Integrating Psychologists into the Canadian Health Care System: The Example of Australia

Abstract

Canada and Australia share many similarities in terms of demographics and the structure of their health systems; however, there has been a divergence in policy approaches to public funding of psychological care. Recent policy reforms in Australia have substantially increased community access to psychologists for evidence-based treatment for high prevalence disorders. In Canada, access remains limited with the vast majority of consultations occurring in the private sector, which is beyond the reach of many individuals due to cost considerations. With the recent launch of the Mental Health Commission of Canada, it is timely to reflect on the context of the current Canadian and Australian systems of psychological care. We argue that integrating psychologists into the publicly-funded primary care system in Canada would be feasible, beneficial for consumers, and cost-effective.

Full text

Mental illnesses such as depression and anxiety disorders
make up a substantial component of the disease burden of
Canada and Australia,1,2 with over 10% of the population
having a disorder in any one year. If left untreated, such disorders
lead to substantial personal misery, disability, functional impair-
ment, disruption to family, increased health care costs, and
increased rates of suicide. However, research shows that these dis-
orders are responsive to certain well-defined psychological treat-
ments,3,4 suggesting that the use of such evidence-based therapies
is one avenue whereby a large proportion of the disease burden
could be averted.5For example, the evidence-based guidelines of
the National Instititute for Health and Clinical Excellence in the UK
recommend depression-focused psychological treatment (problem-
solving therapy, brief cognitive-behavioral therapy [CBT] and counsel-
ing) or serotonergic medication for mild-to-moderate depression; and
combined serotonergic medication and CBT for severe or treatment-
resistant depression.6Such evidence and recommendations leave
policy-makers in both countries with the question of how best to
provide broad community access to evidence-based psychological
treatments. In this paper, we compare the Canadian and Australian
approaches to improving access to psychological treatments in pri-
mary care. We believe that such a comparison is timely, given that
Canada has launched a national mental health commission to
inform the development of sound public policies and to improve
service delivery.7
Comparability of Canadian and Australian systems
Canada and Australia share many similarities in terms of their
demographics, mental health needs, and models for providing
health care. Both countries have a large landmass with an increas-
ingly aged and highly urbanized population that is mainly of Cau-
casian descent, with a proportion of immigrants and Indigenous
peoples. Both have relatively strong primary health care systems,8
with provincial/state level governments being responsible for the
provision of a substantial proportion of health care.9Both have a
universal, publicly-financed health insurance, termed Medicare,
which covers the majority of medical costs, although in Australia
this is controlled federally rather than at province/state level. In
both countries, family physicians/general practitioners operate at
the centre of the health care system, performing a gate-keeping
role, and operating predominantly on a fee-for-service basis.9,10 In
Canada, following the Romanow Report, different models of deliv-
ery and remuneration are being developed to increase access to
family physicians and to encourage team or interdisciplinary
approaches in primary care.9-11
Psychological care in Canada
Canadian family physicians have practices that are burdened by
the most prevalent mental disorders (depression, anxiety) and wel-
come collaboration with psychologists.12 However, such services
© Canadian Public Health Association, 2009. All rights reserved. CANADIAN JOURNAL OF PUBLIC HEALTH • MARCH/APRIL 2009 145
Integrating Psychologists into the Canadian Health Care System:
The Example of Australia
Richard Moulding, PhD,1,2 Jean Grenier, PhD,3-5 Grant Blashki, MD,6Pierre Ritchie, PhD,3Jane Pirkis, PhD,7
Marie-Hélène Chomienne, MD4,5
ABSTRACT
Canada and Australia share many similarities in terms of demographics and the structure of their health systems; however, there has been a divergence
in policy approaches to public funding of psychological care. Recent policy reforms in Australia have substantially increased community access to
psychologists for evidence-based treatment for high prevalence disorders. In Canada, access remains limited with the vast majority of consultations
occurring in the private sector, which is beyond the reach of many individuals due to cost considerations. With the recent launch of the Mental Health
Commission of Canada, it is timely to reflect on the context of the current Canadian and Australian systems of psychological care. We argue that
integrating psychologists into the publicly-funded primary care system in Canada would be feasible, beneficial for consumers, and cost-effective.
Key words: Mental health services; psychotherapy; mood disorders; anxiety disorders; primary health care
La traduction du résumé se trouve à la fin de l’article. Can J Public Health 2009;100(2):145-47.
Author Affiliations
1. Primary Care Research Unit, Department of General Practice, University of
Melbourne, Australia
2. Swin-PsyCHE Research Unit, Swinburne University of Technology, Melbourne,
Australia
3. School of Psychology, Faculty of Social Sciences, University of Ottawa, Ottawa,
ON
4. Montfort Hospital, Ottawa, ON
5. Department of Family Medicine, University of Ottawa, Ottawa, ON
6. Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia
7. Centre for Health Policy, Programs and Economics, School of Population Health,
University of Melbourne, Australia
Acknowledgements: This work was partially supported by a PHCRED Research
Fellowship for author Grant Blashki.
Correspondence and reprint requests: Dr. Grant Blashki, Nossal Institute for
Global Health, University of Melbourne, Level 5, Alan Gilbert Building, 161 Barry St.,
Carlton Victoria 3010 Australia, Tel: +61 8344 2623, Fax: +613 9347 6872; E-mail:
gblashki@unimelb.edu.au
COMMENTARY

remain generally inaccessible.12-14 Below, we describe the typical
Canadian experience of primary mental health care.
Within the Canadian publicly-funded primary care system, a
range of mental health interventions is offered, with the family
physician at the core. Low-prevalence mental disorders such as
schizophrenia are generally referred to psychiatrists for pharmaco-
logical treatment. High-prevalence/common mental illnesses such
as depression are treated either within the public or private system.
In the public system, usual care involves drug therapy and/or gener-
ic counseling delivered by the family physician. Such psychologi-
cal interventions primarily entail emotional support and
counseling (listening/giving advice) rather than formal psycholog-
ical treatments.15
Alternatively, the family physician can refer a consumer to see a
professional such as a psychologist. In 2001, approximately 80%
of consultations with psychologists were within the private system,
with a proportion covered by private insurance and the remainder
funded predominantly by consumers’ out-of-pocket expenses.13,16
In a recent survey, Ontario family physicians reported such costs to
be the greatest barrier to referring consumers to psychologists.12
Recent primary care reform has facilitated the development of
alternative service delivery models involving interdisciplinary care
teams. Examples include “Shared Mental Healthcare” initiatives,17
which most frequently involve collaboration between family physi-
cians, psychiatrists and mental health workers or social workers.15,18
Consumers with severe and/or persistent mental illnesses or those
requiring a psychiatric consultation along with emotional support
are served well with this model, but the most prevalent psycho-
logical problems do not necessarily require psychiatric interven-
tions. Family Health Teams (FHT) in Ontario and Family Medicine
Groups (FMG) in Quebec aim to promote interdisciplinary care.19
Again though, while FHTs increase access to mental health servic-
es, they are generally rendered by counselors/social workers, with
psychologists incorporated into only a few FHTs and none of the
FMG teams.20
We believe that the move towards multidisciplinary teams is to
be applauded. However, there are approximately 15,000 psycholo-
gists working in Canada;21 a workforce that has undergraduate and
graduate-level education and training (e.g., in Ontario it takes
approximately 10 years to achieve autonomous practice) and who
are licensed with authority to exercise controlled acts. We find it of
concern that, despite their range of expertise as diagnosticians, con-
sultants and providers of evidence-based psychological treatments
as opposed to generic/supportive counseling for a range of mental
disorders, this workforce is mostly excluded from the primary care
component of mental health treatment.
Psychological care in Australia
Australian psychologists traditionally operated in similar settings
to Canada, including hospitals, community health centres and pri-
vate practice. In the former two settings, access has been free at the
point-of-service for some time, but until recently, consumers
incurred significant out-of-pocket costs if they visited a private psy-
chologist.
In 2000-01, the Australian Government provided funding for the
Better Outcomes in Mental Health Care program (BOiMHC). The
BOiMHC involves a number of components, one of which explic-
itly aims to improve access to psychologists. Divisions of General
Practice (locally-defined networks of GPs) are provided with capped
funds to manage Access to Allied Psychological Services (ATAPS)
projects. These projects enable GPs to refer consumers to psychol-
ogists (and other selected allied health professionals) for up to 12
sessions of free or low-cost evidence-based mental health care. Like
the Canadian FHTs, the ATAPS projects are tailored to meet local
needs. For example, some Divisions directly employ their psychol-
ogists while others contract them on a sessional basis, and some
co-locate their psychologists with GPs whereas others encourage
them to operate from their own rooms. Ongoing evaluation sug-
gests the projects are achieving positive outcomes for consumers.22
In 2006, the Federal Government instituted the Better Access to
Psychiatrists, Psychologists and GPs through the Medicare Benefits
Schedule (Better Access) program, which now sits alongside the
BOiMHC program. This program increases access to private psy-
chologists via a different means, namely by making services eligi-
ble for a rebate through the Medicare Benefits Schedule. The
program enables a consumer to receive up to 12 sessions of
evidence-based mental health care from registered providers, when
their GP, in consultation with the consumer, judges such services
to be of benefit. The GP retains his role as the provider of contin-
uing care, with psychologist feedback to the GP, and a progress
review by the GP after six sessions.
Several factors seem to have been important in these Australian
reforms, and these may be worth fostering in the Canadian context.
First, consumer advocacy was a strong driver. In particular, reports
by the Mental Health Council of Australia were widely distributed
and had a major impact.23,24 These reports highlighted unmet needs
for basic mental health services, with many individuals relying on
increasingly overworked GPs for such services. Second, there was an
increasing appreciation of the cost of mental illness. The Australian
Burden of Disease Study, for example, found that mental illness had
the greatest burden through Years Lost due to Disability (YLD) of
any illness.25 Third, a series of Australian cost-effectiveness studies
provided compelling evidence that psychological services repre-
sented value-for-money from a public health perspective.26 Fourth,
there was an increased policy recognition of the role of primary care
providers in the delivery of mental health care.27,28 The National
Mental Health Strategy emphasized the need for partnerships
between primary and secondary care; and the General Practice Strat-
egy emphasized that mental disorders could be more effectively
treated with improved primary care services.27 A major theme of an
Australian Senate report on mental health,29 which immediately
preceded the Better Access program, was the heavy load on primary
mental health care workers such as GPs. As a solution, they report
psychiatrist Professor Ian Hickie’s submission: “If the Common-
wealth were to immediately recognise the number of psychologists
who would automatically meet that [standard of training]… we
would immediately double the mental health specialist work force,
and it would not kill the Treasury” (ref. 29, p.146). Fifth, and relat-
ed to these policy drivers, there was strong interprofessional advo-
cacy, with various multidisciplinary groups promoting
developments in primary mental health care, including the incor-
poration of psychologists into the primary care workforce.28,30
CONCLUSION
The multidisciplinary primary care teams in some parts of Canada
share similarities with Australia’s mental health programs, with
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PRIMARY CARE PSYCHOLOGICAL REFORMS
their emphasis on management of mental illness in primary care
and their flexibility to suit local needs. However, in the Canadian
programs, underutilization of the psychologist workforce is an
issue, given their specialist training in providing diagnostic/treat-
ment/consultative services and the evidence for the efficacy of psy-
chological treatments in treating high-prevalence mental disorders
in primary care.4We hope that reflecting on the conditions leading
to Australian reforms will provide some principles-of-value in
increasing access to psychologist-provided diagnosis, consultation,
and treatment within the Canadian context, providing a cost-
effective and immediately available solution to an overworked pri-
mary mental health care workforce, and improving outcomes for
consumers experiencing mental illness.
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Received: April 21, 2008
Accepted: November 11, 2008
RÉSUMÉ
En termes de démographie et de structure de leurs systèmes de santé, le
Canada et l’Australie partagent de nombreuses similitudes; cependant,
on note une divergence dans leur approche et leurs politiques en ce qui
concerne le financement des services psychologiques. Les réformes
récentes des politiques en Australie ont considérablement augmenté
l’accès de la population aux psychologues pour des traitements fondés
sur les preuves dans le contexte des troubles mentaux de forte
prévalence. Au Canada, l’accès aux psychologues demeure limité, la
grande majorité des consultations se produisant dans le secteur privé; la
majeure partie de la population ne pouvant avoir accès à ces services
pour des raisons économiques. Le lancement récent de la Commission de
la santé mentale du Canada suggère que le moment est opportun et qu’il
est pertinent de se pencher sur le contexte actuel des systèmes canadiens
et australiens en ce qui concerne les soins psychologiques. Nous
suggérons que d’intégrer les psychologues dans le système de soins de
santé primaires au Canada est réalisable, bénéfique pour les
consommateurs, et coût-efficace.
Mots clés : Services de santé mentale ; psychothérapie ; troubles de
l’humeur ; troubles d’anxiété; soins de santé primaires