Better Access Initiative Evaluation 2022

cohealth’s experiences of the Better Access program, as conveyed by clients to workers, indicate that while the program has benefits for some people, others face significant barriers to accessing it.

Better Access strengths

Some consumers are able to receive the mental health treatment they need more quickly, rather than attempting to access the public mental health system.

These clients were generally able to access bulk billing mental health practitioners, and had support from cohealth workers to navigate the process of arranging and attending GP and mental health practitioner appointments.

Other consumers prefer to not get involved in the public mental health system, and the Better Access program enables them to obtain mental health support without this involvement.

Some clients who believed that private mental health support was too expensive have been pleasantly surprised that they could see a psychologist at a subsidised rate.

Better Access limitations/areas for improvement

• Out of reach for people who experience disadvantage or have complex conditions or circumstances, because
  •  Few practitioners bulk bill, and the wait lists for these can be long.
  • Even with Medicare rebates, out-of-pocket costs can be in the vicinity of $70-$110 for a concession card holder.
  • These out-of-pocket costs associated with the fee-for-service model under which Better Access operates deter people from seeking care.
  • There are fewer private providers in areas of lower socio-economic status3, the areas that cohealth works in. Provision of services is based on workforce supply, not population need, and hence skews towards more affluent areas.

• Limited culturally specific service
  • Better Access does not include provision for interpreters. Unless interpreting is resourced through other services such as cohealth, or a practitioner can be found who speaks the same language, this can exclude people from culturally or linguistically diverse backgrounds.
  • Difficulty finding practitioners who are from the same cultural background, which may impact on engagement with the program.

• Clients with complex conditions/circumstances
  • Better Access practitioners are most familiar working with people with ‘high prevalence’ conditions such as depression and anxiety. People with more complex conditions such as BPD have to wait 3-6 months for a practitioner with the expertise to provide the treatment they require.
  • Many cohealth clients present with more complex conditions, such as dual diagnosis and/or a history of trauma, requiring specialised interventions that are less likely to be accessible to them through the Better Access program.
  • These clients have mistrust and limited faith in a system that is unknown and unfamiliar to them, and without a ‘warm hand-over’ this group of clients are unlikely to readily engage with a new clinician, or may withdraw, and hence not get the most out of service.
  • Private mental health practitioners are also less likely to accept referrals for clients they deem will have higher rates of not attending appointments or lower compliance.

• Navigating the system
  • Lack of awareness of Better Access – many clients are unaware it is possible to access private subsidised mental health support.
  • cohealth clients who have successfully used the Better Access program have done so with the support of a worker who explains the system, supports them to attend GP appointment and helps locate a practitioner with the appropriate background and expertise.
  • Peer/lived experience workers provide valuable support for people navigating the system.
  • Without this support and ‘warm handover’ people with more complex circumstances and conditions are unable to navigate their way through the processes – GP appointment, mental health treatment plan, arranging mental health practitioner appointments, understanding how to change practitioner if there isn’t a good ‘fit’ with the first one, GP review appointments to obtain further sessions.
  • Even with the level of support provided by cohealth the process of multiple referrals (e.g. GP mental health treatment plan & then to psychologist) delays the process and means that the moment of high motivation for clients with complex conditions and circumstances can pass, missing opportunities for engagement.
  • The therapeutic relationship with a practitioner is critical, particularly for people with complex conditions and circumstances. However, to check out a practitioner generally means using up one or more of the limited number of sessions.
  • Clients need to tell their story more than once, to different practitioners – the GP, then the mental health practitioner/s. This is particularly so for people who do not have a regular GP. This need to retell does not align with best practice in trauma-informed care.

• Additional consequences
  • The requirement for a GP to provide a mental health diagnosis can result in people being denied income protection or life insurance in the future. This is particularly the case if a person had suicidal thoughts, which are common for many cohealth clients with complex conditions and are situationally driven e.g. by homelessness or AOD misuse. Consumers are not advised of this possibility, and it is likely that GPs are not aware of it, so unable to convey to people. Ongoing stigma related to mental ill health underpins this consequence.

Better Access and the social determinants of health

It is important to note that the Better Access program does not address many of the structural drivers of mental ill health and distress, such as trying to live on a low income, homelessness and insecure housing, precarious employment and experiences of discrimination and racism. While cohealth acknowledges that these factors are outside the terms of reference for the current evaluation, reviewing mental health service provision without addressing these underlying causes will guarantee that demand for Better Access will continue to grow at a rapid rate. cohealth urges the Better Access evaluation to recommend the government take urgent action to reduce poverty (particularly by increasing the rate of JobSeeker payment), invest in social housing, ensure people have suitable, secure employment, and address racism and discrimination.

Recommendations to improve equity of access to the Better Access program:

• Increase access to bulk billing mental health practitioners.
• Develop practice incentives that support provision of services under the program to disadvantaged4 and other groups5 currently missing out. This would include economic, social, geographic and cultural groups.
• Introduce system navigation support and ‘warm handovers’ to assist those who face barriers to access.
• Reduce the steps needed to access the Better Access program, to facilitate quicker access to mental health care.
• Provide greater number of sessions per annum (by retaining the 20 sessions per year) where the complex nature of a person’s condition or circumstances supports this.
• Examine whether a clinical diagnosis that is recorded on a patient’s GP record is required, with a possible alternative approach being that records indicate that the GP identified a referral to a mental health practitioner as being clinically necessary.

About cohealth

cohealth is one of Australia’s largest community health organisations, delivering care from over 30 locations across the inner, north, and west of Melbourne as well as statewide services across Victoria. We provide integrated general practice, medical specialist, dental, allied health, mental health, alcohol and other drug, counselling, family violence, and social support services to more than 50,000 people each year.

cohealth prioritises people who experience social disadvantage and are consequently marginalised from mainstream health and other services – such as people who have multiple health conditions, have a disability or mental illness, experience homelessness and unstable housing, Aboriginal and Torres Strait Islanders, people from refugee and asylum seeker backgrounds, people who use alcohol and other drugs, recently released prisoners, LGBTIQ+ communities and children in out-of-home care.

Many cohealth clients have interacted with the Better Access program. Our GPs prepare mental health treatment plans (MHTP) and reviews and undertake MHTP consultations to many clients each year. Similarly, clients of other cohealth programs are referred to Better Access providers, including cohealth and external GPs and private mental health practitioners.

cohealth also has lengthy experience providing responses to people living with mental ill health. Services include mental health nursing, individual support, outreach services, mentoring, residential programs, homeless outreach, and complex care coordination. We operate several Mental Health and Wellbeing Hubs established in response to COVID-19 and undertake mental health promotion work. With our partners, cohealth will operate a new Brimbank Local Adult and Older Adult Mental Health and Wellbeing Service, one of the first six local services being established by the Victorian Government in response to the recommendations into the Royal Commission into Victoria’s Mental Health System.