations as some components of the ATAPS program do. This opens up the issue of means-testing Medicare, or similar proposed measures such as providing additional sessions beyond 10 to those who are disadvantaged. There are a couple of important things to realise here. First, we need to acknowledge that the ATAPS program isn’t means tested either, but rather, the referring GP ticks a box indicating whether they deem a patient to be on a ‘low income’ or not. Second, we need to appreciate that means-testing mental health care is problematic in itself because there are no other areas of health which are means tested under Medicare. The implication is that mental health disorders are given a lower status than all other physical health conditions covered under the universal Medicare system. If the reach of Medicare to disadvantaged populations is really the issue, then the fairness test would dictate that the same tick-the-box system used by ATAPS could be employed. The great difficulty with that proposal is that mental health disorders are experienced by people from all walks of life, living in every suburb, and doesn’t just affect those who look worse off in an appointment with their GP. Deeper than this though, we have to wonder how serious our politicians are about targeting mental health problems in Australian society when the topic is shifted to an issue of class rather than medical or psychological necessity. One would hope that mental health care is as important to our politicians as it is to the rest of the Australian population.

In any case, let’s hope the Minister addresses the questions tonight in an open and honest way. We are looking forward to some constructive proposals on how people can get enough psychological care to recover. Please share your comments and reflections below.