A re-design of psychological care

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Going into the federal election last week, the Alliance for Better Access reflected about our position and decided on a change of stance to suit the times. We share the following summary for your own thoughts and discussion in the comment thread below. If you support us, please sign our online petition.

The following areas of policy change relate to Medicare-supported psychological care. In the current system, Australians must first obtain a GP or Psychiatrist referral for psychological care, which requires a diagnostic label of a mental disorder to approve ten visits of therapy. At the end of those ten appointments Medicare support simply runs out. There are no exceptions, no assessment of ongoing need, just an abrupt end to therapy for those who cannot afford the fee on their own. We think the system stinks and it desperately needs to change.

Access to at least five visits

People often stall making their first appointment of psychotherapy. Sometimes they just want a bit of time to sort things out on their own, but other times it’s because facing a difficult personal issue is confronting and the idea of sharing that with anyone else can be overwhelming. Even with a GP-referral in hand, it is not uncommon for people to hold onto that white envelope for weeks, or even months, before picking up the phone to make their first appointment with a therapist. It’s pretty obvious that we need to make this a little easier.

When you go to see a GP for a medical check-up, there’s no demand on you as a patient to prove that you need care before you can receive medical attention. That’s the beauty of Medicare – Australia’s universal healthcare system. When it’s working as it should be, Medicare allows us to receive timely support before a problem becomes more life-threatening. And if we are serious about addressing mental health care, then that same principle should apply to psychological care.

On that basis, we propose that every Australian should have access to 5 appointments of psychological care each year, if needed, without a GP referral.

Flexible assessment criteria

In cases where more than 5 sessions are required, we suggest that it may be worthwhile getting further opinion. At this point, the system we propose looks similar to the existing Better Access program, where you see a GP and can get a referral for psychological care with a Mental Health Care Plan. The way this program runs currently, you need a GP diagnosis of ‘an assessed mental disorder’ to receive any support from Medicare. This puts symptom-based biomedical factors in the foreground, when most people seeking psychotherapy are looking for a more tailored approach. We typically need to consider personal context, socio-cultural factors, and treatment preferences alongside a diagnosis or list of symptoms. Test results are just one small part of any good psychological assessment. Under the changes we propose, mental health professionals will for the first time be able to integrate all of the relevant factors into a tailored assessment of need. Treatment planning should recognise the whole person and their circumstances. In partnership with their GP or psychiatrist, people will be able to access psychological care on their own terms.

In our view, a Mental Health Care Plan should not be exclusively framed around a diagnostic label because there is far more to mental health than that. Personal context matters and illness-labels do not always help.

Time-based support

When someone needs psychological support it is hard to know exactly how many appointments will be needed. It’s not so different from medical care, where what may at first appear to be a relatively uncomplicated issue could take time to resolve. One must also bear in mind that due to the sensitive and personal nature of mental health issues, trust is critical. It is therefore unlikely in many cases that a brief consult with a GP will reveal all of the relevant aspects of a problem. Access to psychological care across a reasonable period of time will allow further assessment and re-evaluation of the treatment plan, so that all parties involved can arrive at an accurate understanding of how to properly address the mental health issue. As it stands currently, medical practitioners and mental health professionals are forced by the system to make snap judgements in short bursts of care, which leans towards an overly simplistic impression of the problem and solutions in the form of a quick fix. People’s lives are often far more complicated than it first appears, so rather than rushing to judgement that a fixed number of appointments will do, we believe a time-limited system of care might work better.

Mental Health Care Plan should offer access to a 6-month period of psychological care. For those who attend weekly appointments, such a system will arrive at a statistically optimal number of appointments (around 24 sessions). For those who require more than 6 months of therapy, we propose a Mental Health Care Plan review process in much the same way as already exists. Each re-evaluation of the plan will approve access to a further 6-months. This is needed to ensure that psychological support is not prematurely cut short.

Weekly appointments when needed

The Medicare system provides support for medical care on an as-needs basis. That is, when people need to, they can visit a GP or psychiatrist once per week. This is important for the care of highly vulnerable people who find themselves unwell and potentially at risk of harm if they do not get help. The same principle should apply for psychological care. We need to get the balance right between access to psychological care and medical care, so that one is not being traded off or neglected in favour of the other. Under the current system, people with complex needs or low income will ration out their ten Medicare sessions across the year, so that they are not left without access to therapy. What that means is that many people in need currently access less than one appointment per month. As it stands, the only alternative is to use up all of your Medicare visits within a few short months only to find that later in the year you have no access to therapy. We think that policy represents a serious neglect of responsibility in that we ultimately abandon those in need of psychological care.

In our view, at least weekly access to psychological care should be available for those on a Mental Health Care Plan.  In some high-risk circumstances, we suggest that ‘exceptional’ criteria may be developed to allow several appointments per week. For the vast majority of cases however, it is straightforward that allowing people to make appointments at a weekly interval is the responsible way to manage a mental health condition and is consistent with guidelines on best practice in the field.

Will you support our call for change?

If you think our proposal looks good, then please sign our petition. And remember, if you would like to add more suggestions for change, then leave a public comment with your signature when you add your name to the petition. We will collect all of your good ideas and report them alongside the final tally at the end.

If you have more questions or a few points of criticism, please take a moment to quickly go over our FAQ page about this issue. Make sure you come back and leave your comments on the topic thread below so everyone can join in with the discussion.

Oh and by the way, you can also find our group (the ‘Alliance for Better Access‘) on Facebook. Worth checking out and joining in the discussion if this topic interests you.