After decades of neglect, mental health is on the national agenda. Australia is currently faced with an historic opportunity for meaningful and lasting change in mental health service delivery. We last had such an opportunity in 1993 with the Burdekin Royal Commission.
Three recent major reports will influence the May federal budget. All call for increased clinical and health services in the community, with new team work arrangements proposed for GPs, psychiatrists, psychologists and mental health nurses. In addition, new non-clinical and respite services for people suffering mental illness, their families and carers, an increase in the mental health workforce and new programs for community awareness are likely to be funded. The reports are:
- The Mental Health Council of Australia & Human Rights Commission Report: Not for Service: Experiences of injustice and despair in mental health care in Australia (released on 17th October, 2005) used stories and statistics to graphically portray the parlous state of mental health service delivery across Australia.
- The Productivity Commission Health Workforce Study report: ‘Australia’s Health Workforce’ (released 19th January, 2006) saw mental health as a major aspect of a more general problem in the health system. It was critical of the tight preserve many health professions exercise over their territory, particularly in the area of mental health where there are too few people to do the work. It did not advocate the training of generalists, who have no professional heritage. Instead, it acknowledged the value of maintaining clear professions with unique competencies that complement each other, whilst sharing the work more effectively than at present.
- The long-awaited Senate Select Committee into Mental Health: A National Approach to Mental Health: from Crisis to Community (released: 28th April, 2006) claims (as do the above reports) that there is not enough emphasis on prevention and early intervention. There are too many people ending up in acute care, and not enough is being done to manage their illness in the community… because early intervention and community-based care would deliver savings in the long term. It advocates substantially increasing the funding for mental health services to between 9 and 12 percent of the total health budget. A key recommendation of the Report is a Better Mental Health in the Community program to be rolled out over 4-5 years, including the establishment of 300-400 community-based mental health centres for primary health care, staffed by teams of psychiatrists, clinical psychologists, psych nurses, GPs and social workers, funded by Medicare for salaries or contracts, not fee for service. Others, including the Australian Divisions of General Practice (ADGP), support the alternative model of making the Federally-based Divisions of General Practice responsible for providing services to the key front primary care providers — namely the thousands of GPs in general practice across the community.
Not for Service elevated mental health to a prominent position on the agenda of the Council of Australian Governments (COAG) meeting on the 10th February this year. The meeting, troubled by the implications of an ageing population and already committed to considering health as part of a new drive to create a larger, fitter workforce, established the COAG Health Working Group to report in June. It has received submissions (from the ADGPs, the APS, etc) that highlight successful recent trials and service delivery options in the community.
Thanks to Bill Leak.
The Prime Minister has announced, well prior to final reporting deadlines, (specifically on 22.3.06 and 5.4.06) that $1.8 billion – increasing to $500million in the fifth year and ongoing – will be made available for mental health. He has suggested that these funds be matched by the states and territories and that they concentrate on the supported accommodation needs of the mentally ill, improvements in emergency and crisis services, and hospital and prison care. The challenge of providing humane and effective employment options for people who have had severe mental illness and now wish to work does not yet figure in the proposed arrangements.
The Federal Budget to be tabled on May 9th will finalise these allocations at federal level before the COAG Health Working Group completes its report. It is hoped that State allocations will complement, rather than overlap or clash with, federal funding priorities.
Because of the common emphasis among the reports on the provision of care in the community, especially for people in the early stages of mental illness, it is worth establishing a check-list of features that this care should satisfy.
- It should be in a form that normalises the process of seeking help for mental illness , preventing stigma and providing services in a socially acceptable environment where patients are not reluctant to access them.
- It should enable, if possible, effective early intervention and prevention of more serious conditions.
- It should be equitably available across the country providing clear and universal pathways to care.
- It should support GPs, the key primary care providers, and be located close to them.
- It should be built on evidence of effectiveness and so avoid the medicalisation of unhappiness which can make patients demoralized and dependent on inappropriately prescribed medications.
- It should not duplicate expensive health infrastructure.
Since 2001 the Commonwealth Government has funded clinical trials of shared care between GPs and appropriately trained psychologists. These trials have shown that collaborative care – involving short-term, evidence-based, focused psychological interventions — can be highly successful for patients suffering from the common mental disorders (i.e. depression, anxiety and some co-morbid conditions) which are estimated to affect more than 20% of the population every year. The trials demonstrated strong patient satisfaction and high rates of treatment success (including for those in the severe range). GPs expressed a strong desire for this practice-based specialist mental health support to continue – indicating the need for it to be available to all GPs, not just the minority accessing services under the trial arrangements. Medicare-funded psychiatric services are primarily located in more privileged urban areas, whereas the distribution of psychologists more evenly matches that of the Australian population as a whole.
The model of primary care psychological services which provide treatment for the neglected majority would complement care for the minority of patients with psychotic and other severe illnesses; assisted housing for the chronically ill; multi-disciplinary centres and multi-systemic therapy for the acutely disturbed. None of these services, however, would solve the challenge of providing humane support for people who have had severe mental illness and now wish to work. The new ‘work instead of welfare’ arrangements starting on July 1 will not assist those who require gradual and assisted reentry to the workforce. Appropriate resources for this particular group of people will also need to be found.