While all mental health practitioners can agree the mental health system in Australia needs to be reformed, AAPi and I beg to differ with the recent views of Professor Ian Hickie. 

The fact is that in ignoring the recommendations in the Better Access review and cutting back the extra 10 subsidised psychology sessions afforded during Covid, the Federal Government has stripped away vital services without offering anything as a replacement. 

Prof Hickie has long supported “mental health hubs'' which give the impression that services are being expanded and so quickly gain government favour. The cost of providing such services is exorbitantly high compared with Medicare, with the most recent headspace evaluation estimating that each session cost $230 on average, excluding indirect costs such as rent and utilities. This is over 2.5 times the cost to the government of seeing a psychologist under Better Access ($89.65). While hubs may offer a solution in some areas, they are not the only, or in some cases, the best solution. 

Earlier in my career, I worked in three different headspace locations, including one in a significantly low socio-economic area in Western Sydney. I chose to work at headspace for the same reasons a lot of psychologists do: the name is reputable, they do a lot of good work in low SES areas, and they have systems and structures to support clinicians who are just starting out in private practice, as I was at the time, after working in an NGO for five years. 

Ironically, headspace relies on Medicare funding to pay the contracted psychologists working at their services. What I came to understand was that the young people accessing services, particularly in that area of Sydney, blew through 10 sessions in one to two school terms. They needed more consistent support, family support, liaising with their schools, case management, etc. And as a private practitioner in that model, giving a large percentage of the bulk billing rate to headspace to use their rooms, I burnt right out. Even Prof Hickie reported that skilled mental health professionals working in these services are burning out and leaving in droves, often to work for themselves or other practices where they can be valued for their skills and expertise.

The kind of reforms that are needed in mental health care in Australia needs to start from an understanding of what Medicare’s Better Access to Mental Health system is currently. When the then (and now current) Health Minister cut the number of Medicare-rebated psychology sessions in 2011 to just 10 per year, Better Access was said to be intended for mild to moderate cases of depression and anxiety, where brief, short-term treatment would be able to support the person to manage their single issue and be able to get on with their lives. While this may have been a good intention, it is important to understand what actually happens in therapy.

Better Access has meant that a lot more people are wanting to engage with mental health support than ever before. Recent governments have been contributing to the de-stigmatisation of mental ill health, and this has, of course, encouraged more people to seek a psychologist. As psychologists in clinical practice, we develop good, trusting relationships with our local area GPs, and they know us and recommend that their patients come to see us. Of course, to be eligible for a Mental Health Treatment Plan, a person need only show that they are experiencing some form of distress, most notably low mood or anxiety, before presenting to a psychologist. It is then our job as the treating psychologist to further assess and determine what else might be going on. In my experience, a person might not disclose past trauma, awful family of origin stories, or our deepest fears and insecurities until several sessions into therapy. This makes total sense, considering they’ve only known a new psychologist for a short number of hours, and may never have opened up to anyone about these things previously.

Accepting what Better Access has developed into and supporting it to grow to meet the needs of the public is what needs to happen - not defunding or scrapping this essential service to be replaced by “hubs” which are not going to be used by the majority of the population.

Strengthening the workforce means valuing the work that all psychologists do. Prof Hickie calls for more training of clinical psychologists - it is baffling that he continues to perpetuate the myth that one type of psychologist is more effective than the remaining 65% of psychologists in Australia. Research demonstrates that both registered psychologists and clinical psychologists achieve beneficial treatment outcomes. At the same time, there is no evidence to support that clinical psychologists are better skilled at providing services than other psychologists.

We need to have a thriving psychology workforce who are not burnt out and can provide world-class mental health support to anyone who walks through the door. We also need to support small businesses, where the majority of psychologists work. This means increasing the Medicare rebate to a level where it is sustainable for the clinician, and would mean that clients are able to access services that are not financially prohibitive. If the Medicare rebate was raised to $150, I would be able to bulk bill, as would many other psychologists. In fact, recent research by AAPi suggests that over 70% of psychologists would bulk bill. Increasing the Medicare rebate is what we, as practising psychologists, consider a key system-level reform. 

We cannot fool ourselves that these hubs are the answer. We need affordability for all Australians who need mental health treatment to be able to access a psychologist regardless of their income or their postcode. 

Better Access is working - the latest evaluation clearly shows this - but now we need proper investment into this vital program.

Mental health reform needs to start with the needs of the client 

Posted on 20 January 2023