After years of neglect the federal government has shovelled billions of dollars into the mental healthcare system – but the debate on how best to spend it has just begun. In the third of a four-part joint investigation with Inside Story, health journalist and Croakey blogger Melissa Sweet examines the arguments around Medicare funding and the Better Access initiative …

On the wall of psychiatrist Ian Hickie’s office in inner Sydney is a large whiteboard covered with a sprawl of writing, graphs and diagrams that is almost impenetrable to a casual observer. Hickie enthusiastically launches into a vigorous, detailed explanation of the research, clinical and policy questions outlined on the board, despite having just talked almost non-stop for more than two hours.

You don’t have to spend too long with Hickie, executive director of the Brain and Mind Research Institute at the University of Sydney, to understand that “revolutionary” tag (as one campaigner described in part two yesterday).  The qualities that make him “good talent” for journalists — someone who speaks their mind without fear of upset — can also make him unpopular. Or as Hickie himself puts it, he is “disruptive”, “impatient” and a “permanent irritant”.

He doesn’t confine himself to advocating for more money for his sector, but engages in broader health system and societal debate. Much of what he says challenges entrenched interests and the power of groups like the Australian Medical Association or the Australian Psychological Society. He is no fan of fee-for-service healthcare, which he has long argued contributes to inequities.

He is also a critic of private health insurance incentives, which he says means “half of Australia gets a much better deal”, and calls health reform “a damp squib” that has failed to tackle fundamental structural inequities. He offers many examples of the resistance of self-interested professions to change, and states: “Whoever really reforms Medicare, it will probably cost them their political careers.”

Hickie says he can take the heat that is being sent in his direction, but is outraged at the “unsubstantiated personal abuse” being directed at his psychiatric colleague Patrick McGorry. “The failure of people to line up behind him like they line up behind Fiona Stanley or Ian Frazer” —  both medical researchers and former Australians of the Year — “is disgraceful,” he says. Hickie advised McGorry to take an impressive job offer in the United States a few years ago, warning he would inevitably face a backlash in the “small pond” of Australia because his ideas were “so transformational”.

But if McGorry has any regrets about ignoring this advice, he’s not saying so. While he has been feeling the personal heat in recent months, he says he won’t be deterred from advocacy, and holds with the sentiment that when you engage with the media “you’ve just got to take the rough with the smooth”. He adds he doesn’t enjoy having a high profile: “I was always a very shy person. It wasn’t until later in life I would have been able to do anything like this. I don’t like being the centre of attention, to me it’s a necessary evil to get these messages across. I had to really work at it.”

Hickie says he first began to develop an appreciation for the revolutionary nature of McGorry’s work while running beyondblue. It was also around then, when I was researching a 2001 profile of the new organisation’s CEO for Australian Doctor magazine, that I first came to know Hickie.

At that time, Harvey Whiteford, a former director of mental health in the federal health department, told me the beyondblue selection panel had been impressed by Hickie’s ability to think outside the clinical box. Harvey told me that Hickie “had a vision for population-level mental health, for people who weren’t patients. He had a perspective of mental health beyond the specialist sector.” For the profile, Hickie suggested that I interview another psychiatrist, Margaret Tobin, who was then director of mental health in South Australia, and used to be his boss at St George Hospital in Sydney.

That connection was one of the reasons I was prompted to write a book about Tobin after her murder in 2002. Inside Madness was also about the difficulties of mental health reform. As I wrote in the epilogue: “Margaret’s life also told a larger history, of the changes that have occurred in mental health care and of the struggles faced by change agents in deeply conservative health systems.”

I mention this to declare a long-standing association with Hickie (who wrote the foreword to my book), and also because researching it helped me to understand how media reporting often favours sectional interests that are resisting change. As well, I think it almost impossible to make sense of the messy, complex state of mental health reform — for which Hickie’s white board seems the perfect metaphor — without some understanding of history.

In August 2006, Rob Knowles, who was chair of the Mental Health Council of Australia, wrote to Christopher Pyne, a parliamentary secretary to the Minister for Health and Ageing, about plans to open up the Medicare Benefits Schedule to psychologists. The council had been campaigning for increased access to psychology and other allied health services, but Knowles warned against creating a simplistic fee-for-service model as it was likely to result in inequitable access to services and large out-of-pocket expenses for patients.

He said the reforms should focus on improving access to care for disadvantaged areas and groups, and warned against mirroring the inequity of psychiatry, which he described as one of the most poorly distributed specialist services. He said the per capita rate of  annual Medicare funding on psychiatry varied from 0.31 cents in rural north-west WA to $73.79 in inner south-east Melbourne (while these rates may have since increased, the relative gap is very likely much unchanged).

“The current model of fee-for-service payments of psychiatry has led to a situation in Australia where unless you live in the inner metro suburbs of our major cities, access to specialist psychiatric services is extremely difficult,” Knowles wrote. He recommended building incentives into the Medicare reforms to encourage mental health professions to see the most needy clients, and to provide incentives to encourage organisations to hire psychologists. “The time-based fee-for-service model remains very popular with many health professionals,” he wrote, “but it does not deliver more services particularly to vulnerable groups and it does not foster a role of consultant physician among mental health professionals.”

Tellingly, many of the letter’s themes were later echoed in the 2009 World Health Organisation document, which notes the importance of incentives to ensure that mental health services are distributed equitably and says that systems that result in out-of-pocket payments are likely to particularly disadvantage mental health patients.

Faced with concerted lobbying by medical and psychology groups, the Howard government ignored the Mental Health Council’s advice. When the program was launched, demand soon outstripped government projections, with the scheme costing $1.45 billion between November 2006 and June 2010 — about 2.5 times more than expected. The legacy of how Better Access was established is explored, to some extent, in the recent Senate committee report, which makes two things evident.The first is the power of the professional lobby, whose claims seem to have been accepted by the Senate committee without, it appears, any rigorous analysis of the self-interest involved. To give some context, there are currently 24,000 GPs, 14,800 psychologists, almost 2000 other allied health professionals and 1700 psychiatrists using Medicare items under Better Access. This may represent a lot of patients getting care, but it also represents a sizeable industry.

The second observation is that the evolution of Better Access and the Access to Allied Psychological Services program, or ATAPS, as revealed in the report, neatly illustrate both the competing priorities of efficiency and equity, and the principles of the “inverse care law”, which holds that those most in need of health care are least likely to receive it.

ATAPS was established to provide care to the most needy with minimal out-of-pocket expenses. People on low incomes receive two-thirds of all services delivered through the program, and 45% go to rural areas. ATAPS funding is distributed via divisions of general practice and capped, whereas Better Access funds are distributed according to the distribution of providers and uncapped. Under Better Access, 25% of services are delivered in rural areas and the richest quintile of Australians receive 2.5 times the number of services and three times more in Medicare rebates than the poorest quintile.

However, because it is so much larger, Better Access has provided many services to rural and other historically under-served areas. In the three years from 2007, more than two million people received more than 11.1 million services under Better Access, with costs projected to continue rising. By contrast, ATAPS provided a little over 600,000 mental health services between 2003 and 2009 for a total outlay of $80.7 million (although the budget promised funds would be increased to $205.9 million over the next five years).

Not surprisingly, the professional chorus of support for Better Access is deafening compared to that for ATAPS. Even so, the redirection of funds from Better Access has more supporters than is suggested by the headlines being generated by the medical and psychology lobbies. The authors of the much-disputed evaluation of the Better Access program — Jane Pirkis and Meredith Harris — are on the record as supporting the changes, writing in the Medical Journal of Australia: “We believe the budget reforms have struck an appropriate balance between retaining the core features of a program that appears to be working well while at the same time providing additional resources for important existing and new initiatives.”

Gavin Andrews, a psychiatrist who was on a committee advising the Department of Health and Ageing about the Better Access evaluation, believes the changes to the program are well justified and quite “moderate”. He says GPs had been “on a bonanza”, getting up to $165 per mental health plan, often for minimal effort. Helen Keleher, the head of the Public Health Association of Australia, also supports the reforms. “We do need to rationalise and work out where we do need to put scarce resources,” she says.

Dawn O’Neil believes the government made the right decision on equity grounds, and says psychologists and doctors campaigning against the cuts are not being upfront about their personal financial interests. “I hope the government doesn’t buckle,” she says. “I would much rather see the saved money go into developing services in the country and rural and regional areas where there is still so little available.” Barbara Hocking, executive director of SANE Australia, adds: “I support the notion of improving access for groups who did not benefit from Better Access. The strong professional groups have been very effective at jumping up and down.”

One of the clear messages from the Better Access fracas, however, is that there remain huge gaps in systems of care. While 87% of Better Access patients receive fewer than 10 sessions and will not be affected by the session cutbacks, some high-need patients will be hit. Jane Ralls, a GP who is president of the WA branch of the Doctors Reform Society, has a strong professional and personal commitment to equity, and is no fan of fee-for-service. She chooses to work in mental health, although it means she earns less than colleagues who don’t specialise in the area. She works in a well-to-do area of Perth but many of her patients struggle financially.

As Ralls describes the plight of several patients who will be hard hit by the Better Access cuts, distress and frustration are evident in her voice. She believes some will be at high risk of suicide. The argument that Better Access was never intended to support patients with complex, long-term problems is no comfort to Ralls when there are no other systems her patients can access.

“What they’ve done is radically reduced a functioning, not-brilliant but reasonable supportive system. They’ve chopped it right back before they’ve made another system available,” she says. “If I had a roof that was structurally unsound, I would not remove it years before I could put in a good replacement. I would patch it while I was waiting.”

Ralls argues that the uptake of Better Access reflects a huge community need, and that it is a mistake to cut one area of mental health to fund another. She also describes young children who are waiting two and three years to be assessed for suspected autism. “We are a really rich country,” she says. “We have lots of money floating around and there is no need to take money out of mental health to put it back into mental health.”

It is impossible to listen to Ralls without feeling concerned for her patients. But, while researching this story, I also visited a headspace centre in Campbelltown in western Sydney and an early psychosis intervention centre in eastern Sydney, and heard similar stories about young people and their families crying out for a whole range of health and support services.

But one of the troubles with any debate driven by service providers is that you tend only to hear about the needs of those receiving their services, and not those who, for a whole host of reasons, aren’t. Earlier this year, for another story, I spoke with Anne Chirnside, a GP in Geelong who has been working with young people for many years and is a huge fan of the local headspace facility where she works.

Chirnside says that young people with chaotic, stressful lives are unlikely to visit a GP, and that the Better Access program has struggled to serve those who need help the most, including those grappling with mental health problems, poverty, drug and alcohol issues, violence and abuse. “Those people are still not getting psychologists because they can’t afford a gap payment or don’t have the level of functioning to get to a private psychologist,” she says.

Chirnside says the integrated care model of headspace is far better for helping people with complex needs. “It’s almost impossible to do this work on your own,” she says. “You need a team to do it well. You need a GP but you also need a drug and alcohol worker, a youth worker and possibly a psychologist.”

She has found headspace extremely helpful in providing infrastructure to bring together services and support team-based approaches. “It’s not about tearing down what’s there and building a new thing, it’s about bringing services together, identifying gaps and putting people in those gaps.” But she says headspace centres will continue to struggle to attract GPs unless better remuneration is on offer. Headspace told the Senate inquiry that the Better Access cuts to GP rebates will make it even harder for them to recruit GPs.

*Tomorrow: the lessons from the mental health wars, and what does the future hold?

**Declarations: The Croakey health blog, which Melissa Sweet moderates, has received funding from the Brain and Mind Research Institute and the Public Health Association of Australia. The author has also been paid for research (not related to mental health) through the University of Melbourne centre involved in the Better Access evaluation, and the lead author of the evaluation, Jane Pirkis, was interviewed for this article.