By Associate Professor John Gleeson MAPS, Department of Psychology, University of Melbourne, and NorthWest Mental Health, a program of Melbourne Health and Associate Professor Warrick Brewer MAPS, ORYGEN Research Centre and Department
of Psychiatry, University of Melbourne
The introduction of the Better Access to Mental Heath initiative in 2006, which included Medicare rebates for interventions provided by psychologists, brought a new era in the accessibility of psychological treatments for the Australian community. According to data from Medicare Australia, 1,738,915 items were claimed for individual services from psychologists from 1 November 2006 to 29 February 2008. Of these, 577,330 were provided by clinical psychologists and 1,161,585 by other psychologists. This compares with 60,370 items provided by social workers and 11,519 provided by occupational therapists during the same time period (Medicare Australia, 2008).
Although the initiative has had some vocal detractors (Hickie, 2008), it arguably places Australia at the international cutting edge in terms of addressing unmet community need for evidencebased psychological interventions for mental health problems. We note with interest that the British Government has recently announced a scheme with some similarities. The Improving Access to Psychological Therapies initiative is to include £170 million of extra spending on psychological services for depression and anxiety provided by therapists in a variety of settings (U.K. Department of Health, 2008).
The Better Access initiative is ideally matched to the officeor clinic-based private practice context in which individual and group interventions are the mainstay. The Medicare rebates as they are structured give particular incentive to clinical psychologists to offer private consulting. As most members would be aware, disorders covered under the initiative include mood disorders, anxiety disorders, psychotic disorders, and drug and alcohol disorders, amongst others. Personality disorders, frequently encountered within public mental health settings, are not listed, probably because longer-term interventions are indicated. Mental retardation, tobacco use disorder, dementia, and delirium are excluded.
Given that the initiative has been in place for over 12 months, it is timely to address the question of the likely impact of the introduction of the Better Access initiative upon the existing psychology workforce in the public mental health sector. Is the landscape of the mental health workforce undergoing significant change? Will clinical psychologists be retained at their current levels within the system? Will the flow-on effects of this initiative also potentially impact upon neuropsychologists within public mental health? Will the initiative impact on the capacity of mental health services to meet the national standards for mental health (National Mental Health Education and Training Advisory Group, National Education and Training Initiative and National Mental Health Strategy, 1996), especially those standards pertaining to the delivery of care?
These are questions that confront senior psychologists within the public mental health system whose responsibilities include the management of the workforce. The Heads of Psychology Group organised a forum for public sector psychologists on the impact the introduction of Medicare rebates in July 2007 to tackle some of these issues. The forum provided the impetus for the group to devise and conduct a survey in order to better understand the future employment intentions of public mental health psychologists in the context of the availability of Medicare-funded psychological treatment.
This article provides the results of the survey and draws together some recommendations in response to the survey results. To assist in analysing the significance of the survey results, it is important to firstly understand the service structures and roles of psychologists within public sector mental health.
The activities of this traditional workforce can most easily be related to the four redominant service structures and the populations they serve. Consumers of Child and Adolescent Mental Health Services (CAMHS) experience severe and complex mental health problems within a context that often includes a history of severe abuse and neglect, family violence, complex associated physical health problems, and the involvement of multiple systems including juvenile justice and child protection agencies. The clinical profile of children and adolescents attending CAMHS typically includes attention deficit disorders, autism spectrum disorders, depressive and anxiety disorders, psychoses, self harm, and co-occurring substance abuse problems (Department of Human Services Victoria, 2006). In adult services a diagnosis of psychotic disorders, bipolar disorder, often with co-occurring anxiety, mood, and substance abuse disorders and features of an Axis II personality disorder are common. Consumers of adult public mental health services are often at very high risk of poor outcomes across a range of domains. They often have significant psychosocial issues such as very high rates of unemployment, poverty, high rates of contact with the criminal justice system, and often highly deprived social histories (Singh & Castle, 2007). The third and newly emerging service system is youth mental health, which blends strategies of early detection and preventive interventions across the adolescent and early adulthood phase with a focus upon young people with a broad spectrum of emerging mental health problems, including mood and anxiety disorders, substance abuse, psychotic disorders, and emerging personality disorders (McGorry, 2007). Finally, aged person's mental health services provide an array of services to people over 65 years of age who present with organic and/or functional mental health problems, which are often accompanied by complex physical, behavioural and social problems (Victorian Government Department of Health and Community Services, 1996).
Engaging consumers from these four service structures in psychological interventions can pose challenges, requiring a high degree of clinical skill and flexibility (see article by Thomas and Gleeson in this edition). The availability of psychological interventions should be intrinsic to mental health systems, which are designed to offer a wide range of interventions and supports for varying phases of mental health problems ranging from periods of acute disturbance and risk, to enduring residual symptoms and associated problems of daily living.
Public sector clinical psychologists and neuropsychologists in mental health services often carry out highly specialised functions, including the provision of i) consultations within specialist statewide services, ii) specialised psychological and neuropsychological assessments and interventions for consumers with complex presenting problems, iii) training, and iv) evaluation of novel interventions, often in collaboration with research institutions. Provision of discipline-specific supervision is also a key role undertaken by psychologists in public mental health services, including supervision of postgraduate students undertaking external placements in professional training programs, and supervision of level 2 psychologists working towards eligibility for APS Clinical College membership. Despite these specialised activities, researchers have previously identified a mismatch between the training and skills of psychologists and the model of care in many Australian public mental health settings, that is, multidisciplinary case management (King et al., 2002; Lancaster, Milgrom & Prior, 2001).
Lancaster and colleagues (2001) in an article in InPsych concluded, on the basis of their survey of 222 psychologists across Victorian Public Health that "...psychologists despite very specialised training are at risk of becoming deskilled, and...the profession of psychology is undervalued and under-utilised in public health services" (p. 43). King and his colleagues (2002) surveyed psychologists in Queensland and other States and noted that the model of care within community mental health services posed a challenge for the psychology workforce:
If psychologists wish to maintain or enhance their professional profile within the case management system that provides the major part of the community mental health workforce in Australia they would be wise to attend to the training and practice implications suggested by these results. This might mean supplementing their existing practice strengths with greater willingness to embrace the more fluid, multidisciplinary, community-based practice culture that prevails in current policies. The alternative for the profession may be to retreat to a more specialist clinical and consultative role... with the likely consequence of a reduced numerical profile in the mental health workforce. (p 121)
The introduction of the Better Access initiative, at a point when many of the hopes for reform in the public mental health system have been left unfulfilled (Singh & Castle, 2007), may have sharpened the horns of this dilemma considerably for the psychology workforce.
The survey was administered between February 5 and February 22, 2008. The survey was distributed via area senior psychologists to their psychology staff using an on-line platform. Of 103 respondents who began the survey, 98 (mean age = 36.0 years)
completed all questions. The survey asked respondents about their duration of employment, their current roles, the level of their current appointment, their employment intentions over the proceeding 1-year and 2-year period, and if they had taken any active steps towards planning a reduction in their hours of employment in the public sector based on their intentions.
The demographic and employment characteristics of the respondents indicate that public sector psychologists are predominantly middle-aged females, the vast majority of whom have completed a Masters Degree or a Doctorate/PhD. The majority are employed at P2 level, with a third occupying P3-level positions, mainly in the adult sector, although nearly a quarter work in child and adolescent services. Nearly half work full time and most work in clinical roles, with a significant number working in a clinical psychology-specific role. However, a quarter work in generic positions. Over a half of psychologists work either in Continuing Care or Primary Mental Health teams, and nearly a third work in either acute inpatient or acute crisis/assessment roles. Over a quarter had worked in public health for more than 10 years, while nearly 40 per cent had worked for less than three years.
Regarding future intentions, a quarter of respondents indicated that they would remain in public mental health for the next three years and a further quarter would remain for five to ten years or more, while just over 10 per cent indicated they would leave within the next year. However, nearly a quarter of respondents did not know. Reasons for preparation to leave were relatively evenly distributed over increased opportunities and remuneration, greater flexibility, and autonomy.
Close to one half of respondents (44%) intended to remain in their current position with no changes in working hours over the next year (this figure was 20 per cent for intentions over the next two years), while a fifth (22%) intended to reduce their working hours to facilitate private practice work over the next year. However, when they were asked about their intentions within the next two years, a third of respondents indicated they intended to reduce their working hours to facilitate private practice. Over two-thirds of the entire sample reported that they were not currently actively planning or preparing for private practice.
One sub-group of interest was the P3-level respondents. These psychologists are a critical component of the current workforce providing clinical leadership and clinical supervision for both less experienced psychologists and students undertaking external placements. As summarised in Figure 1, 41 per cent of P3-level psychologists indicated that they were intending to reduce their hours of work for private practice in the next 12 months, compared with 12 per cent of P2-level psychologists.
Improvements to current employment conditions that may lead psychologists to reconsider their private practice plans included improved remuneration (40.4%), increased specialist psychology work (27%), promotion opportunities (26.3%), increased study/conference leave (22.2%), additional annual leave (22.2%), improved professional development opportunities (21%), increases in provision of private practice rights (19% ), and research opportunities (14.1%).
The results of this survey indicate that the majority of psychologists employed in public mental health services are committed to remaining actively involved within public sector mental health services for a significant period of time into the future. However, a significant minority, especially P3-level psychologists, intend to reduce their hours over the next year to take up or increase private practice activities, and a significant proportion are already actively making these preparations. We are confident that these intentions were strongly influenced by the introduction of the Better Access initiative, which has significantly increased the feasibility of private practice for these experienced clinical psychologists.
The major strength of the survey was the good response rate from across metropolitan Melbourne, which we believe reflects the active interest in the issue. The limitations were that a metropolitan sample cannot be representative of psychologists in regional, rural, and remote areas, and there may be State-specific issues pertaining to employment conditions, which limit the generalisability of findings to other capital cities. Of course, we also cannot be certain that stated intentions will translate to action.
The findings suggest that there is a potential risk to the stability of the public sector psychology workforce, especially in relation to clinical leadership and supervision resources which could have very significant flow-on effects for the profession of clinical psychology with respect to the impact upon placement opportunities for postgraduate trainees. This could result in an increased reliance upon external sourcing of supervision, creating professional isolation for less experienced psychologists. The risk is that public sector mental health will become a short-stay option en route to private practice settings where the bulk of the expertise and experience will reside. Additionally there is a likelihood that part-time contracts will proliferate for psychologists within the public sector reducing the impact of the profession upon service models - a problem that has been previously discussed in InPsych (Lancaster et al., 2001). The worst case scenario is of course a steady decline in the public sector psychology workforce beginning with the leadership group. This would inevitably reduce the access to effective psychological interventions for consumers and their carers, and lead to poorer outcomes.
The prevention of these outcomes calls for a multifaceted approach. Firstly, it highlights the critical need for regular data on psychology workforce trends across Australia (Robiner, 2006). A survey of postgraduate professional trainees and their employment aspirations, and a survey of psychologists who have left the public sector would provide useful complementary data to the present results and would enable us to more directly assess the effect of the introduction of Medicare rebates upon the transition to private practice. Secondly, senior psychologists in the public sector need to work with their executive management to highlight the workforce challenges and design effective recruitment and retention strategies. For example, it is important that new graduates from professional training programs are fully informed of the opportunities within the public mental health system in terms of professional development. At Northwestern Mental Health (a program of Melbourne Health) we have commenced the ‘Start your career in public mental health' campaign and we plan to open up professional training forums to final year postgraduate students.
Effective staff retention campaigns cannot feasibly rely on altruism alone (Bishop & Rees, 2007). Instead public mental health services need to embrace the aspirations of the psychology workforce for a more flexible career, with improved working conditions, in order to continue to work towards meeting national standards. These data suggest that there is a raft of factors including remuneration, private practice rights, and improved access to professional development opportunities that will shift the intentions of staff. The APS and relevant state industrial bodies have an ongoing critical role to play in this endeavour (see other papers by Kelly et al. and Stokes in this edition).
Ultimately these strategies need to be informed by a broader long-term strategic perspective - perhaps it is now time for the profession to work with government in establishing long-term workforce objectives for both the public and private psychology workforce in terms of supply and demand.
|Summary of public sector psychologists survey|
Bishop, J. P., & Rees, C. E. (2007). Hero or has-been: Is there a future for altruism in medical education? Advances in Health Sciences Education, 12(3), 391-399.
Department of Human Services Victoria. (2006). CAMHS in communities: Working together to provide mental health care for Victoria's children and young people. Retrieved 14 April 2008 from www.health.vic.gov.au/mentalhealth.
Hickie, I. (2008, 8-9 March). The community will expect the Rudd Government to get it right. The Australian, p. 16.
King, R., Yellowlees, P., Nurcombe, B., Spooner, D., Sturk, H., Spence, S., et al. (2002). Psychologists as mental health case managers. Australian Psychologist, 37(2), 118-122.
Lancaster, S., Milgrom, J., & Prior, M. (2001, December). Facing the hard facts: The employment of psychologists in Victorian public health. InPsych, 23(6), 39-45.
McGorry, P. D. (2007). The specialist youth mental health model: strengthening the weakest link in the public mental health system. Medical Journal of Australia, 187(7), S53-S56.
Medicare Australia (2008). Medicare Benefits Schedule (MBS) Item Statistics Reports. Retrieved 27 March, 2008, from www.medicareaustralia.gov.au/statistics/dyn_mbs/forms/mbs_tab4.shtml.
National Mental Health Education and Training Advisory Group, National Education and Training Initiative, & National Mental Health Strategy. (1996). National Standards for the Mental Health Services. Retrieved 1 May 2008 from www.health.gov.au/internet/main/publishing.nsf/Content/mental-pubs-n-servstds.
Robiner, W. N. (2006). The mental health professions: Workforce supply and demand, issues, and challenges. Clinical Psychology Review, 26(5), 600-625.
Russell, L. (2008, March 8-9). Mental health money misses the most needy. The Australian, p. 16.
Singh, B. S., & Castle, D. J. (2007). Why are community psychiatry services in Australia doing it so hard? Medical Journal of Australia, 187(7), 410-412.
U.K. Department of Health (2008). Improving Access to Psychological Therapies implementation plan: National guidelines for regional delivery. Retrieved April 11 2008, from
Victorian Government Department of Health and Community Services. (1996). Victoria's Mental Health Service: The Framework for Service Delivery Aged Persons Services. Retrieved 14 April 2008 from www.health.vic.gov.au/mentalhealth.