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AIHW report shows “mental health funding priorities wrong”

Last week Croakey published an article from Toby Hall, CEO of St Vincent’s Health Australia, in response to criticism by mental health experts that funding for mental health is “locked down” in the hospital system rather than being invested in community mental health services.

Hall said that it should not be a “zero sum game”, and that while there is a need to increase resourcing of community-based mental health services, this should not be at the expense of important hospital-based treatment.

In the article below, Sebastian Rosenberg, Senior Lecturer at the University of Sydney’s Brain and Mind Centre, argues that the reverse is true.

He questions the latest report from the Australian Institute of Health and Welfare (AIHW) on both overall mental health spending and investment in community services and warns that funding trends are undermining commitments to community care made in successive national mental health plans.


Sebastian Rosenberg writes:

The Australian Institute of Health and Welfare released one of their regular updates to the Mental Health Services in Australia dataset recently.  Their media release trumpeted that spending on mental health had reached its highest ever level. One of the key elements of this increase was stated as the “increased investment by state and territory governments in community mental health care”.

This is a critical matter.  Simplistically, when the asylums were closed, the theory was that people with all sorts of mental illness would be better managed and live with dignity in the community.  There would be a range of clinical and psycho-social support services to enable this to occur, including supported housing.  When people were really crook, they would go to the acute psychiatric wards of general public hospitals.

As repeated inquiries by parliaments, human rights commissions and others abundantly demonstrate, the theory described above has been largely a mirage. Community mental services are often very hard to find.  It is a common experience for families in need that help is impossible to find between the cognitive behavioural therapy (CBT) funded by the Federal Government under Medicare and the emergency department of the nearest hospital.

This makes the AIHW’s claim all the more puzzling.  A closer look at the published data reveals that in 2010-11 per capita spending on community mental health services was $83.61 and that in 2014-15 it was $82.49 – a small decrease. Spending on residential services was up from $11.98 per capita to $12.88 – a small increase, from a very low base.  Further, it should be noted that the definition of ‘community’ used by the AIHW in fact includes a range of hospital outpatient services rather than non-hospital services provided genuinely in the community. Australia cannot currently separate spending on hospital outpatient services from those actually provided in non-hospital settings.  The reality is that in most jurisdictions a high proportion of supposed ‘community’ services are in fact provided on a hospital campus, as outpatient services.

The only place where a significant increase in state and territory funding is to be found relates to spending on the psychiatric wards of public hospitals. Per capita expenditure here increased from $64 in 2010-11 to $72.35 in 2014-15.  States and territories are continuing to focus their effort and expenditure on hospital-based services, prioritising these above community care or the establishment of suitable community housing for people with a mental illness.

Increases in spending have indeed lifted the number of staff employed in public hospital mental health services. The direct care workforce employed in state and territory mental health services increased by 72 per cent, from 14,084 full‑time equivalent (FTE) in 1992‑93 to 24,292 FTE in 2010‑11. But at the same time the states and territories have found it impossible to lift the rate of access to care.  According to the National Mental Health Report 2013, the percentage of the population seen was 1.6 per cent in 2006-07 and the same 2010-11.

In addition to hospitals, the other main driver of increased spending in mental health is the Commonwealth’s ongoing investment in the Better Access Program which offers subsidised access to psychological care.  Medicare mental health spending as reported by the AIHW was $890.43 million in 2010-11, rising to $1.1 billion in 2015-16.

These spending patterns align with people’s experiences. You can get CBT.  It often helps.  But not always.  And when it doesn’t your next stop is likely to have to be the Emergency Department of a public hospital.  As Toby Hall suggested, hospital-based mental health care is often necessary and most people leave hospital better than when they were admitted.  But this is postvention – in cancerous terms waiting till your lump has grown big enough that it can no longer be ignored.  This is uneconomic, inefficient and very poor quality care.

Further, mental health’s share of the overall health budget has not shifted and remains low. Mental health represented 5.2 per cent of the total health budget in 2010-11 and this figure remains unchanged in 2014-15.  This share seems low when you consider the impact of mental illness on families and communities.  Another AIHW publication indicates that mental illness represents 12 per cent of the total fatal health burden and 24 per cent of the non-fatal burden of disease.

Rather than paint a promising picture, the AIHW data in fact shows a dangerous situation where state and territory governments are continuing to invest rare and precious mental health resources into hospitals, making care available only once a person has become critically unwell and the situation where we continue to make people have to go to hospital to get care.

This is a moribund approach.  It renders hollow repeated commitments to community care made in successive national mental health plans. It is negligent in relation to prevention and early intervention.  Meanwhile the Federal government continues to blindly invest in the Better Access Program without any call for greater accountability, to verify whether this spending is actually helping.

Australia is a rich country.  But rather than build a modern, contemporary approach to mental health based around community care, we are continuing to direct new funding into old and failed systems.  When will we learn?

Mental health does urgently need new funding but it needs to be directed to the right places. The real problem here is: while the Feds are responsible for primary care and the States the hospitals, who is responsible for building secondary mental health care services in Australia?

Any takers?

Comments 3

  1. The article above makes some excellent points about the need to lift the scale of investment in mental health care and support. However, criticisms leveled at Medicare support for psychological care (i.e., Better Access) are out of place.

    There is an enormous amount of evidence that Australia needs to provide more support for psychological care, not less (see http://drben.com.au/d/DrBen_summary_2015.pdf). Adjustments to the program based on the evidence lean in the direction of expansion, not reduction of the program. Taking aim at Medicare to make the case for more funding in other areas of mental health care, is reminiscent of suggestions that we should fund the NDIS by cuts to welfare (see http://www.smh.com.au/federal-politics/political-news/turnbull-government-ties-welfare-cuts-to-ndis-funding-20170213-gubmxs.html?). Both are cases of “robbing Peter to pay Paul”.

  2. John Mendoza says:

    As the author states there is no reasonable basis for more funding for hospital based acute mental health care. Indeed our analysis, with colleagues at University of Sydney, Brain and Mind Centre, shows that the number of acute care hospital beds in a number of PHN regions in Brisbane, Sydney, Melbourne and Perth, is equal to or greater than the same service in almost every other region in European examined using the same methodology.

    In Brisbane North, its not too far from the reality, that the only public mental health services are acute care beds or a mobile non-acute clinical team. Not much bang form $160m of state government spending. As Seb Rosenberg points out, less than 2% of the population get access to these services.

    Furthermore, these analyses show the lack of alternatives to hospital – there are too few of the out of hospital services to support recovery and prevent re-admission to acute care. In particular there are almost no specialist rehab programs – veterans can access some specialist PTSD programs but not much else – and there are almost no specialist employment support programs. We have ample information and awareness programs and an oversupply of assessment and referral type service, But if you actually need a residential facility with psycho-social and possibly access to out of hospital clinical services, then good luck. Homeless service providers too can provide assessment, a hot meal, some access to crisis accommodation and not much else.

    As many consumers say – “I want something to do, something to look forward to and something or someone to love” – if we get real mental health reform and not more of the same as we have for the past 25 years (since so-called reform commenced), then that desire could be satisfied. Given the state of the nation’s finances, that will require moving funding from acute care, and to a lesser extent, awareness programs.

    • I agree with all of those points John. We should be clear though that Medicare-supported psychological care is not hospital-based acute mental health care. The Better Access program allows people to access psychological support in their own community. Programs of this kind help an enormous number of people in our society remain functional and recover from distress, so that they can avoid hospital. To improve the system we need to strengthen those parts which are working well and expand our investment to cover more areas.

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pharmaceutical industry
pharmacy
Pregnancy and childbirth
primary health care
Primary Health Networks
private health insurance
quality and safety of health care
rural and remote health
screening
sexual health
social media and healthcare
suicide
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swine flu
telehealth
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TGA
trauma
women's health
youth health
Indigenous health
#CTG10
#NTRC
Acknowledgement
cultural safety
Indigenous education
Lowitja Institute
NT Intervention
social and emotional wellbeing
Uluru Statement
WA community closures
News about Croakey
PIJ Commissions 2021
Public health and population health
#PreventiveHealthStrategy
#UnmetNeedsinPublicHealth
air pollution
alcohol
consumer health matters
COVIDwrap
environmental health
Fetal Alcohol Spectrum Disorders (FASD)
food and nutrition
gambling
Government 2.0
gun control
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health impact assessment
Health in All Policies
health inequalities
health literacy
human rights
illicit drugs
injuries
legal issues
marriage equality
Media Doctor Australia
media-related issues
nanny state
National Preventive Health Agency
obesity
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road safety
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Web 2.0
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Royal Commission
Social determinants of health
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education
justice
Justice Reinvestment
NBN
Newstart
poverty
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Summer reading 2020-2021
Tasmanian election 2021
Testing Croakey News category 1
The Croakey Archives
#cripcroakey
#HealthEquity16
#HealthMatters
#IHMayDay (all years)
#IHMayDay 2014
#IHMayDay15
#IHMayday16
#IHMayDay17
#IHMayDay18
#LoveRural 2014
Croakey Conference News Service 2013 – 2019
2013 conferences
Australian Centre for Health Services Innovation Forum 2013
Australian Health Promotion Association Conference 2013
Closing the Credibility Gap 2013
CRANAplus Conference 2013
FASD Conference 2013
Health Workforce Australia 2013
International Health Literacy Network Conference 2013
NACCHO Summit 2013
National Rural Health Conference 2013
Oceania EcoHealth Symposium 2013
PHAA conference 2013
2014 conferences
#IPCHIV14
AIDA Conference 2014
Congress Lowitja 2014
CRANAplus conference 2014
Cultural Solutions - Healing Foundation forum 2014
Lowitja Institute Continuous Quality Improvement conference 2014
National Suicide Prevention Conference 2014
Racism and children/youth health symposium 2014
Rural & Remote Health Scientific Symposium 2014
2015 conferences
#CPHCEforum
#CRANAplus15
#HSR15
#NRHC15
#OTCC15
Population Health Congress 2015
2016 conferences
#AHHAsim16
#AHMRC16
#ANROWS2016
#ATSISPEP
#AusCanIndigenousWellness
#cphce2016
#CPHCEforum16
#CRANAplus2016
#IAMRA2016
#LowitjaConf2016
#PreventObesity16
#TowardsRecovery
#VMIAC16
#WearablesCEH
#WICC2016
2017 conferences
#17APCC
#ACEM17
#AIDAconf2017
#BTH20
#CATSINaM17
#ClimateHealthStrategy
#IAHAConf17
#IDS17
#LBQWHC17
#LivingOurWay