Negotiating the Australian mental health system in search of suitable treatment is enough to drive anyone nuts. For someone experiencing a significant mental health problem, it can be a total nightmare. Pathways to care are unpredictable and highly variable and access to treatment is inadequately funded, ensuring that the well heeled are frequently the only ones able to afford appropriate interventions. In rural areas, even this is problematic.
Over the past twelve months a number of enquiries and reports have once again highlighted the parlous state of our mental health services and have resulted in making the issue a high political priority – perhaps for the first time since the Burdekin Royal Commission in 1993. Amongst these have been the Senate Select Enquiry into the nation’s mental health system; the Productivity Commission Report on the Australian Health Workforce and, perhaps most effectively, the Mental Health Council of Australia’s Not for Service Report. Launched in October last year, the Not for Service Report was responsible for putting mental health on the agenda of the Council of Australian Governments’ (COAG) meeting early this year. Extremely positive signs emerged from this February meeting. In early April the Prime Minister pledged to spend an additional $1.8 billion on mental health services, with an implied expectation for State Governments to match this spending on a pro rata basis. In May the Federal Budget consolidated the Commonwealth Government’s commitment and outlined a number of key funding targets:
- increased access to GPs, psychiatrists, clinical psychologists, mental health nurses, helpers and mentors;
- further training of drug and alcohol workers;
- extra training places for 420 mental health nurses and 200 clinical psychologists;
- improved access to services for people living in rural and remote areas;
- suicide prevention programs;
- 7000 extra places for the mentally ill in programs designed to help with cooking, shopping and social outings;
- a new network of community-based mental health care made up of GPs and community health workers to help people live active lives and to prevent illnesses escalating to the point where patients need hospitalisation;
- 24-hour mental health care hotlines staffed by medical experts;
- $1million over five years for the Mental Health Council of Australia.
Some of these targets were based on emerging State-based promises, others were pure Federal initiatives.
But after the initial euphoria of both consumer and professional groups in the face of this political will and the promise of effective change, doubts have begun to surface. Not only is it clear that the State Governments are not meeting expectations on their side of the funding bargain, but the translation of policy into action in time for the November launch of the new reforms has remained a well kept secret. Adam Cresswell’s excellent article in The Australian: ‘COAG mental health plan — on the rocks’ (5.8.06) highlights the State-by-State funding shortfalls compared to pro rata estimates of what they should be contributing. His earlier article: ‘Mental health push falters’ also emphasises the lack of an appropriate ‘road map’ for the reforms, quoting the follow-up Mental Health Council of Australia Report: Time for Service, which was launched the same week.
Few people have any idea what the framework to be unveiled in November will look like. It is not at all clear why it has taken so long for something of substance to emerge nor why, after so many years of research and enquiry into the area, the outcomes seem to be a lot of good ideas cobbled together in a please-all package which everyone hopes will work. What is missing is a unified, evidence-based, coherent model of service delivery which provides universal pathways to effective treatment. Whatever the final amount of funding provided, a rational and systematic approach is needed to ensure that all new services are accessible, accountable and provide early intervention for those who need them. There is no point in perpetuating and replicating, albeit on a larger and more expensive scale, the mish-mash of pathways to care and service options currently in operation. Many of these lack an evidence base and create an enormous amount of confusion. They also waste time and money. What is needed is a coherent framework providing patterns of care that make sense to those who use them, particularly patients themselves and their referring doctors.
An integrated proposal of this kind was put to the Federal Health Minister in November 2003 following a series of successful control trials of collaborative care between GPs and appropriately trained psychologists in a number of locations across Australia. It is well known that General Practice is the first port of call for the majority of people suffering from mental health conditions. These early intervention trials, supported by the Access to Allied Psychological Services framework under the Commonwealth Better Outcomes in Mental Health Care initiative (2001-2006), clearly indicated that primary care psychological services were a highly effective model of care. The proposed training and workforce development proposal, which was put to COAG again in January 2006 involves both salaried public-health psychologists and clinical psychology registrars working in Divisions of General Practice across the country who would be complemented by privately practicing, Medicare-funded clinicians (equivalent to current privately practicing psychiatrists) in each community. The aim of having salaried psychologists located in local Divisions is to provide appropriate coordination of clinical services available to referring GPs and their patients in each region. This removes the autonomy and fragmentation inherent in the current situation where private practices operate independently under Medicare.
The emerging COAG framework (where details of it can be detected) suggests that Medicare-based psychological services are being favoured as an alternative to salaried coordinating positions. There are hints that the fledgling GP Division-based services which have emerged under ATAPS may be dismantled, possibly to release funds for the promised Medicare rebate on psychological treatment. If these services were to be cut, this would belie the promise that the new developments under COAG will represent a real increase in, rather than a shifting of, resources.
If we are truly serious about reforming the plight of those suffering from mental health conditions instead of just creating vote-winning political window-dressing, then adequate provision must be made for well-structured, universally available and evidence-based early intervention. Such an early intervention program must be easily accessible for patients without the additional burden of the stigma associated with many current service delivery options. Primary care psychological services provide such a model of care. They need to be adequately resourced as a core part of the COAG framework. Funding projections indicate that a fully-coordinated network of psychological services across the country involving both salaried public-health positions and Medicare-funded practitioners would cost a fraction of current expenditure under Medicare alone for psychiatry. There is ample room for both if the political will is there.
We have a huge and rare opportunity to take a gigantic leap forward in reforming the terrible state of our mental health services. It would be to Australia’s detriment to let this opportunity pass to resolve or at the very least considerably improve the public mental health service delivery framework through high quality, equitable early intervention. Estimates from Commonwealth surveys indicate that more than 20% of the population has some form of mental illness in any one year, resulting in demoralisation, de-motivation, diminished creativity and productivity. Apart from the sheer misery of it all, the magnitude of the problem and its flow-on effects are simply terrible — catastrophic both for the economy and our country. We’ve got to be smarter than that — even if doing so is not an immediate vote-winner. However, with public concern about the state of mental health care on the rise, political leaders may well find themselves rewarded for doing the right thing.