The 2006-7 Federal Budget is large on promise but slim in detail in its increased funding to mental health care — an area deemed by many, including the Prime Minister, to be in need of radical reform. Of note is the increased support for general practitioners – the front-line providers of most primary mental health care services — and the first ever allocation of Medicare rebates to clinical psychologists. These developments are to be highly commended.
What are the key allocations?
A major funding boost of $1.9 billion over five years has been provided to address the currently estimated shortfall of 50% of mental illness in the community remaining untreated. This includes:
- $538 million to improve access to GPs, psychiatrists and clinical psychologists under Medicare (of which $381.8 million over five years will be spent on rebates to improve availability of potentially life-saving treatments);
- $191.6million over five years for private psychiatrists and GPs to hire mental health nurses to co-ordinate patient care, provide home visits and monitor patient medication;
- $284.8 million over five years for 900 personal “helpers and mentors” to ensure mentally ill patients get appropriate treatment, income support payments, accommodation services and other benefits they are entitled to;
- $73.9million over five years for non-government organisations to train drug and alcohol workers to detect signs of mental illness in people battling drug and alcohol problems;
- $51.7 million to improve access to mental health services for people in rural and remote Australia;
- an extra $62.4 million over five years for suicide prevention programs;
- $103.5 million to provide training places for 420 mental health nurses and 200 clinical psychologists;
- $46 million for 7000 extra places for the mentally ill in programs designed to help with cooking, shopping and social outings;
- $1million over five years for the Mental Health Council of Australia.
The government estimates that in the fifth year the initiative is likely to result in:
- an extra 35,000 people being able to see a psychiatrist;
- about 400,000 Medicare-funded services being provided by clinical psychologists.
There are a number of anomalies in the overall design of the allocations.
Firstly, if the extra 35,000 patients are provided with current psychiatric rebates and average number of sessions per patient, the allocation to psychiatry increases considerably beyond the current funding base, estimated in 2001-2 to be approximately $196million per annum. This is despite recent research evidence indicating a mal-distribution of these services with fewer than 7% of psychiatrists practicing in rural areas. The majority are located in the affluent leafy suburbs of Melbourne, Adelaide and Sydney.
Second, if 400,000 rebated sessions are provided for patients with clinical psychologists at $100 per session – (one of the unanswered questions in the new package remains how much Medicare will pay out on these new rebates) – a total allocation of $40 million for 66,700 patients (ie. an average of 6 sessions per patient) will be provided. If these patients are to be referred by the 8,000 treating GPs who have undertaken mental health training and are currently eligible to access psychologists for their patients, the doctors can refer an average total of 8.3 patients per year. Given that a conservative estimate of prevalence of psychological disorder in GP patients is 20-40%, and GPs often see more than 30 patients per day, this would seem slightly inadequate.
Thirdly, an allocation of $191.6million over five years for GPs and psychiatrists to employ mental health nurses flies in the face of the findings of the Access to Allied Health primary care trials (undertaken since 2001 under the Better Outcomes in Mental Health Care Initiative). In 90% of these trials, general practitioners chose psychologists as their key collaborative allied health service providers, resulting in the program being renamed Access to Psychological Services (ATAPS). In addition, research indicates that focused psychological interventions are the treatment of choice for most high prevalence mental health conditions, as well as most chronic conditions (in combination with pharmacotherapy). It would therefore be more productive for GPs themselves to have the ultimate choice as to which mental health practitioners they employ with the additional $191.6million to be provided to assist them.
Finally, missing in all of this is a clear allocation for people who have had severe mental illness and now wish to work, many of whom require gradual and assisted reentry to the workforce. Relevant support services need to be included.
Recent estimates from Commonwealth surveys indicate that more than 20% of the population has some form of mental illness in any one year. Most have the high prevalence disorders (e.g. depression and anxiety) and are referred to as the neglected majority. These conditions frequently result in demoralization, de-motivation, diminished creativity and productivity. (In Britain, for example, ½ million people are absent from work each day as a consequence of depression alone). Apart from the sheer misery for the person, the flow-on effects are simply terrible — catastrophic both for the Australian economy and the country as a whole if they remain un- or ineffectively treated.
This is the first time since the Burdekin Royal Commission in 1993 that the political spotlight has been turned full-wattage on the parlous state of mental health service delivery in Australia. The budget allocations show that it is a high priority. However, the rationale for the current distribution of these much-needed resources remains unclear. Access to psychological services, in which pathways to care are clear and universally accessible, are a crucial part of the equation. It is important that we get it right this time and systematically and effectively resource them.
(Thanks to The Australian health editor Adam Cresswell for the figures. See Medicare yet to win over psychiatrists, Weekend Australian, p.31, 08.04.06)