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Community Affairs References Committee
Accessibility and quality of mental health services in rural and remote Australia

TUNNECLIFFE, Mr Michael, Clinical Psychologist, Ashcliffe Psychology


Evidence was taken via teleconference—

CHAIR: Welcome, Mr Tunnecliffe. Do you have any comments to make on the capacity in which you appear?

Mr Tunnecliffe : I have a special interest in rural and remote area mental health—in particular, the use of telehealth, tele mental health.

CHAIR: Can I check that information on parliamentary privilege and the protection of witnesses and evidence has been provided to you?

Mr Tunnecliffe : Yes, it has. I've read all that.

CHAIR: Excellent. I invite you to make an opening statement and then we'll ask you some questions.

Mr Tunnecliffe : Sounds good. Thank you. Good afternoon, everyone. I appreciate the opportunity to speak to the committee. I have never done this before, so you will need to bear with me on this one. Basically, as a clinical psychologist I have been, for quite a number of years, involved in tele mental health. I developed that interest probably about six years ago, with my colleague Kerryn Ashford-Hatherly, also a clinical psychologist.

We were at that time working with Western Australia Police Force. I was executive manager of the WA police psychology unit, and we had police officers in some of the remotest areas of Western Australia, as you can imagine. Western Australia police is the largest police jurisdiction in the world. So, when critical incidents happened or when police officers had challenging events or mental stress themselves, we needed to get online to them or on the phone to them and provide a variety of support systems. Most of this was done by phone; however, we had some police officers who wanted to talk to us privately, after hours, away from work, and at that time we used Skype. I have come to understand now that Skype is not optimal simply because we cannot guarantee the confidentiality of Skype. But one of the things that I found very useful was that ability to speak to officers in their own home or away from their worksite about some of the experiences they were having in their location, particularly those that put them under a lot of stress and strain.

Subsequent to that, when I left the police department, I joined a group called BSS Employee Assistance. BSS primarily was an employee assistance provider to the Western Australian resource sector, which included iron ore and oil and gas, as well as a number of goldminers. Kerryn had also joined me at BSS. In that role, we looked at setting up a tele mental health program we called OVC, online video counselling. We offered it as a service, and we found we were able to provide counselling to some of the workers in some of the really remote FIFO sites, because the companies put a lot of effort into making sure that, I suppose, the communications via internet were of reasonably high quality. We worked at that for quite a while, and I've had experience in talking to people overseas, because we have a number of FIFO workers who live overseas. They come in through Perth and then go to wherever they live, in Thailand, the Philippines or somewhere else. We were able to connect up at their home bases as well, using tele mental health.

The primary reason for my interest is that, as you're probably aware, towards the end of last year the federal Minister for Health, Mr Hunt, made an announcement by which tele mental health would be available to remote and rural areas, which we got very excited about because we could see the need there. But then I was a little bit astounded, when I followed up and checked on it, that you had to have face-to-face contact after the first three sessions and, of the 10 sessions allowed under Medicare, four had to be done face to face. To me, that immediately rules out the most remote and rural people in Western Australia, because you can't have three sessions with someone in Wiluna and then expect them to travel all the way to Perth, and Wiluna's pretty close compared to Halls Creek, Derby and places like that. So I've been petitioning through various members of parliament to have this changed, but the response has always been, 'This is the way it is, because we believe that you must have face-to-face contact to develop rapport.'

I'll just finish off with this and leave it open to questions: my research and my experience says that is simply not the case. There is ample research that says there is great evidence for rapport in tele mental health, and my colleague Kerryn Ashford-Hatherly two years ago completed her master's dissertation, in which she had 16 FIFO workers who had a diagnosed sleep disorder with comorbid depression and anxiety. As you probably know, FIFO workers still go to work regardless of what happens, because they can't afford not to. With a small group of well-trained psychologists, she treated 16 workers for insomnia with comorbid depression and anxiety, and the results were outstanding. Not only did they build really good rapport with these people, but every single participant improved. They didn't all improve to the same degree, but there was statistically significant improvement with the insomnia and the anxiety and depression. These people were never seen face to face. They were always dealt with via the OVC, the online video counselling.

I know my colleagues I've been talking to through the Australian Clinical Psychology Association are not even going to bother about trying to do the tele mental health, simply because the requirement of having a face-to-face session after the first three means you're going to set people up, do your assessment, do your evaluation, do your formulation and say, 'Right, now you've got to come to Perth, Sydney, Melbourne or wherever the therapist's working from.' To me, that is not going to help rural and remote people. So that's my point of view.

I'll add one more point. I was asked last year to assist with a film production company who were doing a video, which I believe is still in production, on veterans—both Australian and international veterans—who had been part of military service in places like Afghanistan, Iraq and various other locations, about how they had recovered from that. What they wanted was a psychologist to monitor these veterans, to just check that they were in a fit mental state to be in the production and to do a follow-up afterwards. I was one of those asked to take on this role. The veteran I worked with and dealt with was located overseas. I can honestly say that we developed a great rapport. I did the assessment via OVC, online, and I did the follow-ups online, and we developed a great rapport. The whole concept of having to talk to someone face to face I believe is extremely detrimental to people living in remote and rural Australia. That's my point of view, everyone, so I'll leave it to you now to ask any questions you have. I'm happy to take any questions from the committee.

CHAIR: Senator Pratt, do you want to kick off this time?

Senator PRATT: Yes, thank you, Chair. In terms of people who want to have access to a counsellor with whom they have a rapport, it seems problematic that people would be limited to either a centre that they are able to travel to or a psychologist who is prepared to travel to where they live. It would seem obvious that some people won't be able to access treatment at all.

Mr Tunnecliffe : I can give you an example of that. Two years ago we were asked by Argyle Diamonds, which was one of our client organisations, to provide support and assistance to one of their employees who was living in Fitzroy Crossing. We were the EAP provider. We were asked if we could see that person face to face, simply because it was difficult—where he was there was no internet access or anything else. He was one of the remote ones. I made some inquiries to see if we could organise someone in the East Kimberly to see him. There was actually no psychologist, either government or private, in the East Kimberly at the time and no psychiatrist in the East Kimberly at that time. We are talking about regions of Australia where mental health support and assistance is not only really thin on the ground but sometimes nonexistent.

I see using online video counselling or the tele mental health is a great way to overcome that lack of staffing in those areas. I was talking to a colleague in the education department. It's not due to them not trying to get someone up there or not wanting to have someone up there; there is a huge reluctance of a lot of professionals, both medical and mental health professionals, to work in remote and rural locations like that. I was told they've really been struggling to find someone. I'm not sure if that answers your question. We're talking about massive distances here. I don't think that people realise just how far some of these distances are. I know probably members of the committee would because of the work you're doing. I was in Melbourne two weeks ago and my colleagues in Melbourne had no idea of the distances in Western Australia.

Senator PRATT: I am a supporter of online delivery of these services, but if government were to say that we need some checks and balances in this, can you think of alternative ways of doing it? It's not that I necessarily think that they're needed. I don't necessarily think you're less likely to have a rapport because it's online. Either you have a rapport with your psychologist or you don't.

Mr Tunnecliffe : Yes.

Senator PRATT: Sometimes it takes a while for people to shop around and find one that they do have a rapport with. In fact, we're doing people a disservice if we limit them to whoever is available in their area.

Mr Tunnecliffe : I think that's where our Medicare system would overcome that, because if Medicare were available, as it is now—I can only talk about my profession of psychology, we get six sessions and then we put a treatment report in to the referring GP, the GP then can authorise another four sessions, so that is 10 sessions. And in most mental health issues, unless they're really long-term and chronic, or very, very complex, you can actually get some really good progress in 10 sessions helping the person. Now I see Medicare as being the checks and balances, because, if you can get the GP on side, and you talk them through the GP and build up a good liaison there, what happens then is, you have to report to the GP after the first session, then you report to the GP after the sixth session, and then you do another four and you do a final report to your GP. I think the checks and balances are that Medicare already has some built-in ways just to make sure that what the patient is getting is going to be helpful to the patient.

Senator PRATT: I note that Medicare is already underspent in regional areas because of a lack of access to clinicians.

Mr Tunnecliffe : Yes, that's right.

Senator PRATT: So it would be a shame to make this worse—as we currently are.

Mr Tunnecliffe : Yes, and I don't know any clinicians that I've spoken to who are even prepared to go down this track and set themselves up to do the telehealth, under the current situation. Because, as I said, your first session is making contact, getting all the history, and getting the information, and any assessments you need to do, and then you do a formulation of how you're going to treat the person. Your third session is where you really start to commence treatment in any meaningful way; you do give a lot of suggestions earlier on, but your third session is where you start. And then to just tell the person, after the third session where you start to treat meaningfully: 'You'll have to come and see me face to face now.' That's not going to work.

Senator BROCKMAN: On the same issue, you spoke about the evidence base of using telemedicine in this context: are there international examples we can look at which tell us that this is an effective way to approach this issue?

Mr Tunnecliffe : I'd have to check. The big problem we have is you're looking at developed countries, and developed countries with large areas. Your obvious example is the United States. The United States now proves a real complicator for us, because in the United States, you cannot do telehealth across a state line—and because they've got 52 states or something there's lots of state lines there, and also the population size means they've got a much wider access—being able to get, I suppose, easier access to mental health support. In essence, to your question: the amount of evidence is very limited.

There was a conference the year before last in Melbourne where this was one of the keynote addresses, and they weren't talking about large distances or rural and remote areas, they were talking about rapport in general. And there was some good evidence about the rapport that came through in that presentation, and what they were looking at was the outcomes. The outcomes were—in many cases—for some disorders, equally as good as face-to-face. With two conferences that I've attended in Adelaide on tele mental health, the guest speakers at those all thought that the rapport factors weren't a major issue.

I'm very happy to research further for you and look for some of that international data; however, my personal view is we've got to look at Australian data, and we have a bit of that. Because Australia is very unique in its rural and remote areas, and its lack of mental health support in those areas.

Senator BROCKMAN: Even if you don't research it, if you could just point the secretariat in the direction of where that research exists, so the committee can consider it as much as possible.

Mr Tunnecliffe : Yes, I'm happy to do that.

Senator BROCKMAN: One of the things that we heard earlier today is that service providers would be wary of a telehealth approach—or an electronic approach—being used, effectively, as a way of saving money and displacing face-to-face services that are essential. So, obviously, government is going to have to balance those two priorities at some point.

Mr Tunnecliffe : Yes. I think that was covered by who could access the telemental health. You have your Monash areas, and you can only access it in areas 4 and 5. That means they have to be truly remote and regional areas. If you were around Kalgoorlie, say in Kambalda, you'd have to go to Kalgoorlie because Kambalda doesn't come under this system. So I see these very much as being applicable to areas where there is no support available.

Senator BROCKMAN: Fair enough. Is there a spectrum in which you think that this is more worthwhile? I would assume that at a more serious end of the spectrum it would become more problematic to do things via telehealth?

Mr Tunnecliffe : That's a really good point, actually, because if you get very complex disorders—and I'm talking about things like some serious PTSD, or if you get people with quite complex personality disorders which are comorbid with other issues that manifest in depression and anxiety—just simply treating the depression and anxiety won't treat the underlying problems. Those people really do need to be seen face to face and probably assessed—because the use of medication—by a psychiatrist. When you get complex mental health issues, I think that telehealth becomes more supportive than interventional. However, the vast majority of the cases that we come across are simply reactive depression, or some kind of underlying anxiety or people having anxiety attacks. They are very, very treatable with online CBT.

I will put my up my hand up-front: I'm a CBT practitioner. I lectured in CBT at the University of Notre Dame. I find that CBT is a great medium for using telehealth. The program that we used on the mine sites for insomnia with comorbid depression and anxiety is called CBTI, which stands for cognitive behaviour therapy for insomnia. It's got some great evidence behind it, and it works well. So it's not a cure-all; it's not for every situation using telehealth. And I would certainly say that complex mental health disorders need to be looked at in a face-to-face context.

Senator BROCKMAN: Great, thank you very much.

Senator HINCH: I don't want to put words into Senator Pratt's mouth, but she was generally supporting you before. What I'm keen for you to explain to us is: is there any form of—it's an awful word—compromise, or any other way the government may seek to move more and more towards what you are doing, and not be so rigid on the six and four?

Mr Tunnecliffe : There's already a mechanism in place. I must say that we're a little unique because we're a bulk-billing practice. We don't put gaps on or anything like that—mainly because we're older, more mature and probably better off, so we don't have to do that.

One of the things that we find is that there are the six and the four, and then there are the conditions that have some chronicity about them—they're chronic conditions. Let's say you get a person who has really suffered from depression for most of his or her life. They get some treatment and they're able to function a lot better; they're able to maintain a job and function reasonably well. However, it's almost like every now and again they do need to return and sort through some other cues that have cropped up for them. When they finish their six and four, the GP can apply for another provision which means they can continue to be seen. Under Medicare it has almost no limit, but the rebate is then cut to, I think, a $54 flat fee.

That's the sort of thing that we'd certainly be prepared to do. It's a way of saying that if there is a person in a remote or rural area who really has a long-term condition—we're not talking about complexity, we're talking about chronicity now, which is a little different—they could be supported ongoing with very minimal imposts on the Medicare budget. I'm not sure if that's the sort of thing you're after—

Senator HINCH: Thank you, that's good.

CHAIR: Thank you very much for your evidence today, it was very helpful.

Mr Tunnecliffe : Thank you to the committee. I appreciate having the opportunity to speak to you all.

Proceedings suspended from 15 : 10 to 15 : 24