FOR some time there has been concern about the effectiveness of the Medicare Better Access to Mental Health Services program, and the Minister for Health, Nicola Roxon, has committed to an evaluation and review of the scheme.

An update of previous analyses ("$1.5bn blowout in health program", The Australian, 13 October 2008 shows that the uptake of this program continues to grow much faster than predicted, with no signs of any slowing in demand. The number of services provided under this program increased by 44 per cent over the 12 months from June 2007 to June 2008. In this period services provided by GPs grew by 38 per cent, and services provided by mental health professionals (primarily psychologists) grew by 47 per cent.

The total number of GP mental health management plans written or reviewed in 2007-08 was 664,419 and this represents the maximum number of patients treated in this financial year under the Better Access program. The patients treated received more than 2.5 million mental health services (this figure excludes those from psychiatrists), or about four services per patient.

Data for psychiatry services show a steady increase in the uptake of Medicare items for management plans and initial consultations, but the number of psychiatric consultations has continued to decline. In 2007-08 psychiatrists provided 185,300 fewer outpatient consultations than in 2004-05. At most 77,212 new patients got to see a psychiatrist as an outpatient in 2007-08, and only 11,119 of these had a psychiatric management plan.

While the majority of these patients would have been referred to psychiatrists by a GP, it's not clear how many of these referrals were made under the Better Access program.

In 2007-08 3.2 million services were provided under this program by GPs, psychologists, occupational therapists and social workers, at a cost to Medicare of $308.1 million. This is dramatically higher than the budgeted cost of $92 million, which presumably also includes boosted psychiatry fees and education and training programs.

The 2008-09 budget papers predicted that the cost of this program would be $753.8 million over four years, up from the $538 million over five years initially given when the program was introduced. However, this is still a major underestimate. In the absence of reforms and/or cutbacks, costs over the forward estimates are likely to approach $2 billion, a prediction supported by an updated analysis of the program's spending published by the Mental Health Council of Australia earlier this month.

Realistically, given that currently over 60 per cent of people with a mental health problem go without treatment, this program was always going to be underfunded. The focus therefore should be ensuring that services are directed to those most in need.

From the publicly available data it is not possible to know how many of the 900,000 Australians who have received a mental health care plan since November 2006 were receiving mental health services for the first time and how many were already receiving mental health services under programs such as Better Outcomes in Mental Health and the Chronic Disease Management program. We don't know what their mental health condition was, what treatment they received, and what the outcome has been. Did they get quality care and the necessary follow-up that made a difference to their health and wellbeing?

We know that the majority of services delivered under the Better Access program were provided to women living in metropolitan areas. Given that the average patient out-of-pocket cost for these services is over $30, we can also assume that the less well-off are less likely to get these services.

Despite the strong uptake of the Better Access program, data from Bettering the Evaluation and Care of Health (BEACH) analyses shows that only about 10 per cent of GP services for mental health related problems are provided under this program. So we don't know if GPs still perceive barriers to the use of Better Access MBS items and what these barriers are.

The data suggests that many GP mental health management plans are not reviewed, and we have little evidence of teamwork between GPs and mental health services in the co-ordination of patient care. It is very likely that mental health workforce shortages have an impact of the ability of people outside metropolitan areas to access needed services.

A related area that needs further investigation is the affordability of prescription medicines for people with mental illness. Recent data from the Australian Institute of Health and Welfare show that the cost to government of PBS medicines used to treat depression has declined by 11 per cent since 2005 co-payment increases and safety net changes.

An examination of prescription numbers rather than cost also indicates that there has been a major decline in prescription numbers filled under the PBS since 2004-05. Recent research by Anna Hynd of the University of Western Australia strongly points to this not being due to an increase in the number of prescriptions costing less than the co-payment, and therefore not being recorded by Medicare Australia as a cost to government. Instead the evidence now strongly suggests that the most likely explanation is that increasing out-of-pocket costs have led many people to forgo their needed prescription medicines.

As work proceeds on the development of the Fourth National Mental Health Plan, and the implementation of election commitments in health reform, it is imperative that we analyse and evaluate the effectiveness of Medicare initiatives to tackle mental illness so that we can be sure that increased funding is providing maximum benefits to those most in need.

Lesley Russell is the Menzies Foundation Fellow at the Menzies Centre for Health Policy, University of Sydney/Australian National University