When was the last time you saw an ENT for the flu?

“I have spent many thousands of dollars on a Masters degree. I hold a full college membership. I also hold a further postgraduate qualification in a related field, ie 8 years of relevant training, more than many clinically endorsed psychologists. I am a tier 2 psychologist. Why? Because I took the wrong masters.

I respect my colleagues who took a Clinical Masters, but I do not view them as superior to myself. I also respect my colleagues who took the 4+2 route. From what I have seen this is not easy. They have had to demonstrate their proficiency to the board just as we have. We had our competence mostly assessed by a university. They had theirs mostly assessed by AHPRA. So? We have all been assessed as competent.

I am watching employment opportunities dry up. Most private practice positions ask for clinical endorsement, for obvious reasons. Most public health positions also ask for clinical endorsement. When you read job ads many will advertise for a mental health worker, with mental health nurse, social worker, occupational therapist, or clinical psychologist being considered relevant. What about the rest of us? Can we not even be considered?

I have a specialty area, but a clinical psychologist will get paid more for a consult even in my specialty area. How is this fair? How is this better for the client?

On top of all of this Better Access was only intended for people with mild to moderate problems. These presentations should not require a specialist. If a higher rebate is to be paid at all it should be reserved only for complex clients who require specialist treatment. When was the last time you saw an ENT for the flu?

The current 2 tier system has to go. It does not make sense.”

13 thoughts on “When was the last time you saw an ENT for the flu?

  1. Thanks RAPs for facilitating this debate.

    Dear colleagues, before publicly repeating assertions that there is “evidence” that different groups of psychologists are “the same” please read the cited studies yourselves and use your training to critically analyse this “evidence”.

    1) Remember the research maxim: “absence of evidence is not evidence of absence”

    Please read the “evidence” yourself – you will see that it is not “evidence” at all.

    The Better Access study was an evaluation, not an outcome study. It did not even try to assess equivalence. The authors stated that it should not be used as evidence of equivalence in the one v two tier debate amongst psychologists.

    Misusing research to further a financial agenda will simply destroy psychology’s reputation as an evidence-based profession and remove a point of difference from other service providers.

    2) Contemplate the consequences of advocating “one tier”

    If you still want to use these data despite the authors’ warning, try calculating the effect sizes for GPs. You’ll see that GPs have large effect sizes, just like psychologists. The authors say the BA outcomes were similar to those of stepped care in the UK as well as online CBT.

    If you argue that all psychologists are “the same” based on these data, then you need to accept that psychologists are “the same” as GPs, IAPT practitioners and online programs.

    There is no evidence that psychologists are any better than social workers, counsellors, enthusiastic amateurs or computer programs.

    And all these groups are very keen to achieve “parity” with psychologists and say they do “the same” work.

    3) Better Access has more than two tiers – can you afford a rebate cut to $65?

    Look at the comments on the Mental Health Party’s website:

    Social worker BA rebates are $10 lower than Psychologist rebates and they want parity because they do “the same” work.

    Counsellors want BA rebates too and have been lobbying hard for years. In their submission to the Mental Health Commission Review, they proposed $65 BA rebates for Counsellors – $10 less than the Social Worker rate.

    If you were a government planner and you accepted that all psychologists are “the same” why would you not accept that all providers are “the same” then sign up counsellors and create a single tier with a $65 rebate?

    Reform the profession by all means but do your due diligence by reading the research before citing it then think through the consequences!

    1. But what you propose is not evidence based, but vested interest based. Surely you should be proposing research that answers the questions you pose.
      Secondly if you read other posts and comments on this blog you will find that there were post-hoc analyses done on the review information that are robust in supporting the no difference hypotheses in the absence of evidence to the contrary.
      Why are the APS and others not advocating for and funding sound research to answer the question, “Is a higher rebate for “clinical psychologists” justified on the basis of better ourcomes?”. Perhaps because the answer is clearly already, “No!”
      Are you suggesting we should all go quiet on this in case Social Workers are also able to demonstrate equivalence and get an equal rebate? Where is the science and public good in that? Isn’t that just conniving self interest?
      If “Clinical Psychologists” are so certain of their superiority over other psychologist clinicians and other mental health workers they are at liberty to charge a higher gap payment and some do.
      Personally I charge a range from the top APS rate of 246 and lower by means testing in incriments of $20 down to $140 and even bulk bill at $84.80 for those on health care cards or otherwise strapped for cash. In this way those who can afford it subsidise those who don’t in true socialist fashion. I guess it is the Social worker in me who cares about the central value of Social Justice.
      Personally I think all mental health workers should be given the same rebate for the same work for the same outcomes.
      I honestly believe there are some excellent Social Workers and Occupational Therapists getting great results for a pittance, and the families and individuals coming to them should not be financially disadvantaged for chosing a good fit for their situation in those workers.
      Food for thought. I have often pondered that one Psychiatrist’s wages would pay for 4 Social workers and they would probably between them: 1) attend, in total, less big-pharma sponsored conferences, lunches and dinners than the one Psychiatrist; 2) Provide more than 4 times the number of sessions to clients; 3) see clients more frequently; 4) have a broader, more far reaching scope of pratice including family therapy and systems approaches with individual therapy, addressing social determinants of heath and illness directly thus increasing prevention at the level of the family and community 5) ameliorate mental illness issues very well.

      I wonder what the ratios would be at funding psychologists with the savings from one less Psychiatrist, and what the maths would be for how many social workers could replace a clinical psychologist in a mental heath service? Probably 2:1.
      Whatever the facts are I think it is important that we deal with the facts and not just rubbery figures that paint one group as superior over another simply because one group has greater access to constructing the discourse around the available information and filters out unsupportive information that might lead to questioning the logic of the institutionalized eminence of one group over the other.
      Are you really saying, don’t go down this path because the truth will show there is no better outcomes for “Clinical Psychologists” over other “Psychology Clinicians” and that might lead to the realization that other professions also get really good outcomes with mental health clients and therefore deserve equal status and pay?
      Because if we ignore that reality, it will be VET sector TAFE graduates who will take on the Mental Health work for $27/hr instead and we will be looking for work as TAFE lecturers (similar to which I have done, by the way, when training Cert II community work Orientation to Mental Health Work students from remote communities in Northern and Eastern Arnhemland and the Tiwi Islands… so pick me! pick me!)

      1. Hi Greg,

        I think we all agree that the system needs reform and it is good that we are discussing it, but let’s maintain professional respect and dignity.

        My concern is that smooth narratives have been constructed by the “anti-clinicals” which are not based in reality or an understanding of the bigger picture and these are being repeated as if they are “facts”.

        I simply urge psychologists not to repeat these narratives without checking them out for themselves.

        The post hoc analyses you mention may sound impressive but they are simple calculations that do not warrant the claims made for them. Read the evaluation paper and do the calculation for the GP outcomes and you will see this for yourself.

        We’d all welcome some clear outcome research. This is possible for specific therapies but its not really possible to evaluate professional training with current methodology. No other profession does it. One of the defining characteristics of a profession is that its members define what should be included in the training for a particular job because professional practice is complex and draws on a range of specific competencies.

        Is there evidence that social workers have better outcomes than welfare workers? Or that MH nurses do better than other nurses?

        This is why professional salaries are usually based on training not outcome data.

        You have contributed many posts to this debate, so I am glad that you are aware of the bigger picture and that TAFE or untrained people will increasingly pick up MH work. Big workforces are needed so this is a good thing.

        The question is whether there is still a role for professions like psychology and social work and if so, what should they do and how should they be trained and paid?

        I am not advocating that we cover anything up, just that our colleagues understand clearly that:
        1) there is no “evidence” of equivalent or different outcomes
        2) professional salaries are based on training not outcome data
        3) if you insist that professional salaries etc be based on outcome data, then you need to understand that the same argument will be used by others.

        There are many ways to reform the system. Getting rid of mental health professions is one possible path.

        There are others – such as your point about looking at distribution of funds through the system such as psychiatry rebates.

        Each of us needs to decide where we should put our energy for the greatest public good. For myself, I’d like to see the diversity of professions and training retained and expanded further to include people with diverse training and experience.

        1. Well said, psychology needs diversity and no one is saying otherwise. But what does diversity mean? It should mean a base level of standard training with opportunities then to diversify / specialise I would think. We are on the verge of this. Wouldn’t it make sense to make clinical the base qualification and then offer further specialised training from there – counselling / therapy, health, forensic, etc. Also – project forward 10 years. We will likely have a slightly smaller and more specialised psychology work force according to current moves with training and registration – do we want to have a lowered rebate for all now and then are stuck with this in the future? Surely levels based on training and specialisation is the way to go, with opportunities for psychologists to undertake this training perhaps across specific settings?

  2. Psychologists have so much to learn from GPs
    Only 8 days after the psychologists’ GM for the governance change the General Practitioners’ GM had a different fate, a much better fate for their entire profession.
    The GPs voted against the governance change proposed by the management of the GPs’ professional association (RACGP). The GPs strongly voted “NO”!!! to the governance change.
    It wasn’t a vote without problems.
    During the entire campaign RACGP advocated only for the ‘yes’ vote, totally ignoring the ‘no’ option…Does it ring a bell?
    The initial attempt to vote for the governance change was scheduled a fortnight prior to the final vote. However, it had to be aborted due to “technical problems”…another bell!!!
    And the GPs voted “NO”!!! to the governance change!
    And the GPs voted “NO”!!! to the proposed creation of more tiers within their profession.
    We still have a great deal to learn from GPs.
    To learn how to not divide our profession by falsely making a very few “more equal” than the rest of us.
    To learn that “together” does not mean “two tiers”.
    To learn that “fair” also means “equal” and not “above”.


  3. Right On! The reason health organisations advertise for Clinical Psychologists is to get the higher rebate. Pure and simple. And because of the misinformation supported by the APS that MPsychClin’s are superior. Yes the medicare rebates are not for complex cases! but many generalists are better suited to complex cases than the over specialised Clins anyway. Go figure. Averice is the motive. pure and simple. Averice.

  4. I obtained a PhD in psychology- (i once heard an Australian academic state this was the highest award of excellence a university can award)- and thanks to the APS/PBA junta, it is worth no more than the HSC i obtained as a 17 year old.

    1. Well that’s not true James…. you have a PhD which is a (hard earned) research degree, not a professional practice training program – a PhD does not provide you with professional (as opposed to research) training any more than a PhD makes a medical practitioner a practicing ‘doctor’. Unfortunately this is a good example of the conflation of issues present in the current arguments – you have a higher research degree, but the argument is about training pathways and recognition of expertise. Congrats on the PhD, surely hard earned and a lot of work, but a PhD does not make you a practicing psychologist nor lead to registration.

      1. Well silly me… I was a general 4 +2 and went to the trouble of paying for a Masters in Clinical Psychology, having already done a different psych Masters. Gave up some work and studied, paying fees and then did a PsyD and then PHD Clinical Psychology.
        I sat the same exams as Clinical Masters – yes that was 8 three hour exams as well as assignments. then did a Clinical PHD. I feel yes, their are inequities but really lots of generalists I know do lots of short courses, lucky them keep working, don’t pay out much in fees, and did not have to sit exams to show they can diagnose and develop case work plans according to standard criteria. Are you saying I should not have bothered ?
        Instead of talking about this methodologically limited outcome study I would like to hear how you can ensure people have a standard level of clinical knowledge ( diagnosis and the research skills to know how to interpret clinical efficacy and outcome studies) if they do not do higher degree.
        What are the specifics of educational and post degree pathways you all propose ?

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