Chapter 5
Mental health
5.1
Many submitters voiced great disappointment with the COAG proposals and
funding agreements in relation to mental health in terms of the level of
funding, a lack of reform to mental health services, as well as a lack of
integration of mental health in the planning and reform of the whole health
system.[1]
Lack of funding
5.2
Of most concern was that the funding for mental health services does not
reflect the burden of disease. The Royal Australian & New Zealand College
of Psychiatrists (RANZCP) noted that one in five Australians experience a
mental illness in any one year, but pointed to the poor level of funding:
Current funding for mental health is inadequate. Funding for mental
health should be reflective of the burden of the disease attributable to mental
health. At least 14% of all health care funding should be directed towards
mental health are, rather than the inadequate 6% it currently receives.[2]
5.3
Professor Patrick McGorry noted that whilst there were some positives
for Australians with mental ill-health in that the 'agreement establishes a
policy direction that emphasises the importance of providing young people with
increased access to models of care', there were also negatives and
uncertainties.[3]
He continued:
The principal negatives for Australians with mental
ill-health are that the agreement exacerbates rather than addresses the
structural under funding of mental health services and does little to advance
the "historic reshaping of mental health services" that has been
promised by the Prime Minister and that is urgently required.[4]
5.4
The lack of adequate funding was seen by the Mental Health Council of
Australia (MHCA) as being particularly inexcusable given the funding of the
reforms through a new tobacco excise:
With 42% of all cigarettes sold in Australia being smoked by
people with mental illness, the fact that the COAG health agreement is to be
funded by the new excise on tobacco suggests that the primary role of mental
health consumers is to underwrite improvements in systems that do not meet
their needs.[5]
5.5
The funding of mental health was the critical issue for many other
submitters. It was acknowledged that the Commonwealth's mental health package
of $175.8 million includes $25.5 million over four years for new Early
Psychosis Prevention and Intervention Centres (EPPIC) and $78.8 million over
four years to establish up to 30 new Headspace sites reaching an
additional 20,000 young people a year.[6]
However, the MHCA submitted that the budgetary measures do 'little to address
the crisis in the mental health sector in Australia' and are not a reflection
of the outcomes of the consultation process undertaken prior to the COAG
agreement.[7]
The MHCA concluded these initiatives 'constitute vague in-principle support and
incremental increases in just a few areas of urgent unmet need'.[8]
5.6
There was also concern that much of this funding was simply redirected
or re-badged funding, rather than representing new resources directed at mental
health. The Australian College of Mental Health Nurses (ACMHN), for example,
argued that the mental health funding component included $31.4 million in new
funding and $65.4 million in restored or redistributed funding.[9]
Mr David Crosbie, of the MHCA also noted that the Commonwealth is providing
more funding for mental health nurses but funding had been taken away from
mental health nurses in the last budget.[10]
5.7
Professor John Mendoza also commented on the level of new funding:
In mental health, the COAG package provides just $115m new
funds over four years. There is a return of some of the previously reduced
funding for mental health nurses (just $13m) and a further $57m of redirected
funds from the Better Access program to tally up to the headline figure of
$174m.[11]
5.8
The resignation of Professor John Mendoza was reported in the press on
20 June 2010. In a front page article entitled Rudd Adviser Quits,
the Chairman of the National Advisory Council on Mental Health tendered his
resignation in a letter to Minister Roxon last Friday (18 June). He is reported
as stating:
"It is now abundantly clear that there is no vision or
commitment from the Rudd Government to mental health," he wrote.
"The Rudd government is publicly claiming credit for the
increased investment in mental health when almost all of this is a consequence
of the work of the Howard government."[12]
5.9
Professor Mendoza's letter of resignation dated 18 June 2010, and
effective immediately, includes this scathing assessment of the Rudd
Government's efforts:
Two years ago when we first met to develop the work plan for
the Council you requested we develop a vision for mental health, a framework
for accountability, proposals to improve the Commonwealth’s current mental
health investments and specific proposals for new investments based on evidence
and (with emphasis) consumer and carer views. The Council has also responded to
the requests for advice on the revised National Mental Health Policy, the 4th National Mental Health Plan, the revised
National Mental Health Service Standards, the Better Access Program and the
ATAPS program. All those requests were met.
However, it is now abundantly clear that there is no vision
or commitment from the Rudd Government to mental health. While significant
improvements have been made in disability employment policy and to a lesser
extent in housing and community services, there is no evidence of a change in
policy or investment in mental health. The Rudd Government is publicly claiming
credit for the increased investment in mental health when almost all of this is
a consequence of the work of the Howard Government.[13]
5.10
The RANZCP argued that over five years, the additional funding allocated
to mental health amounts to $120 million compared to $7.3 billion for health in
general. The RANZCP concluded that:
Quality and integrated mental health services cannot be
achieved through such a piecemeal approach to funding. These funding
differentials will only serve to widen the gap further between mental health
and other health services.[14]
5.11
This concern was shared by Professor Patrick McGorry who argued that $57 million
of the $58.5 million flexible care packages is pre-existing funding and that
$47.5 million of the $78.8 million in Headspace funding represents a
continuation of the existing level of funding for Headspace. He argued
that, on this basis, the allocation to mental health care represented a
widening gap between mental health care and physical health care funding.[15]
Professor McGorry continued:
The 2% of additional health funding allocated to mental
health under this agreement is alarmingly small. It is one fifth of the
proportion of health funding that mental health currently receives (6%) and
about one tenth of the proportion of health spend recommended by the 2006
Senate Select Committee on Mental Health (up to 12%). It is less than a tenth
of the share of Australia's health burden attributable to mental ill-health
(13%). Such minimal growth is simply nowhere near enough to achieve any
meaningful reform and better outcomes in mental health care.[16]
Unmet need for mental health services
5.12
Witnesses provided the committee with an overview of the level of unmet
need for mental health services. Professor McGorry commented that there is a
hidden waiting list in mental health of several million Australians including
750,000 young Australians. Lack of services for people with mental illness
leads to more unnecessary and premature deaths and unnecessary disability.[17]
5.13
Mr Crosbie, MHCAH, illustrated the level of unmet need through the
experience of those presenting with a mental health crisis at hospital
emergency departments:
Of the 76,000 presentations in 2006 in New South Wales
emergency departments, 21,000 gained admission and 55,000 did not.[18]
5.14
Emergency departments are a first point of contact for persons seeking
after hours care and those seeking assistance for the first time. However, 63
per cent were not admitted or provided with referral to another hospital. The
MHRC quoted a 21 April 2010 newspaper report in The Australian to
highlight the state that many people with mental illness would be in when they
reached a hospital emergency department:
For three days, Vittoria Tonin took a cocktail of drugs she
expected would kill her, then wen it did not, she presented herself to the
emergency department of the Royal Melbourne Hospital asking for help. She was
17 and in the final year of school. Although she had "some quite developed
suicidal plans", the psychiatrist who saw her only offered her a late
school pass.[19]
5.15
The MHCA noted that two-thirds of people with mental illness report that
they didn't receive mental health care in 2006–07 whilst one in four people who
made a suicide attempt did not access services for mental health problems in
the previous twelve months.[20]
It also highlighted the need for recovery support systems for consumers
discharged from hospital without adequate assistance including that of
accommodation, employment options and other support. It argued for a more integrated
model for mental health services, which:
...acknowledges the whole of life needs of consumers and which
effectively links treatment to ongoing recovery outside the hospital based
acute setting, would improve treatment effectiveness and long term health
outcomes.[21]
5.16
The RANZCP argued that there was an 'inherent unmet need' within the
population that must be considered which was:
...approximately 60% of those with mental disorders receive no
specific mental health care. Concurrent to this projections suggest that mental
health related disease burden will grow markedly as a proportion of overall
disease burden, and community expectation of mental health care is increasing
as specific campaigns raise awareness and expectation of treatment.
Substantial additional investment in the prevention,
diagnosis and treatment of mental illness will achieve both health benefits for
individuals and families affected by mental illness in the short and longer
term, but also bring broader community benefits such as increased productivity
and workforce participation.[22]
5.17
The unmet need for mental health services is not restricted to only one
part of the health care system with the AMA noting that:
There is significant unmet need in the mental health system
across the service spectrum, for prevention and early intervention, to
sub-acute and acute care and specialist follow-up in both community and
hospital settings.[23]
Community based services
5.18
Many submitters argued that the lack of community services is the major
issue underlying unmet need for mental health services. Mr Crosbie, for
example, stated that over the last 15 years, the number of community treatment
beds halved, not withstanding the development of the National Mental Health
Strategy.[24]
The level of community based residential care for people with mental illness
ranges from two beds per 100,000 in two states to 24 in another.[25]
Mr Crosbie went on to comment:
We need the community programs in place that we have really
run down, if anything, since we closed all the institutions. We had 30,000
acute beds for eight million people in the sixties. Many of them were beds that
we would never want to recreate, of course. We are down to 8,000 acute beds for
double that population and we have halved the number of community beds. If I am
a frontline service provider, a GP or anyone, who do I send someone to if they
present, are starting to lose touch with reality and need some time out, maybe
some medication and maybe some containment? What are the options at a community
level? I go to countries like New Zealand and they have community run options.
They do not have to go to a hospital.[26]
5.19
The MHRC's submission highlighted the ramifications for the health
system as a whole when community services are not available:
It is the case that many people with mental illness have
little access to appropriate mental and other support in their local community
and increasingly become unwell. This results in a vicious cycle that leads them
back to the need for acute hospital based care, which could have been averted
with adequate access to treatment options and community supports.
Lack of strategic alternatives for many mental health
consumers to adequately manage their illness in the community means that
hospital emergency departments are a significant first point of contact in the
mental health system.[27]
5.20
Mr Crosbie concluded:
Everyone agrees, from the Prime Minister's statements to some
of the senators sitting around this table, about the need for a greater
investment at a community level, and yet I do not see that investment.[28]
5.21
SARRAH emphasised that people with chronic and severe mental health
needs would be better cared for in the community if funding for community based
mental health services were channelled through the PHCOs arguing that:
To achieve better health outcomes for those with mental
health problems, reforms must empower local structures in rural and remote
communities to use funds flexibly and make decisions about the most appropriate
packages of care.[29]
5.22
Concerns were raised regarding the $58.5 million funding directed at
individual care packages which are to support up to 25,000 people. According to
the Minister for Health and Ageing, the individual care packages will support
clinical and non-clinical care for up to 25,000 people with severe mental
illness living in the community.[30]
Mr Sebastian Rosenberg, for example, stated:
The package also offered $57 million to develop tailored
packages of care for 25,000 Australians with severe mental illness. Leaving
aside that this amounts to $2280 per person, the exact nature of what model of
care this expenditure seeks to advance eludes me.[31]
Funding for mental health services
for young people
5.23
The Commonwealth has provided additional funding for Headspace
and EPPIC. Professor McGorry stated that this was 'significant and positive in
direction, but timid in scope and scale'.[32]
He commented on the limited impact of the Commonwealth's proposals:
The investment that has been announced will probably reduce
by about three to four per cent the number of young Australians who are
currently unable to get access to mental health care, and that is about 750,000
young Australians. So we will make some inroads, but the model that we proposed
to the government earlier this year would have made a much bigger impact. Our
target was to reduce the waiting list of 750,000 by about 200,000 to 250,000.
Our goal was to make a much more serious inroad into that waiting list because
people’s lives are at stake here—young people’s lives through premature suicide
and death, their careers, their vocational opportunities and their families.
The burden on their families is extreme...The frustrating thing is it is all
preventable if we scale up these sorts of models more rapidly.[33]
5.24
Professor McGorry raised concerns regarding the practicability of the
EPPIC investment model given that the 'allocated funding of $6.35m p.a. is
significantly less than the cost of even one EPPIC centre (depending on scale
these centres would cost between $10-20m p.a. to run)'.[34]
Professor McGorry went on to comment:
Therefore, even with co-investment by State Governments there
remain significant implementation challenges to be overcome to provide young
Australians with psychosis access to the most evidence based care.[35]
5.25
Professor McGorry argued that the recent allocation for Headspace
and EPPIC should be increased to $200 million a year.[36]
He noted that this level of funding would increase capacity to make
'sustainable inroads into a huge hidden waiting list of young Australians
currently denied mental health care'.[37]
Professor McGorry highlighted that the new youth mental health funding (for Headspace
and EPPIC) translates as $13.9 million per annum over new funding to provide
care to an additional 23,500 people each year. He went on to state:
This represents just 3% of the 750,000 young Australians who
experience mental ill-health each year without accessing appropriate supports.[38]
5.26
Professor McGorry also noted that:
EPPIC is demonstrably the most evidenced based model in the
spectrum of mental health care and highly cost-effective. Though it is an
internationally acclaimed Australian innovation that has been implemented in
hundreds of centres across the world over the past 15 years, it has not yet
been made available to the Australian population, except in heavily diluted
fashion in Victoria.[39]
5.27
The MHCA held a similar view arguing that the 'welcome endorsement for
proven youth mental health models is not matched by appropriate funding
levels'.[40]
It continued that there were good practice models that informed the
recommendations of the 2006 Senate Select Committee inquiry into mental health
services and the report of the NHHRC. It was also noted that:
What is urgently needed now is serious consideration of why
such services are not the norm in Australia's mental health system today and
the implementation changes to the funding system that support this status quo.[41]
5.28
The concern that the initiative would only reach an estimated three per
cent of young people with mental ill health was shared by the Mental Health
Council of Australia.[42]
Need for further reform
5.29
Witnesses commented on significant underlying problems within the mental
health system and stated that the Commonwealth's proposals do not address these
problems.
5.30
Professor Patrick McGorry argued that mental health has been 'largely
neglected' and that there was a 'mismatch between the urgency to act, scale of
the need and power of Government rhetoric on the one hand and the timidity of
action on the other'.[43]
The MHCA similarly commented:
...despite the rhetoric, state, territory and Australian
governments do not seem to be committed to providing appropriate mental health
services for consumers and carers or the Australian community.[44]
5.31
The MHCA also stated that 'the disconnect between the policy documents, the
words, the plans and people's experiences is huge'.[45]
5.32
The MHCA argued strongly that since the release of the National Health
and Hospitals Reform Commission final report in July 2009 and development of
the National Health and Hospital Network, the focus of the Government has been
on the hospital sector with 'only limited changes in the form of new funding
initiatives to the mental health sector'.[46]
The MHCA continued that:
These announcements are not the strategic approach to reform
that is needed in the sector. They do little to address the cycle in which
mental health funding is used to support the increasing need for acute services
in the hospital sector and little to address the urgent areas of unmet need in
mental health, particularly in the community sector. If use of mental health
funding in this way continues to remain a priority for state, area, local
health services and hospitals, the access to mental health services, community
support and early interventions that are so desperately needed will continue to
remain elusive.[47]
5.33
Professor Patrick McGorry also commented on the focus on the hospital
system, in particular, the increase in funding to decrease hospital waiting
lists by a relatively small amount while the 'hidden' waiting list in mental
health is much more serious. Professor McGorry stated:
I just think it is logically bizarre that we see billions of
dollars invested in reducing waiting lists by this much in the acute hospital
system while we have got hundreds of thousands and even millions of Australians
whose lives are at risk because of that other waiting list being totally
neglected.[48]
5.34
Professor McGorry also questioned why this 'critically underperforming
area of Australian healthcare has been largely neglected – with only confusing
and unconvincing reasons offered to date'. He also stated that:
It also remains unclear as to whether the Government has a
plan to address this neglect. The current 4th National Mental Health
Plan is manifestly inadequate and lacks vision, priorities and any evaluative
framework of goals, targets and indicators or mechanism for accountability.[49]
5.35
Professor McGorry maintained that a new mental health investment program
was needed which has an 'explicit overarching goal of ensuring Australia's
mental health system is progressively scaled up to meet the same standards of
quality and accessibility as our physical health system by 2020'.[50]
He continued that:
Until the Government announces a clear vision of mental
health reform and a plan with specific targets to achieve it, and a serious
growth strategy, confidence will continue to drain away from the mental health
sector.[51]
5.36
Professor McGorry also argued that that health reform without mental
health reform is 'both unfair and unlikely to succeed'. Professor McGorry
stated:
Better mental health means that we are more likely to enjoy
better physical health. When we do become physically ill our stays in hospital
are much shorter if our mental health is better. On top of that, these physical
health benefits are further enhanced with better personal and social outcomes
such as better career and educational success and reduced incidence of
unplanned pregnancies, homelessness, violence and stress on families. It is
actually a no-brainer that we need to invest in both physical and mental health
care.
However, most Australian communities are provided with an
outdated model of health care that seeks to heal bodies but neglects minds...Australians
are two to three times more likely to access quality care for physical health
as for mental health. In other words, there is a huge discrepancy that is
unfair, produces worse health and social outcomes and, perhaps more importantly
from the point of view of the government at the moment, it wastes precious
resources. This neglect is terribly wasteful. We have very good cost
effectiveness studies showing that money is saved by early investment is mental
health care.[52]
5.37
Professor David Penington argued that the recommendations of the 2006
Senate Select Committee on Mental Health inquiry report in relation to mental
health funding should be revisited.[53]
5.38
The Consumers Health Forum of Australia also raised concerns in relation
to what it saw as a lack of integration of mental health as part of the reform
package:
CHF is concerned by the absence of significant new mental
health funding in the 2010-11 Budget, and the lack of any detailed plans around
mental health as part of the National Health and Hospitals Network. We argue
that it is essential that mental health is included as a fundamental element of
the National Health and Hospitals Network, so that mental health care and
treatment are integrated with the models of health services delivery.[54]
5.39
Submitters raised a number of other issues in relation to mental health
services. The MHCA noted for example, that there was a need for greater
accountability mechanisms to drive mental health reform. The MHCA argued:
There is little or no comprehensive national public reporting
of significant areas of interest to mental health consumers and carers such as
health outcomes or service quality indicators. This means that there is little
urgency for change and no way of evaluating the outcomes of initiatives that
are implemented.[55]
5.40
In evidence, Mr Crosbie commented further that there were no measures of
people's mental illness in Australia and what happens to them. There is limited
data on use of mental health services 'but we do not know whether [people with
mental illness] got better, how beneficial those interactions were and the
degree to which it actually meets needs'. Mr Crosbie concluded:
...it is this public transparency and accountability about
people’s experience of mental illness, their attempts to access care and the
quality of care they get that need to be accurately documented or at least
reflected if we are going to get real reform.
I must say the health minister has made some quite powerful
statements about the need to better document and to be more transparent and we strongly
support those statements, but we are yet to see that reflected in the kinds of
processes that have led to this agreement so we have real concerns about the
degree to which they are going to offer the benefit that they potentially offer
because there is a lack of transparency and a lack of accountability.[56]
5.41
The Dietitians Association of Australia noted that as a high proportion
of consumers with mental health conditions also have co-morbidities, some of
which develop as a side effect of pharmaceutical intervention, there needs to
be a 'concomitant allocation of funding for allied health services such as
dieticians to prevent and treat obesity, diabetes, and cardiovascular disease'.[57]
5.42
The ACMHN raised concerns that the coordinated care packages under the
Access to Allied Psychological Services (ATAPS) program were to be introduced
at the expense of removing mental health Social Workers and Occupational
Therapists from the Better Access initiative, noting moreover, that mental
health nurses working under the ATAPS were 'well placed to provide coordinated
care packages as well as mental health Social Workers and Occupational
Therapists'.[58]
5.43
The RACGP welcomed the funding for adolescent and young adult mental
health services but lamented the lack of recognition and support for the role
that GPs play in the early detention and treatment of mental illness and of the
need for coordination between GPs, allied health professionals and other
community support services.[59]
The RACGP argued that the Medicare Benefits Scheme needs to be appropriately
structured to allow GPs to dedicate time required to assess and understand
their patients' mental health needs, provide cognitive and/or pharmaceutical
treatment, and that of ongoing monitoring of their patients' condition.[60]
Conclusion
5.44
The promised leadership on mental health by the Commonwealth has
evaporated. What has emerged with the announced reforms is a small, incremental
change to the system which will do very little to address inequity in access to
services and decrease unmet need for mental health services.
5.45
The committee notes the comments by Professor Patrick McGorry who
pointed to the excellent evidence-based programs which are available in this
country that, if provided with adequate funding could have a tremendous, positive
impact for those Australians with mental illness. In particular, expanded
funding for the Headspace and EPPIC programs would see many more young
people access services.
5.46
The committee also notes that there is overwhelming evidence that the
benefits of providing increased access for young people far outweigh the
additional cost to the health budget. The reduction of disability, the
improvement in survival rates, the decrease in use of services and improved
outcomes point to the high cost effectiveness of early intervention programs.
Professor McGorry stated that the costs are three times as much over an
eight-year period if a person goes through the normal late intervention system.[61]
5.47
The committee considers that the Commonwealth has not delivered on its
promise of reform of mental health services. Indeed, Professor Mendoza's
comments in his letter of resignation show that the Rudd Government has not only
failed to deliver, but is also falsely claiming achievements of the Coalition
Government as its own:
It is now abundantly clear that there is no vision or
commitment from the Rudd Government to mental health...
The Rudd Government is publicly claiming credit for the
increased investment in mental health when almost all of this is a consequence
of the work of the Howard Government.[62]
5.48
Rather than honesty and accountability from the Rudd Government, the empty
rhetoric continues and inadequate levels of mental health services remain.
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