Disparities in access to health care in Australia for people with mental health conditions

Additional keywords: accessibility of healthcare services, equity, vulnerable groups.

Ensuring access to health care for everyone in need is a goal of the health system in Australia. In 2017, the National Mental Health Commission released a consensus statement with a vision to improve the lives of people living with mental illnesses by improving equity in access to quality health care.¹ As part of the National Health Performance Framework, accessing care is described as people being able to ‘obtain health care at the right place and right time irrespective of income, physical location and cultural background’.² Access can be considered as the ‘fit’ between the patient’s needs and expectations and the service delivered.³ Access to care has been broadly conceptualised across five dimensions: (1) approachability (awareness of the existence of services, how to reach them and the effect they have on one’s health); (2) acceptability (social or cultural factors that affect the use of services); (3) availability (ability to reach the service both physically and in a timely manner); (4) affordability (ability to pay for services); and (5) appropriateness (the ability to engage in care that is of a reasonable quality).^3–5 Barriers to access to care can occur at any or all of these stages.

Disparities in access to care have been shown to exist across a range of population groups. Within the literature, regarding equity in access to care both globally and in Australia,^2,6 there is a focus on income when identifying groups ‘vulnerable’ to barriers to access to care. Australians from low socioeconomic status areas are more likely to face barriers in terms of foregone dental care and delayed prescription medication due to cost compared with those from the highest socioeconomic status areas.⁷ Barriers to access to care have also been shown to disproportionately affect Indigenous Australians and those living in rural areas.^2,6,8–10 There is also some evidence that compared with people with no conditions, people with chronic conditions are more likely to have barriers reaching care after-hours and to wait several days to get an appointment when sick.¹¹ However, research exploring access to overall care for people with mental health conditions is a notable gap given that people with mental health conditions have been shown to have higher out-of-pocket health care costs and to be more likely to forego care due to cost than people with no chronic conditions.¹² Indeed, a review of performance measures for public reporting on healthcare in Australia recommended that populations with mental health conditions be considered.¹³

Studies have shown that disparities in health care provision faced by people with mental illnesses contribute to poor physical health outcomes.^14,15 For example, people with a mental health condition have an average life expectancy >10 years less than the general population. For those with a serious mental illness, such as schizophrenia or substance disorder, the gap in life expectancy is >20 years.¹⁶ Australian research shows that physical health conditions are one of the main causes of early mortality among people with mental illness.¹⁷ Improved access to care could help reduce the gap in life expectancy for people with mental illness.^16,18 Thus, identifying disparities in access to all care is an essential first step in strengthening equity and improving health outcomes for people with mental health conditions.

This study examined disparities in barriers to accessing health care for people with mental health conditions using a broad conceptualisation of access to care. The study aimed to to address the following questions.

1. Are Australians with mental health conditions more likely to experience barriers to access to care across a range of access measures?

2. Do disparities remain after considering factors such as income, education, age and rurality?

3. Which access measures reflect the largest disparities between Australians with and without mental health conditions?

The 2016 Commonwealth Fund International Health Policy Survey of adults aged ≥18 years was conducted in Australia and 10 other countries.¹⁹ The focus of the analysis in this paper was the 5248 respondents from Australia, responding by landline and mobile telephone with a response rate of 25.4%. Results of the analysis were calculated using sample weights provided so that the estimates are representative of the age, sex, regional and education profile of Australia.

The Commonwealth Fund International Health Policy survey contains more than 60 health and health care-related questions.¹⁹ Thirty-nine survey questions that were considered a measure of access to care or a reasonable proxy were retained in the present study because they mapped to one of the five dimensions of access based on the conceptual model proposed by Levesque et al.⁴ The objective was to examine differences in access by mental health status using the framework as a guide. We excluded questions related to processes where no clear direction of good could be established (e.g. ‘Do you email your doctor?’) and those about safety or efficiency of a service (e.g. given the wrong medication or dose, unnecessary tests ordered). Responses were selected to frame each question as an access barrier. Where responses were not dichotomous, responses of ‘sometimes’, ‘rarely’ and ‘never’ were categorised as no, whereas ‘always’ and ‘often’ were grouped as ‘yes’.

Survey responses, as access barriers, were mapped to each dimension of access to care as detailed below:

1. Approachability: no affiliation with a regular provider and aspects of a lack of trust are captured in questions that reflect whether respondents do not have a regular doctor, if they were not treated with respect or felt that the medical care they received was poor or the health system needed to be completely rebuilt

2. Acceptability: reflections of challenges in autonomy or ability to seek care for people with chronic conditions were captured in responses where people felt they had no professional support for their condition or they could not manage their health problem at home

3. Availability: barriers of long waits to get a primary or specialist care appointment and time waiting in emergency or to get to elective surgery were captured under this dimension, as was perceived availability of after-hours care

4. Affordability: problems paying medical bills or foregoing different types of care due to cost were included

5. Appropriateness: problems with coordination of care, aspects of communication with care providers where records were not available, a lack of engagement of patients in their own care with an absence of written plans and a lack of involvement in decisions were captured in this dimension.

Complete questions are available in Appendix 1.

For the purpose of this analysis, people with mental health conditions were identified as respondents who reported they had been diagnosed with a mental illness or answered ‘yes’ when asked whether, in the past 2 years, they experienced anxiety or great sadness that they found difficult to cope with themselves. Participants who did not respond to both questions (n = 13) were excluded from the analysis. The resulting prevalence of people with a mental health condition (Table 1; 23%) aligns well with national prevalence estimates, which was the primary reason for considering not only those who had a mental illness, but also to include people who experienced emotional distress. In 2007, 20% of Australian adults had a mental illness based on the Mental Health and Well Being Survey.⁸ In 2014–15, 18% had a mental health condition² and 12% had psychological distress based on the National Health Survey.²⁰

Table 1.  Population characteristics by presence of a mental health condition
Data are presented as % (n)

Descriptive analysis was conducted to estimate the prevalence of each access barrier for people with and without a mental health condition. The percentage of respondents reporting each barrier was calculated by group as well as the percentage point difference between groups. Logistic regression models were run using SAS/STAT Proc Surveylogistic, Version 9.3 (SAS Institute, Cary, NC, USA) to assess the likelihood of experiencing barriers in access to care for people with mental health conditions, unadjusted and after adjusting for age, sex, income, immigrant status, rurality and highest level of education.

Almost one-quarter of Australian adults said they had been diagnosed with a mental illness or experienced emotional distress and felt they could not cope in the 2 years prior (23%; Table 1). Those with a mental health condition were more likely to be female, Aboriginal or Torres Strait Islander and have lower education and income than adults with no mental health conditions.

Compared with people with no mental health condition, adults with a mental health condition were more likely to experience barriers to access to care on 29 of 39 access-related measures grouped into five dimensions of access (Fig. 1).

Fig. 1.  Percentage of adults reporting access barriers by presence of a mental health condition. Descriptive results are based on unadjusted percentages by population group. Results are sorted within access dimension grouping or subgrouping in ascending order by the size of the barrier for the mental health condition group. *Unadjusted odds ratios >1 (P < 0.05). GP, general practitioner; ED, emergency department.

The size of disparities is described in Table 2 as unadjusted and adjusted odds ratios (ORs) for each of the 39 access-related barriers. In four measures, differences were no longer significant after adjusting for these factors, including approachability measures related to trust, availability measures and appropriateness measures related to engagement. For the remaining 25 measures, disparities experienced by people with mental health conditions remained statistically significant after adjusting for age, sex, education, income, rurality and immigrant status.

Table 2.  Disparities in access to care for people with mental health conditions, as differences, odds ratios (ORs) and adjusted ORs (aORs) compared with those with no mental health conditions in Australia
Shading indicates where odds or adjusted odds are significant at P < 0.05. The adjusted model includes age, sex, immigrant status, income, education, self-rated health and rurality. All results based on n > 30. CI, confidence interval; GP, general practitioner; ED, emergency department

The largest disparities, measured as differences and ratios are given in Table 3. People with a mental health condition were more likely than those with other chronic conditions to report that they were not confident about managing their condition (OR 9.2; 95% confidence interval (CI) 4.0–21.0) and that they did not have the professional support needed to manage their condition (OR 7.5; 95% CI 2.7–21.1). Adults with a mental health condition were over 20 percentage points (the largest absolute differences) more likely to experience a lack of courtesy and respect in hospital, to forego dental or other care due to cost and to receive conflicting information from care providers.

Table 3.  Questions reflecting the largest disparities as adjusted odds ratios (aOR) or percentage point differences
CI, confidence interval

This paper presents an initial analysis of the disparities in access to overall care for Australians with and without mental health conditions. This is the first analysis we are aware of to demonstrate that Australians with mental health conditions are significantly more likely to experience barriers in access to care compared with people with no reported mental health condition. These disparities were large, with the mental health condition group 10 percentage points more likely to report barriers, on average, and varied, with disparities spanning affordability, integration and coordination of care measures. Moreover, the disparities persisted after adjusting for social and demographic characteristics, including rurality and income.

In Australia as well as internationally, there are evidence-based interventions seeking to improve the physical health of people with mental health conditions. Internationally, a multilevel intervention framework to reduce excess mortality outlines interventions for people with mental illness across individual, health system and community levels to improve engagement around lifestyle factors, early detection of physical health conditions, address stigma and provide social support.²¹ Domestically, the Mental Health Commission of New South Wales has published the Physical Health and Mental Wellbeing: Evidence Guide, which outlines a comprehensive approach across multiple levels, including awareness of physical health effects of medications (e.g. antipsychotics and obesity), training for staff and population approaches to reducing stigma.²² For clinicians, Australian research has suggested an assessment and monitoring package for the physical care of people with mental health conditions.²³ Although there is growing attention on integrating services to improve access and addressing physical health conditions of people with mental illness, there is little evidence of monitoring the progress achieved by these efforts.

The analysis presented herein provides a baseline measure of disparities in access to overall care, and demonstrates substantial disparities in access between those with and without a mental health condition, which can be used by health services with the aim of service improvement. Similar studies have shown people with multiple chronic conditions were more likely to forego care due to cost, have long waits to see the general practitioner or specialist and have problems with medical bills compared with people with no conditions in Australia, based on findings from the 2010 Commonwealth Fund International Health Policy Survey.¹¹ The present study builds on findings demonstrating that people with mental health conditions faced multiple barriers to access to primary care across several countries.²⁴ We look more broadly at measures of access to care and expand the definition of mental health conditions to include those experiencing emotional distress but who do not have a diagnosed condition.

Survey data reviewed for this study demonstrated that, in 2016, more than one in five Australian adults (23%) had been previously diagnosed with a mental illness or had experienced distress and had difficulties coping in the previous 2 years. Improved evidence and monitoring of the access to and quality of care for people with mental health conditions is a policy and research priority.^13,25 In 2016, the National Mental Health Commission released a consensus statement with a vision to improve the lives of people living with mental illnesses by improving equity in access to quality health care.¹ As noted previously, The Equally Well Consensus Statement: Improving the Physical Health and Wellbeing of People Living with Mental Illness in Australia, highlights a goal of monitoring progress through performance indicators that focus on people’s experiences of physical healthcare services among other measures.¹ Disparities in access to care for Australians with mental health conditions identified in the present study may reflect barriers to either physical or mental health-related services or both. However, using population surveys to reflect on access contributes evidence towards the goal of monitoring by highlighting particular vulnerabilities of people with mental health conditions in accessing and navigating the health system.

There are limitations to this study that should be acknowledged. The survey does not capture institutionalised populations and therefore likely underrepresents those with severe mental illness. Barriers regarding access to care may reflect either physical or mental health services or both, and cannot be attributed to a specific healthcare sector. The conceptual framework of access was used as a guide and is not covered comprehensively by the survey questions; for example, measures of people’s ability to perceive needs and seek care are not considered. Further analysis is limited because there are several survey questions asked only of people who had elective surgery, used specialist or hospital services or needed after-hours care, or had care for a chronic condition. For these measures, based on smaller numbers of respondents, the sizes of disparities were large, which highlights possible methodological challenges to be overcome. Measurement of disparities through ratios and percentage point differences does not reflect the population effect of the disparity. The survey questions were dichotomised to focus on barriers in survey questions. There is room for future work to validate disparity measures to ensure they meet rigorous indicator criteria be useful in health system performance reporting.

The findings presented here highlight the vulnerabilities of people with mental health conditions in navigating the health system and throw up a red flag in relation to a key dimension of the Australian National Health Performance Framework: equity and access to care. The results of this analysis speak to disjointed care processes along the continuum of primary through to hospital care that disproportionately affect access to overall care for people with mental health conditions. These findings can be used to inform service delivery improvement by highlighting areas where healthcare services are currently performing poorly for people with mental health conditions.

The authors declare that they have no competing interests.