Expanding access to psychotherapy in Canada: Building on achievements in Australia and the United Kingdom

Introduction

Equitable access to psychotherapy is a striking gap in the Canadian health system. The long-standing exclusion of allied mental health professional services from provincial and territorial health insurance plans has contributed to (a) high rates of unmet need for mental health services (particularly for psychotherapy), ¹ (b) greater financial barriers for the estimated 12 million Canadians without access to employment-based psychotherapy benefits, ² and (c) broader underfunding of mental health services (at only 5%-7% of total public spending on health in Canada). ^3,4 This gap is particularly concerning given the strong evidence of the effectiveness of psychotherapy and the return on investment through reduced healthcare costs and improved productivity. ^{5 –8} Introduced in 2017, a $5 billion targeted federal transfer to improve access to mental health services presents a significant opportunity for provincial and territorial governments to implement similar reforms over the next decade.

This article provides a brief overview of a recent comprehensive policy analysis mapping lessons learned from Australia and the United Kingdom onto the Canadian context undertaken by the Mental Health Commission of Canada ⁹ , and extends this analysis with a specific focus on what Canadian health leaders can do to work toward expanded access to psychotherapy. Lessons learned from Australia and the United Kingdom are particularly instructive for considering options in the Canadian context. First and foremost, both Australia and the United Kingdom have implemented major reforms over the past decade that have significantly expanded access to psychotherapy. At the same time, while all three countries are parliamentary democracies with broadly universal healthcare systems, Australia and the United Kingdom have adopted highly contrasting service system designs that are in keeping with the unique features of their government structures and healthcare systems.

Supporting evidence for the comparative analysis of the history, service system design, and outcome of reforms in Australia and the United Kingdom, as well as for the analysis of the implications for Canadian health leaders, is drawn from the policy and academic literature. The term psychotherapy is used in this article to refer to counselling, various psychotherapies, and psychological services. Psychotherapy can be delivered to individuals, families, and groups in many forms (in person or via telephone, video or Internet platform), in a wide variety of healthcare settings (from private practices to mental health clinics, primary care networks, and hospitals), and in settings outside of the health system (such as schools and community agencies).

Expanding access to psychotherapy in Australia and the United Kingdom

Despite very different approaches to reform, both Australia and the United Kingdom have made significant progress in improving access to psychotherapy and mental health outcomes at the population level.

In 2006, the Australian Commonwealth government introduced the Better Access to Psychiatrists, Psychologists, and General Practitioners through the MBS Initiative (Better Access) in response to 1997 population health survey data showing that only one of every three Australians with common mental disorders was utilizing mental health services. ^10,11 Through the Medicare Benefits Schedule (Better Access) initiative is an insurance-based approach that expanded universal public insurance (through Medicare) to cover psychotherapy provided by psychologists, social workers, and occupational therapists. Better Access is more a specific set of Medicare items than a distinct program per se, with providers working in private practice and regulated by their respective professional associations. Providers can choose whether to charge copayments or to provide services free at the point of delivery by bulk-billing at the Medicare rate. Better Access is complemented by smaller amounts of federal funding for two other kinds of services: Access to Allied Psychological Services, which is a grant-based program targeting low-income and vulnerable populations, and various Internet-based Cognitive-Behavioural Therapy (CBT) initiatives coordinated through a digital mental health gateway.

The estimated treatment rate for mental disorders in Australia increased from 37% in 2006-2007 to 46% in 2009-2010. ¹² With such high demand, Better Access experienced higher than projected costs: spending increased an average of 8.5% per year between 2007 and 2011. ¹³ Growth in utilization rates (and associated costs) slowed after caps on the number of sessions were lowered in 2011 from 18 to 10 sessions. ¹⁴ Although outcome data are not routinely collected, a representative sample of Better Access clients shifted from having severe or moderate levels of depression, anxiety, and stress pre-treatment, to having mild or normal levels post-treatment. ¹⁵

Improving Access to Psychological Therapies (IAPT) was introduced in the United Kingdom in 2008 in response to National Institute for Health and Care Excellence (NICE) guidelines for the treatment of depression and anxiety, coupled with a very strong business case. ¹⁶ In 2004, NICE identified CBT and interpersonal therapy as effective alternatives to antidepressants, ¹⁷ and the 2018 depression guidelines suggest that CBT may even outperform antidepressants over the long term. ¹⁸ Policy-makers were further convinced by a cost-benefit analysis showing the costs of expanded psychotherapy services would be fully recouped within 2 years, as a result of improved productivity and reduce disability benefit payments.

Improving access to psychological therapies approach to expanding access to psychotherapy differs from Better Access in just about every way. Improving access to psychological therapy is a grants-based program with distinct staff and standards, centrally administered by National Health Services (NHS) England and offered in every district. The program is free at the point of delivery and provided by a workforce with either IAPT-specific or IAPT-approved training. Improving access to psychological therapy follows a stepped-care model, with the majority of services offered through lower intensity interventions (such as on-line CBT-based self-help and psychoeducation groups) and a smaller number of face-to-face therapies offered as required. Pre- and post-measures of symptoms are collected at every session and reported monthly through NHS Digital on a district-by-district basis. Clear targets for access, wait times, and recovery were set at the outset and have since been met. ¹⁹ Although IAPT’s initial 15% treatment rate target is far below the 46% achieved in Australia, 900,000 of the 6 million adults estimated to have depression and anxiety in England enter IAPT treatment each year, and a new 25% target has been set for 2021. More than 75% of referrals are seen within 6 weeks and 95% are seen within 18 weeks. Lastly, more than 50% of the people who complete treatment have moved from meeting diagnostic criteria for depression and anxiety disorders to no longer meeting these criteria (IAPT’s definition of recovery).

Although both the grants-based approach taken by IAPT and the insurance-based approach taken by Better Access have achieved impressive results, both models have also confronted challenges with inequity. In the United Kingdom, while IAPT targets have been met on average, there is considerable variation between districts and population groups. For example, treatment completion rates drop off in the most socio-economically deprived decile, and recovery rates are only 35% compared with 55% in the least deprived decile. ²⁰ Part of this inequity has been explained by lower quality services in more socio-economically deprived districts ²¹ ; accordingly, quality improvement is a key priority for IAPT in the coming years. ²² In Australia, utilization of Better Access services has been found to be much higher in urban than in rural areas, and much lower in areas with greater socio-economic disadvantage. ²³ Although such disparities existed prior to 2006, they were likely compounded by the ability of allied mental health professionals to charge copayments under the Better Access scheme. Such copayments not only pose financial barriers for service users, they also provide disincentives for providers to practice in more disadvantaged (often rural) areas. Coverage of telehealth services under Better Access has been expanded to improve reach in rural areas.

Expanding access to psychotherapy in Canada: A call for health leaders

With a $5 billion federal mental health transfer and lessons learned from Australia and the United Kingdom in hand, Canada is well-positioned to address long-standing gaps and inequities in access to psychotherapy. Recent examples of provincial and territorial initiatives include Ontario’s $73 million investment (over 3 years) in a new Improving Access to Structured Psychotherapy program ²⁴ and Quebec’s $35 million investment in the first phase of a new public psychotherapy program. ²⁵ British Columbia has also included services for people with mild-to-moderate mental health and substance use conditions in its 2017 guidelines for primary care networks, ²⁶ and Newfoundland/Labrador has included expanded access to on-line therapy and dialectic behavioural therapy as part of its bilateral funding agreement with the federal government. ²⁷ As these new programs are implemented and as other provinces and territories consider their options, there is considerable potential for more widespread reform.

What can health leaders do to move forward with reforms in the Canadian context? For example, to what extent can IAPT’s command-and-control approach be adapted to Canada’s more decentralized federation? What would need to be done to adapt Australia’s Medicare-with-copayments model to Canada’s deep but narrow Medicare model, without triggering runaway costs? With the third of Canadians without access to employment-based benefits also the least likely to be able to afford to pay out-of-pocket, ²⁸ can Canada lead the way in reducing inequities alongside of overall increases in access to psychotherapy?

First, health leaders can recognize that provincial and territorial governments have the policy levers to implement either a grants-based or insurance-based reform, even within the constraints of Canada’s decentralized federation. Granted, the Canadian federal government does not have either jurisdiction over Medicare as does the commonwealth government in Australia or full jurisdiction over healthcare as does the United Kingdom government. However, Canadian provincial and territorial governments do have jurisdiction over Canadian healthcare. They administer public health insurance plans, provide grants to community mental health centres and other services, and raise 77% of their spending on health through provincial and territorial revenues. ²⁹ Although fiscal pressures in the health sector are considerable, the federal government’s $5 billion targeted mental health transfer provides a new opportunity to increase provincial and territorial spending on mental health. Even if provinces and territories decide to implement Australia’s model of expanded Medicare coverage, they are well-positioned to closely track expenditures and adjust caps if required.

Second, health leaders can take a strong approach to performance monitoring, with clear equity targets set from the outset of psychotherapy reforms. Without strong leadership, it will be difficult to achieve strong accountability for results in such a decentralized system, where no one level of government has full responsibility for all aspects of health policy. The bilateral agreements for the $5 billion federal transfer and the associated set of six pan-Canadian indicators will help to hold governments accountable for making measurable improvements in access to mental health services. ³⁰ However, health leaders will need to collect much more detailed data on psychotherapy reforms to get closer to the standard set by IAPT’s session-by-session monitoring, or even to Better Access’ evaluation of pre- and post-treatment outcomes. Health leaders have a further moral imperative to set clear targets for access by lower income Canadians and other equity groups with a view to ensuring that the impact of Canadian reforms is more equitably distributed than those in Australia and the United Kingdom. In the context of Canada’s deep but narrow Medicare model, public funding covers the full cost of psychotherapy when provided by physicians, in hospitals, or in limited community-based services. However, the broader range of psychotherapy services that are provided by psychologists, social workers, and other mental health professionals is not covered. Canadians pay the full costs, pay what is not covered by employment-based benefits if they have them, or go without.

Third, health leaders can focus on workforce planning. Workforce engagement, capacity development, and increased supply have been key drivers for reform in both the United Kingdom and Australia and may even be more so in Canada where mental health workforce planning is relatively weak. Data on baseline workforce capacity are limited and what exists is fragmented. The Canadian Institute for Health Information does compile some data on psychologists, social workers, and occupational therapists, with new data released early in 2019. Provinces and territories likewise have varying degrees of data on their allied mental health workforce, often gathered through provincial professional associations. There is likely to be at least some degree of underutilized capacity among non-physician mental health service providers that could be mobilized by expanded public funding. ³¹ However, underutilized capacity was not sufficient for increasing access in the United Kingdom and Australia. Workforce capacity in Canada will need to be more closely tracked to ensure that new public funding results in a true increase in supply, rather than just a shift from employment-based insurance provision to publicly funded service provision, or from pre-existing to new publicly funded services.

Lastly, health leaders can form a coalition to act as a focal point for efforts to expand access to psychotherapy in Canada, much as the Coalition for Access to Psychotherapy has acted as a focal point for reform in Quebec. ³² Although the $5 billion federal mental health transfer has opened a window of opportunity for reform, it is not the same thing as a new national program such as IAPT in the United Kingdom, or the federally driven expansion of Medicare under the Australian Better Access initiative. The federal government could play a leadership role as part of its reform of federally funded pan-Canadian health organizations. ³³ However, the bilateral nature and varying content of funding agreements, and the fact that to date only 8 of 13 provincial and territorial governments have been signed, suggests that the new federal transfer is most likely to accelerate innovation province by province at various levels of the service system. ^34,35

A full scan of Canadian innovations in improving access to psychotherapy is beyond the scope of this brief article, with its primary focus on reform in the United Kingdom and Australia. However, there are many long-standing and emerging strengths that warrant a brief mention. Reforms in Canada can build on decades of innovation in collaborative mental healthcare models that integrate psychotherapy services into primary care settings, and lessons learned from direct federal funding for psychotherapy services for First Nations and Inuit, veterans, and refugees. E-mental health initiatives have been gaining momentum and have tremendous potential to improve access to psychotherapy in Canada’s rural, remote, and otherwise underserved communities much as they have in Australia. ³⁶ In the absence of universal public funding in Canada, the justice and education systems have become increasingly involved in psychotherapy service provision, whether through campus mental health services or diversion programs. Employment-based benefits also play a more significant role in the Canada, where two-thirds of the population have coverage, than in either Australia or the United Kingdom. Accordingly, collaboration and coordination are required to minimize the risk for cost-shifting from the private sector to the public sector, or between different publicly funded services. ³⁷ All told, a coalition is needed to draw on the strengths of these diverse psychotherapy service systems in Canada, to spur innovation and transfer learnings across jurisdictions and sectors, and to coordinate efforts so as to maximize the benefit of reforms for Canadians.

Conclusion

Australia and the United Kingdom have significantly expanded access to psychotherapy over the past decade. With this international experience, the many Canadian innovations that are underway and a new $5 billion federal mental health transfer to draw upon, Canada is well positioned to address long-standing gaps and inequities in access to psychotherapy. In Canada’s more decentralized context, a concerted effort from health leaders at all levels of government and across multiple sectors and professions is needed to make the most of this opportunity for reform. Key priorities for health leaders include using the full range of provincial and territorial policy levers for either a grants-based or insurance-based approach; implementing a strong approach to performance monitoring, with equity targets built in from the outset; addressing gaps in workforce planning; and forming a pan-Canadian coalition for expanding access to psychotherapy.

Improving access to psychotherapy is only one of many priorities for mental health and broader health policy reform in Canada, and action on broader determinants of health such as housing and employment may ultimately contribute more to the mental health and well-being of the population. Nevertheless, reforms in this area will not only generate health and economic benefits but will also help to turn the corner on the more inequitable features of Canadian Medicare. Ideally, a coalition for expanding access psychotherapy will work in tandem with reforms in other areas such as pharmaceutical drugs and homecare.