Dr Lesley Russell from the Menzies Centre for Health Policy at the University of Sydney, has had a close look at the budget’s mental health papers, and prepared a 12-page analysis which can be downloaded here.
She has also provided an abridged version for Croakey readers. It seems that all is not quite what it seems, or what it could (and should) be…
(Update: Here is today’s National Press Club speech by the Minister for Mental Health, Mark Butler).
Some good news, but many gaps and holes
Lesley Russell writes:
After much prodding and shaming, the Gillard Government finally delivered on its election commitment to mental health reform in the 2011-12 budget. The Government has put $2.2 billion (not all of it new money) on the table over the next five years.
However, given the magnitude of the burden of mental illness and the scope and extent of the needs in mental health, even this significant down payment on new and expanded services cannot be considered the endpoint of work in mental health but only the beginning.
In reality this mental health package is the replacement for the $1.9 billion commitment made by the Howard Government in 2006. It is salutary to note that, six years on, the returns on the Howard investment are hard to see in many areas, and mental health’s share of the total health budget has continued to decline as total health spending has increased.
The best thing about the new mental health package is that it invests in mental health services for teenagers and young adults such as the Early Psychosis Prevention and Intervention Centres (EPPIC) and headspace – initiatives that have been clearly demonstrated to deliver improvements in mental health outcomes.
However, experts have expressed real concerns that this funding is insufficient to deliver new services that are faithful to the tested models and maintain current services, particularly as EPPIC will rely on additional funds from the states and territories for full implementation.
A strength of this package is that it recognises that people with serious and continuing mental illness and their carers need a range of services such as flexible community care and care coordination services. Many of these services are not medical, so their delivery through the auspices of Medicare Locals will need to be carefully monitored. However this mechanism does potentially allow for the better integration of mental health into the health care system.
There are other positive steps towards a more holistic approach to the delivery of mental health services. The establishment of a National Mental Health Commission in the Department of Prime Minister and Cabinet should help drive this forward, and ensure that mental health is a high priority for the Commonwealth Government across all portfolios.
One obvious and serious omission which must be remedied is that there is no current effort to link in substance abuse services, despite the strong links between mental illness and substance abuse. Failure to do this will inevitably mean a failure to achieve the best, most cost-effective outcomes in behavioural and physical health.
The biggest disappointment in this package is the failure to make evidence-based reforms to the Better Access program.
No amount of gloss on the evaluation report, released in March, can hide the fact that evidence about the effectiveness of the Better Access program is weak, and many key population groups do not have better access to the services they need. It is hard to see how the changes made in this budget will improve the program; it appears they are more about achieving savings than improving access or outcomes.
About a quarter of the whole mental health package ($580.4 million) is funded by savings from the Better Access Program. The cost blow-out of this program has been so substantial that it cannot be ignored – it is expected to cost $3 billion over the next budget period. This amounts to $10 million per week, which does put the totality of this budget announcement, which in 2014-15 will provide just $407 million more for funding in the allocated areas, into some perspective.
Apparently the plan for the delivery of mental health care in the primary care sector is to confine Better Access services to those with mild to moderate mental health conditions and to expand the Access to Allied Psychological Services (ATAPS) program to cover the care of those with more complex conditions, Indigenous patients and those in rural and remote areas.
But there are no mechanisms or incentives to deliver this plan or to prioritise access for those most in need, and the likelihood is that those patients best equipped to manipulate the system will get services ahead of those who need them.
For health policy analysts who have attempted to follow the way that federal funds are spent on mental health services over the years and the success or otherwise of these investments, this task has become increasingly difficult.
There’s a lot of obfuscation in the budget papers. The names of programs change along with responsibilities for their delivery, and continuing programs are often presented de novo, with the pretence that these represent new funding investments. There is a lack of policy commitment and/or strategy, as evidenced by the dismantling of a major part of the suicide funding package announced during the 2010 election campaign.
There is some strange accounting in this funding package, and it seems there is a $52.6 million hole in the mental health budget. Some of the funds applied to flexible care packages are redirected from a provision in last year’s budget funded by changes in the Better Access program that are reversed in this budget. And $200 million of the $549.8 million provided for flexible care packages is unallocated.
Most egregiously in all these pea and shell games, there is little focus on the evaluation of quality and effectiveness, with measures of activity presented as program outcomes.
Real reforms in mental health require moving beyond this focus on the volume of services delivered by individual mental health providers to a team approach that integrates care and social needs and rewards improved patient outcomes.
(Note from Croakey: Two paragraphs previously at the end of this story have been deleted. They were not meant to be at the end of the abridged piece).
• Update: For Croakey readers who have been following Lesley Russell’s reporting from Washington, she has news:
After nearly two years as a Visiting Fellow at the Center for American Progress, I’m leaving to take up a position as a Senior Health Policy Fellow in the Office of the US Surgeon General, Dr Regina Benjamin, at the Department of Health and Human Services.
I will be working on prevention and health disparities issues. The new health care reform law recognises that health is about more than health care, and sets up a National Prevention, Health Promotion and Public Health Council which engages, at the highest levels, 17 federal departments to deliver a “ whole of government” approach to prevention. The Surgeon General chairs this Council and its external expert Advisory Group and I will be working with the SG on the issues related to the Council and the Advisory Group. See this statement for more background.
Mental Health policy and funding has been out of touch with reality since de-institutionalisation. At that the time there was not enough on community support. The failures of the past have just continued to fester and grow to such an extent that no government can fix the systemic problems in one budget. There are huge infrastructure projects that must be undertaken as well as the various community programs.
Anything is better than nothing and there is now a recognition that mental health is a real issue on the social and political agenda. There is not an acceptance, as yet, that many $billions must be spent over a number of years to catch up.
Historically State-based services have provided for the “severely mentally ill” (usually taken to mean schizophrenia and severe borderline personality), with Federal the rest (which includes high-mortality/high-impairment disorders such as anorexia and bipolar, this has never been about “worried well”)
The new ATAPS “complex case-management” and Federal EPPICs seem to mean the Feds are “muscling in” on State territory, probably because State services are seen as inadequate. Understandably Roxon is hardily going to hand the States a blank cheque to fund their services, as the States will simply reduce their own contribution by the same amount, but the alternative runs the risk of some very expensive duplication and additional complexity.
Thank goodness some one is talking about evidence-based reforms and evaluation of quality and effectiveness.
The routine provision of evidence based treatment and best practices in mental healthcare is an international challenge, and a significant priority for Australia.
A large number of bio-psycho-social empirically supported therapies have been available for many years but there is little evidence to suggest that the clinical workforce has begun to deploy these treatments.
The challenge for all mental health services (Government, Private and Non-Government) is to overcome workforce barriers to implementation.
The Australian Government and state Governments can throw all the money it likes into these services, but the challenge will still exist for mental health services to develop their clinical workforce to practice in accordance with the evidence.
Inadequate practices are ingrained and for the most part, unconscious at the individual level. They seem to occur at both clinical and managerial levels across the mental health system. Naively they are introduced and sustained, embedded in culture; intermittently reinforced by colleagues, work teams, service managers, management groups and funding personnel that have governance accountabilities.
It is time for managers and leaders to concentrate their efforts with the clinical workforce towards the implementation of what works and in doing so maximize the effectiveness of known treatments to their consumers, families and communities
As well, Consumers, Carers/families and the consumer and carer movements across Australia should be informed of the provision of bio-psycho-social evidence based treatments and best practices so they can advocate for them on a national, state and service level
Evidence about the effectiveness of headspace is also weak, contrary to the prevailing gospel. Those who laud headspace would do well to look at the actual evidence about it. The independent evaluation by Muir et al. (http://www.sprc.unsw.edu.au/media/File/Report19_09_headspace_EvalReport.pdf) did not compare headspace with a control group. Muir et al. reported: ‘Inclusion of a control group was precluded by the timing, budget and funding requirements for the evaluation, coupled with the introduction of the new model and delayed implementation of the initiative. This limits the validity of the outcomes because it is not possible to determine what would have occurred if young people had not received the headspace intervention’ (p. 134). The evaluation concluded: ‘there is little tangible evidence to conclude the extent to which services are evidence based’ (p. xv).
However, Patrick McGorry repeatedly refers to headspace as an ‘evidence based’ model, and this is accepted at face value.
I’m interested to hear that about the headspace research. I personally think it could lead to excessive diagnosing in young people.
I think a better idea would have just been to provide more counsellors in Colleges. Unis etc. Also beef up support for GPs.
I’m interested to know how the Early Intervention and Prevention of Psychosis can happen? Could someone enlighten me how they intend to prevent Psychosis?