A free mental health consultation for Gillard, Abbott (and the rest of us)

Sydney psychiatrist Professor Alan Rosen has some tips for Tony Abbott on how to improve his “half-baked” mental health plan, and also some advice for Prime Minister Gillard on how to resurrect her Government’s credibility in mental health.  He writes:

“Mr Abbott’s platform for mental health is a healthy start, but the obvious question is “where is the rest of the plan, for all the other phases of care and age-groups urgently needing mental health care that have been sadly neglected, and how will you fund it?”

The pragmatic view is that the Coalition saw a gaping hole in the health reform agenda, that both badly needed plugging, and that had broad public interest and media appeal (youth mental health and early intervention). So they threw the whole box and dice at them. And good on them, as far as it goes.

They need to clarify whether the  800 early intervention beds proposed are not just more hospital beds for young people (who are much more receptive to care in the community). They should be mostly located in community-based  24 hour staffed residential respite facilities, to be used as an alternative to many emergency department presentations and hospital admissions, as you can find in nearly every catchment throughout Victoria, New Zealand and Italy. They can be modularized by gender or age-group if need be, but they need to cater for a wide range of ages and psychiatric problems.

The charitable view is that the Coalition policy may not have been ready to go out. It looks like just the front end of what could have been a reasonably broad  mental health service plank of the coalition platform if  they had time to keep going, and to get beyond only the first two recommendations of the National Health and Hospitals Reform Commission, and to check back with some of the mental health constituency with drafts ( as the Greens did assiduously).

But that may not be the way the Opposition leadership works in Canberra. They may not be inclined to check back, even with their shadow cabinet or parliamentary colleagues, once they have one big idea in their heads.  However, it seems that they were told to clear the decks, as they expect that Gillard will call the election for early August either by this weekend, or as soon as Ms Gillard can get the mining tax issue off the boil.

Most agree that the federal election is on a short fuse. However, so far, Labor has put most of mental health on the back-burner, effectively until after the election after next, except perhaps a bit of Headspace and those fee-for-service interventions for mild disorders which have a strong interface with GPs.

The states argue that otherwise the feds absolutely refused to include a decent package for mental health in the CoAG reform plan on the basis that they wanted mental health to be a state responsibility.  Nicola Roxon argues (eg in response to my question at the Sydney Institute this week) that the states would not agree to the Commonwealth taking over responsibility for funding and enhancing community mental health services, even though some of the States had presided over them being whittled away to an ineffective shadow of their former evidence-based selves.

Who do you believe? Maybe it was a bit of both.

The good news is that the Federal Coalition have put a plan, however half-baked, with some needed enhancements, and some substantial dollars attached to them, on the table, as have the Greens.

There is now a challenge out there for Labor to come up with something more comprehensive and sustainable before the election, which commits them to resourcing and implementation in the next term.

What is needed in this platform?

• A national mental health taskforce leading to a broad consensus for a national mental health program. It must overarch the national policy, plan and standards which have been diluted and downgraded as a political compromise between the state and federal bureaucracies.  While there is substantive agrereement across the constituencies of what needs to be done, it is vital that the mental health community should stay  united about the way ahead.  This entails promoting the enhancements urgently required for all phases of care, and all age-groups.
• Regional integrative commissioning authorities ( as established in New Zealand, the UK and now in WA) ensuring integration of all mental health and support services, which can purchase flexibly and independently from all  funding streams, public, fee-for-service, private health organizations if need be, and the non-government communally managed sectors.
• A Mental Health Commission, at both state (eg WA) and federal (eg Canada, New Zealand) levels, to pro-actively promote a positive agenda of community-centred, evidence-based and recovery-oriented services, delivered consistently  from urban to remote settings, and to provide transparent arm’s length accountability monitoring to ensure that the national or state strategy  is carried out properly. It can also ensure that consumer, family and minority voices are heard regularly by representation on the commission, frequent consultation and sampling.
• Shifting the centre of gravity of mental health services from being so hospital-centred with occasional outreach to the community only when convenient for staff, back to the community, with in-reach to hospitals only as necessary. This includes re-instating and rolling out community based 24 hour mobile crisis intervention services, early intervention services, community residential respite facilities, and assertive community treatment teams, located in the local shopping centres in all regions.
• Residential rehabilitation (so-called “sub-acute beds”) mainly based in small-scale community facilities.
• Dealing with “multiple whammies”, so common with mental illness, including drug and alcohol problems, physical, dental and intellectual disabilities, forensic complications, economic deprivation, and special needs of indigenous and multicultural communities.
• Establishing formally accountable expectations of and partnerships with stable housing, employment, education, and community participation services, to enable a person with mental illness to live well in the community and regain full citizenship.
• Provide access to E-Health strategies to all who can use them, and rationalize the blow-out in fee-for-service allied health services to prioritize only well supervised evidence-based interventions (as in UK), on an affordable/bulk-billing basis.
• Reorient funding of CoAG funded support programs like Personal Helpers and Mentors to community mental health services for more severe disorders and the NGO’s working with them, rather than placing these programs with  GP’s who will use them up for milder less needy individuals.

The Federal Coalition could now fruitfully augment their worthy, if very incomplete, first bid.

If Labor is to regain the confidence and support of the burgeoning community of mental health stakeholders, Ms Gillard needs to  intervene directly and soon, to stop the Labor government stonewalling and perseverating on the same old theme, “you’re not ready yet”, (as if the physicians and surgeons were any more ready!)  and to give Ms Roxon new riding instructions well before the looming election.”

• Alan Rosen is Professorial Fellow, School Public Health, University of Wollongong, Clinical Associate Professor, Brain & Mind Research Institute, University of Sydney, and Secretary, Comprehensive Area Service Psychiatrists Network