A comprehensive analysis of the budget’s mental health announcements

(Update, 23 May: see also this comprehensive analysis by Dr Lesley Russell from the Menzies Centre for Health Policy at the University of Sydney)

The budget’s mental health announcements (outlined here) have excited many. But plenty of challenges lie ahead, cautions Sebastian Rosenberg, Senior Lecturer, Brain and Mind Research Unit at the University of Sydney. It would be premature for any decision makers to cross mental health off their “to-do” list, he says.

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Positive steps have been made for mental health, but there are many caveats

The key message arising from the Federal Budget is the acknowledgement by the Government that putting new money into old systems won’t work. The Government is making new choices about where to invest and these are exciting.

There are overdue investments in EPPIC (Early Psychosis Prevention and Intervention Centre) and also funding for headspace, new services for new clients.  In relation to EPPIC in particular, there is a solid evidence base to justify this spending.  The key issue will be if Pat McGorry and his colleagues have enough funding under this Budget to ensure the national roll-out can be achieved without compromising the integrity of this model of care.

There is new investment in flexible care packages – $343.8m.  The concept of individually tailored packages of care is attractive and there is some evidence to indicate that this approach can be successful in meeting client needs.  However, this funding is supposed to assist 24,000 Australians with severe and persistent mental illness over 5 years, meaning $2865 per person per year.  NGOs are familiar with running on the smelly of oily rags but there are clearly limits on how much coordination and service purchasing can be done for this price.

Access to this funding is up for tender, between NGOs and the new Medicare Locals.  For the Government this a neat way of bringing the new Medicare Local enterprises into the community mental health service realm.  The risk here is for a continuation of a bio-medical approach to these packages of care at the expense of more psycho-social approaches.

The establishment of a pool of incentive funds for states and territories to engage particularly in the development of supported accommodation is most welcome. Housing is one of the key areas so far neglected in mental health.

This positive move must be balanced by evidence emerging from the states and territories that, with the support of the Commonwealth, sub-acute funds are being used to build new warehouses, often on hospital campuses.  This is not genuine community-based living options for people with a mental illness and must be discouraged. The recent decision to build services in Queensland offering shared accommodation to people with dementia and schizophrenia is an example of this.

The commitment of some funding for new e-health approaches is also a very positive sign.  There is mounting evidence that for some treatments, e-mental health care is at least as effective as face to face services and this is critical if we are to address the needs of remote and regional Australia.

The establishment of a new National Mental Health Commission is also exciting, offering a new level of federal scrutiny and accountability over a system characterised by an inability to demonstrate the impact it makes on people’s lives.  Another key signal is the placement of this Commission within the Prime Minister’s portfolio, rather than Health.  This demonstrates the Government’s appreciation of the need to provide a level of systemic accountability which properly reflects consumer experience, rather than trying just to count occupied bed days.

Again, however, the Budget papers indicate expenditure of only $12m over 5 years, limiting the initial capacity of the Commission to really drive new accountability.  Interestingly, there is a national role here too, as WA and now NSW look to establish their own Mental Health Commissions.  It would be very useful if this work could be done with some coordination.

How a Commission will operate is as yet unclear but it will obviously need strong statutory powers if it is to deliver the level of accountability, independence and transparency necessary to properly report on progress.

Many of the Budget measures require the active involvement of states and territories, all of whom are part way through their own mental health plans and strategies.  The Federal Government has given no indication of their intention to seek jurisdictional support for CoAG National Action Plan on Mental Health MkII.  As it stands, they are bringing around $200m to CoAG, seeking co-investments from the states.  The last CoAG Plan delivered $5.5bn.

As has been commented on elsewhere, much of the mental health Budget occurs in the ‘out’ years.  According to the Health Budget papers in fact, only around $200m is slated for expenditure between now and 30 June 2014.

Around a quarter of the whole mental health package is funded by savings from the Better Access Program, with reductions to the Medicare rebate to GPs for each mental health care plan they write, and a reduction in the number of subsidised sessions of psychological therapy from 12 to 10 each year.  The Better Access Program is growing so fast the Department of Finance could not ignore it.

The $10m spent on this Program per week does put the totality of this Budget announcement into some perspective.  The evidence about the impact of this Program is still quite weak, with data still showing that key groups missing out before the introduction of this Program are still missing out on care – young people, people in non-urban areas, men etc.

At the macro level, the Health budget of course continues to grow.  According to the AIHW, in 2008-09 Australia’s total spending on health was $113bn, having grown by $9bn since 2007-08.  The National Mental Health Report 2010 says that in 2007-08, mental health spending nationally was $5.32bn.

Even allowing for increased spending flowing from the CoAG Action Plan since 2007-08, subsequent increases to the whole health budget means that mental health’s share is almost certainly declining not increasing.  The 2011 Federal Budget, providing new spending of $300m per year over five years, does almost nothing to arrest this decline.

Perhaps the most critical aspect of this Budget is that it makes good Prime Minister Gillard’s commitment to make mental health a priority.  Even with the caveats listed above, there can be no doubting her Government’s commitment to contributing to reform in an area long neglected.

At another level, it brings Labor into line with the Coalition and the Greens, creating all-party support for mental health reform.  Cancer, diabetes and heart disease all enjoy this type of support.  Over recent years, mental health has become politicised.

This Budget offers an opportunity to re-assert bipartisanship.  The new national Commission could become a vehicle for this to occur, reporting to Parliament rather than Government, and perhaps having cross-party representation as part of its governance structure.

This Budget sets out many challenges for the sector.  But perhaps the most significant challenge is for the political gods to resist the urge to simply now cross mental health off their ‘to do’ list. Now is the time for advocates for mental health reform to be pointing out how much there is still to do.

People with mental illness and their families are used to waiting, often with sad, sometimes tragic consequences.  This Budget does not mean that wait is over.

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Update: In this piece I wrote for today’s Crikey bulletin, Professor Ian Hickie sings the praises of the PM and Mental Health Minister Mark Butler, but takes the stick to the AMA, Australian Psychological Society, colleagues in the broader mental health sector and, by implication, the Department of Health and Ageing. The broader point of the piece is that the budget announcements are one thing – implementation will prove quite another and is likely to involve many ongoing challenges.