The mental health lobby has been celebrating Tony Abbott’s announcement of “a real action plan for better mental health” (although the Royal Australian and New Zealand College of Psychiatrists statement contains plenty of qualifiers).
I have written a piece for today’s Crikey bulletin arguing that while the mental health sector deserves a win or 20, I am not altogether sure whether Abbott’s policy (which also involves cuts to e-health and primary care) and a lobbying-based approach to health policy represent a real victory.
I suggest (perhaps naively) that it would be nice to have a bipartisan, population-based approach to health planning and funding that emphasises primary care and under-served areas, including but not limited to mental health.
Meanwhile, here are a range of views from Croakey contributors on the announcement, including those who fear Abbott is robbing Peter to pay Paul, while others raise concerns about the merits of Patrick McGorry’s model of early intervention for psychosis and some support it.
One thing is abundantly clear: no-one is speaking in defence of the Federal Government on this issue.
Dr James Gillespie, Menzies Centre for Health Policy, University of Sydney:
The government left itself wide open to this attack, stalling on the mental health issue, tantalizing with vague, but empty promises and recycling programs dating from the Howard era as its own while displaying an increasingly hostile and dismissive attitude in public encounters with advocates.
Abbott’s initiative could be seen as a reply to the invitation ‘Game On’, entering into opportunistic election mode. Responses that query the costing, and the cuts in other services that will be shifted to mental health will fall flat, unless
a. The government comes up with a coherent alternative, or even ‘me-too’ fairly quickly
b. Starts a better job of explaining how its broader reform agenda will improve health outcomes for patients.
At the moment we have reforms focused on governance changes that, after considerable confusion, appear to end us with a set of empty boxes being filled by the very states which (with varying degrees of justice) were recently castigated for causing the problem. And with many significant changes promised two elections down the track.
Without a decisive shift in rhetoric and immediate content, the government faces an election campaign where it will be portrayed as playing musical chairs with bureaucratic arrangements – a game in which patients always seem to end up on the floor – while the opposition takes up practical programs targeted at real problems (and people).
Ben Harris Roxas, UNSW Research Centre for Primary Health Care and Equity:
Any investment in the early psychosis intervention would certainly be welcome. These services have demonstrated their effectiveness in altering not only the course of individuals’ mental illnesses but also their entire lives. The Productivity Commission has also identified this as one of the few areas of health service expenditure with the potential to increase workforce participation. Professor McGorry and others have done an excellent job in raising the profile of this issue and Headspace’s work.
My concern is that the Coalition’s proposed investment may come at the cost of primary health care services. Most mental health problems are still identified and treated by GPs and community health services. By reducing funding to local, accessible primary health care services in order to fund required specialised services there’s a risk that we’d be robbing Peter to pay Paul.
Dr Peter Mansfield, Healthy Skepticism:
Patrick McGorry has a hypothesis that early intervention will do more good than harm. That hypothesis should be tested with adequate trials before a national role out because early intervention may do more harm than good for some people.
A/ Prof Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity:
Yes, credit to Patrick, and thumbs down to the government. To Abbott: thumbs half up: good to have a response, probably partly from the heart, but he is far too reactive and opportunistic.
Health will always be political and involve advocacy, and we’re unlikely to shift to a neutral, burden of disease approach. But it would be good to move closer.
The proposed cuts to e-health etc are just stupid, and show that Abbott hasn’t really got much real clue about primary health care and what it requires.
Health is under-resourced at present. Funding for mental health (broadly defined) does need to be increased, but not at the expense of other areas of health, an area creaking under the strain of community demand without the resources to match it. I viewed yesterday’s announcement as a cynical populist approach to a complex issue.
Public health expert Professort Peter Sainsbury
Any additional funding should go to specific services and interventions for which there is evidence of effectiveness, not to, for instance, generic psychology or social work services.
Sebastian Rosenberg, Senior Lecturer, Brain and Mind Research Institute, Sydney Medical School
Bottom line, as Michelle Grattan said on AM this morning, is that the Coalition have cleverly moved to exploit a palpable policy failure on the part of the Labor Government in relation to mental health. In doing so, they have targeted the areas widely acknowledged as the highest priorities for investment in mental health service reform – early intervention and youth services. I would contend that still more will need to be done, particularly to overhaul system governance and accountability, both of which currently militate against reform. Further investments in community services and social housing are also vital.
Economist Ian McAuley
We have shortcomings in mental health, but do we need more money and more resources or do we need to make better use of our existing resources? I don’t know, but because mental health is so multi-faceted, I suspect we could make huge progress through better integration.
Because mental health is so multi-faceted, with so many providers attending one person, it seems absurd to abandon electronic patient records, which can help avoid conflicting therapies, and can ensure the sharing of clinical information.
Professor Kerin O’Dea, University of SA:
Love the idea about a bipartisan approach to health strategy – we need it on Indigenous affairs as well. Early intervention and prevention have been totally sidelined in Labor’s “Health Reform”.
In principle I support what Abbott is proposing on mental health as significant components of the package are aimed at early intervention.
BUT, like you I am very concerned at policy on the run – and the unintended consequences that can unleash.
Isn’t that what we have been trying to escape from with the Kevin Rudd approach: procrastinate (or ‘do research’) til the very last minute, then rush out a poorly thought through and often very costly compromise.
Jan Barendregt, Assoc Prof of Epidemiology, School of Population Health, University of Queensland:
You’re right that the ‘yell the loudest’ approach is not what should happen.
The gold standard would be to have an assessment of effectiveness, costs, and cost-effectiveness of all possible interventions across all health problems, and use that as a basis, along with other considerations such as equity and feasibility, to allocate health care money.
The problem is that such an assessment doesn’t exist, and that it would be huge undertaking to obtain it. But it can be done: we will release later this year a comparative assessment of ~150 interventions, mostly preventive ones in non-communicable disease. The same approach could be extended further to curative interventions.
One problem specific for mental health is that the data on effectiveness of interventions is not fantastic. In particular for non-drug interventions the data is pretty weak, while for drug-based interventions the data is suspicious because of manipulation by the pharmaceutical industry.
I realise that what I’m saying is that more research should be done, while the health needs are now. But the research costs only a fraction of what is being spend on health, so a bit of investment there will probably money well spend.
There has certainly been a lot of noise from the mental health interest groups but this is not the best way to make health policy.
It seems curious for the position of Australian of the year to have been used in this way.
It seems curious that one person’s particular program has been the focus of so much interest and indeed so much funding – Is there not a conflict of interest?
The sector’s main complaint seems to be that they are 12 or 13% of the burden of disease that only 6% of the health dollar. Counting things this way is a bit simple, especially given comorbidities, and is likely to end up with a total of 180% of the health dollar, if you see what I mean.
Rural people will probably support or at least feel okay about the coalition’s plan to cut back the money to GP superclinics but not to e health.
Despite the reservations about the feasibility of a uniform e health system, confidentiality etc etc, e health has very much to offer rural and remote areas and it has to be funded.
Professor David Penington, Melbourne University:
I applaud Patrick making the most of the opportunity. The mindset of ALP thinking has always tended to be control of institutions by bureaucratic processes and this is why the whole reform agenda has been preoccupied with external control of hospitals.
Labor planners have great difficulty in getting their minds around how to handle developments with are primarily community based, except where this can be handled through central dictates, such as pronouncements in preventive strategies. (The one exception was Gough Whitlam’s Australia Reconstructed in 1973).
Mental health was very poorly handled by the Reform Commission and disappeared from the reform priorities, as did aged care, except where it could be said to be involved in the allocation of money for ‘sub-acute’ hospitals and more nursing home beds (again a preoccupation with institutions). The key issue is health care for the elderly in and near their homes wherever possible, with a major investment in community nurse practitioners. Other issues of primary care which have been largely ignored include existing community health centres (State establishments now to come under the Commonwealth in some way) and needle and syringe and other programs for illicit drug strategies.
I have no truck with Abbott cutting other primary care funding to meet these needs. Mental health needs funding on its own right with a vastly improved structure to ensure co-ordinated services. I have no doubt Roxon expects Medicare Locals to do everything to manage all aspect of primary care, but they do not exist yet and will have to be thought through with extensive negotiations to ensure recruitment of appropriate skill-sets to staff them. Maybe Abbott needs the Super Profits Tax to get the revenue needed!
Public health physician Dr Jan Savage:
I am concerned about the opportunity costs with respect to primary health care, e-medicine and also probably preventative health – it’ll be the first to go.
The siloed disease approach I think was an attempt to rationalise, but as it isn’t integrated fails to meet the community’s needs and in the end is inefficient.
Dr Peter Parry, Consultant Child & Adolescent Psychiatrist:
It is very good news that the Federal Opposition has promised more funding for the neglected area of mental health services and early intervention amongst young people is a vital area.
However care needs to be taken that new services meld with established services to aid continuity of care for young people. Also the area of young people at risk for psychosis but not actually suffering a clear psychotic illness is an area of debate at present in psychiatry.
Such young people often need guidance and support and often some psychotherapy, but there is concern that too pre-emptive a diagnosis may lead to deleterious effects to self-image and self-confidence as well as side-effects from medication. A recent paper by Bosonac, Patton and Castle in the journal “Psychological Medicine” summarised these concerns. (Early intervention in psychotic disorders: faith before facts?)
Also early child development and targeted support for expectant parents and parents of very young children are areas where research suggests there is greatest value for preventing mental illness. On this issue Mr Abbott’s policy of extended maternity leave is worthwhile.
Professor Wayne Hall, University of Queensland:
I share your ambivalent response to the Opposition’s announcement about increased funding for mental health. Mental health has been underfunded by the Government and services deserve to be better resourced but I do not welcome health policy decisions being made on the run in the lead up to an election.
It is not obvious that the decision to abandon e-health is based on a reasoned analysis of the costs and benefits of this policy. We have seen the bad effects of this sort of policy making in criminal justice at the state level. More bipartisan support for a reasoned process of making health funding decisions would be a much better way to go.
Mary Chiarella, professor of nursing, University of Sydney:
I share the concern about a reduction in funding for primary health care – even before the increase has begun!! Primary health care should be the cornerstone of proactive mental health care so once again we would be putting the ambulance down in the valley for mental health if this were to occur. A reactive and sensationalist approach to a critically important and under- served issue. Very disappointing.
Journalist and author Ray Moynihan:
Is this also a small victory for Get Up? I’m not sure, I know there has been lots of lobbying from lots of players but it would be interesting to know whether Get Up are actually having an impact. Thought it might be an interesting political angle.
Associate Professor Heath Kelly, epidemiologist:
This is not my area of expertise, but my reaction was that this unexpected policy announcement is a reflection of Abbott and the coalition looking for a way to catch the government on the hop. Is there any reason to believe this actually represents a reasoned and seasoned approach from the Opposition? It looks more like opportunism. But it might nonetheless have good consequences. There is a parallel in Victoria. In a pre-election climate, both sides of politics have promised more paramedics in regional Victoria. We may now see an unedifying bidding war on mental health leading up to a federal election.
Justine Caines – Consumer Advocate:
In relation to mental health and post-natal depression. Post natal depression is an area of reasonable concern. Whilst there must be appropriate mental health services (with a strong community focus) there must also be an assessment of the possible causes of the depression. Holistic maternity care, rather than fragmented medical treatment could have a huge impact on post natal depression.
With the care of a known midwife, women do not fall through the cracks and the trauma associated with surgical birth is reduced. Considering more women die at their own hand after childbirth than from any other cause this is very important. Abbott is no doubt throwing money. Nicola Roxon has led a maternity reform that 18 months on looks like a dogs breakfast. Where’s the consumer focus in health, stop pandering to the medical lobby, start in the community.
Edited extract from statement by John Mendoza:
“The Opposition’s announcement of $1.5bn in mental health spending will be warmly welcomed by the mental health sector,” said John Mendoza, Director of ConNetica and Adjunct Professor, Health Science, University of the Sunshine Coast.
“This announcement represents a very significant commitment by the Coalition to a fundamental restructuring of Australia’s mental health system, away from acute care and late intervention, and towards a focus on youth and early intervention. These investments are based on solid evidence regarding effective services and will make a real contribution to preventing a new generation of young Australians from succumbing to mental illness and a lifetime of disability,” Mr Mendoza said.
This type of early intervention services will deliver a real community dividend.
“The Programs supported today by the Coalition are pre-requisites for good health, particularly among young people for whom mental illness ranks as priority number one. Early intervention can facilitate social inclusion and permit young Australians to overcome mental illness and make enduring contributions to our national prosperity.
“The Coalition’s announcement is also a welcome departure from the current funding arrangements, which continue to pump funds into failed systems of care. There is still more to do including the development of a national mental health report card so the Australian community can monitor the quality of our mental health system. We also need a complete overhaul of our existing moribund system of governance in mental health, where there is no accountability, no targets and no leadership. The Australian community deserve better and the Coalition’sannouncement goes a long way to delivering a positive future for mental health in Australia.”
Public health policy consultant Margo Saunders:
Not my area of expertise, so would only add a reminder that mental health is really intermeshed with a number of other health issues (the ones that immediately come to mind are Indigenous health, alcohol & other drugs, and adolescent health as well as men’s and women’s health), which means that serious consideration really needs to be given to how to integrate mental health into a range of policy and program areas. This can be a challenge, especially given the ‘silo-ed’ approach that characterizes how things are done within the Department of Health and Ageing.