Equity and parity of service provision is essential to transforming the lives of those with mental ill health

Professor Patrick McGorry, Executive Director, Orygen Youth Health Research Centre writes:

Australia can be very proud of the substantial progress that has been made in recent years in bringing the subject of mental ill-health and mental illness from out of the shadows and into the mainstream of public discourse, however timely access to high quality mental health remains elusive to most Australians.  This is in stark contrast to the scenario in physical health care and particularly cancer and cardiovascular disease, the other two of the top three contributors to health burden in Australia.

In addition to stigma reduction, much more information is available regarding the various forms of mental ill-health, and over the past two decades, Australia has developed world-first innovative models of care in community mental health, early intervention and youth mental health.  Yet structurally mental health investment has failed to close the gap between the level of burden/need for care caused by mental ill health and the availability of quality care, resulting in large numbers of Australians being excluded. This is especially so for those with disorders too complex for Federally funded primary mental health care yet not sufficiently life-threatening or end-stage to prise open the triage door of state funded mental health services.  They are lost in no-mans land.

Responding to this crisis, over recent years, the Australian community and the leadership of the mental health sector have united strongly around one high level common goal: to get a fair deal for all Australians who experience mental ill-health.  This means the same access to and high quality of care as is available for those with physical illnesses.  In concrete terms this means equal investment in proportion to the share of the burden of disease produced by mental illness.   At 7.7% of the current health budget, we are currently investing at slightly less than 60 % of this level.

Regrettably the recently released report Crossroads: Rethinking the Australian mental health system, from the support and information website Reachout.com has broken ranks with this principle and long term goal.  Perhaps influenced by the current climate of financial austerity, Crossroads argued that, under the current system the cost of achieving better access to timely and appropriate mental health care would be too high, requiring at least $9 billion over 15 years, and an additional 8,800 professionals.  While, ironically, this is a significant underestimate of what is truly required for equity and parity with physical health care, even this is painted as an unrealistic goal.   Instead e mental health and peer support workers are proposed as a much cheaper alternative.

The word alternative is the problem. E mental health and peer support are vital components of a 21st century system of mental health care, but they are complementary, not an alternative.  Alone they certainly will not address the needs of the more complex patients who fall between the Federally funded office based primary and specialist care and State public mental health  systems.

To provide some further context, over the past decade health expenditure has risen by over $40 billion pa in real terms but mental health has not made up any ground in closing the gap.   Investment in mental health care, which carries 13% of the overall health burden is approximately 7.7% of the total health budget – that’s around $6.9billion, well short of what is required.

Another recent study of the mental health expenditure, namely “The case for mental health reform” report from Medibank Private, has also confused the issue by conveying an inflated impression of investment in mental health care.  Medibank Private estimated that mental illness costs Australia $29 billion per annum.   However actual mental health care is a fraction of this figure, which actually rolls in the “costs of failure”, failure to provide timely and effective mental health care to Australians.  So the costs of disability support and other welfare payments, the costs of incarceration of the mentally ill, the costs of secondary drug and alcohol misuse; the costs of homelessness, marginalisation, unfulfilled potential and generations consigned to the scrapheap.

This large figure, in a similar vein now to the Crossroads report, is introduced to suggest that investment in quality mental health care is unaffordable and to some extent wasteful and unnecessary, and that with greater efficiency and lower cost options not only can outcomes be improved but money can be saved.  This is at best naïve and certainly a risky strategy to adopt, one which parts company with the position of the mainstream mental health sector and its leadership in recent years, and which exposes mental health care to the possibility of cuts when everyone knows that growth is required.  It puts many people at risk.

There certainly are savings to be made but these lie in the huge downstream costs of failure, notably the DSP and incarceration.  In both these areas one expects the Federal government’s focus on early intervention for young people to bear fruit.  This needs to extend across the lifespan.  I believe the government is acutely aware of this.  There is also inefficiency and duplication in some program areas and the National Mental Health Commission is examining this issue so that every precious dollar is well spent.   But we cannot resile from the fact that mental health care needs to grow and provide much easier access and specialist quality, similar to what we all expect in cancer and heart disease.

More specifically, the Crossroads report proposes that funding should be redirected towards low cost peer workers and online services. Perhaps this was unintended, but the paper gives the impression that the solutions lie in redirecting existing expenditure by reconfiguring services.   E mental health and a peer workforce are vital innovations that should be part of all mental health services now.  They are certainly prominent features of headspace and Orygen, services which I am directly involved in.  Crossroads appears to see this as an “either-or” issue.   While information and support are crucial across all health care, there is no way that cancer patients, for example, would accept peer support being substituted for expert care.

To give Federal and State governments the confidence to grow investment in mental health care, the public need to make it clear they expect the same access and quality as in the rest of health care, and the sector must remain united in its commitment to an equitable solution.   Mature advocacy in other domains of health and social care is typically reflected in a capacity for all sides to come together and argue as one for funding, especially on the high level goals.

Mental health care needs growth in many areas and this will only be achieved if we avoid the trap of setting up false dichotomies e.g. Early intervention vs chronic care or e mental health vs direct services.  Obviously the sequence for investment is a matter for priority setting.  The best available evidence must form the basis for informed decision making on “best bets”, with a better evidence base typically flowing from the initial exploration.

Equity and parity, in terms of access and real quality with the rest of the health system, based on evidence-based solutions, must remain our common goal.   E mental health and peer support are key innovations but on their own are not the answers to transforming the lives of Australians with mental ill-health.

Professor Patrick McGorry AO

Executive Director, Orygen Youth Health Research Centre