Following on from Part One of Croakey’s mental health election wrap, Sebastian Rosenberg, Senior Lecturer, Mental Health Policy, Brain and Mind Centre, University of Sydney, provides the following analysis of the major parties’ policies and identifies their strengths and weaknesses and points out some key areas that neither major party has addressed.
Sebastian Rosenberg writes:
The mental health packages offered by the Government and Opposition as part of their election platforms are now clear. There is considerable similarity. Because of the persistence of people like John Mendoza, both parties focus their attention on suicide prevention.
Suicide prevention trials
Labor and the Coalition both back twelve regional suicide prevention trial sites and also provide funding for suicide prevention-related research – Labor $9m and the Coalition $12m. Labor has indicated its support for a target to halve the number of suicides over the next decade. The Coalition has not set any such target.
Both parties have also undertaken to create a truly independent National Mental Health Commission. Both have promised to maintain investment in headspace, though the Coalition are promising an additional 10 sites, lifting the number to 110 nationwide. Both have also responded to the strong calls made by Professor Pat McGorry to guarantee funding for the nascent early psychosis centres.
But there are some important differences. The Coalition’s plan also supports continued development and implementation of Project Synergy, an online system of mental health support. This program offers people the chance to monitor their mental health and welfare, seek information, advice and then actual treatment for their mental illness from the safety of their own homes and their own computers.
Role of technology
This kind of technological response will be critical to meeting Australia’s unmet demand for mental health care which could never be achieved through traditional face to face service approaches alone. In another indication of the importance of technology, the Coalition has also funded Lifeline for a follow-up crisis text messaging service.
The Coalition has also responded to the strong evidence about the key role of mental health nurses by funding a new workforce strategy in this area.
Overall, Labor has pledged around $84m and the Coalition $192m. Not only is there tangible difference in the scale of the commitments made, It is also clear that the Coalition have thought carefully about how best to support implementation of key elements of the review into mental health services conducted by the National Mental Health Commission.
Community mental health a major gap
But massive challenges remain. Minister Ley was very quick to rule out support for one key recommendation made by the National Mental Health Commission; that a small fraction of anticipated hospital growth funding be redirected towards community mental health services.
While reasonably uncontroversial and consistent with the thrust of four successive mental health plans, the Minister saw fit to rule out this idea on the very day the Commission’s review was leaked to the media.
Australia remains far too focused on hospital-based mental health care, overly dependent on the most expensive and often traumatic locus of care. By contrast community mental health services have either failed to flourish or withered.
It is these community services that often provide the bridge between mental health services and the other determinants of health, such as housing, social inclusion, employment, education and psycho-social support. Neither Labor not the Coalition have policies designed to boost these community mental health services.
While the National Mental Health Commission’s Review contained many laudable suggestions, it was by no means comprehensive. It focused on federally-funded services, ignoring the largest provider, the states and territories. In this light, the Coalition spurned an opportunity to provide national leadership and instead perpetuated fragmentation.
Also of concern is the giant pea and thimble game the Government is playing with services earmarked to transition to the NDIS. Partners in Recovery, Personal Helpers and Mentors and others, as well as a raft of psychosocial support services previously provided or funded by the states and territories, will be transferred to the responsibility of the NDIS for eligible clients.
Exactly which programs and which clients will be affected is not yet clear but the mental health sector holds grave fears that many clients will miss out on care they currently receive.
It is also unclear how much funding will actually be transferred from governments to the NDIS during this start-up phase but cuts to existing programs could easily be hidden in this transfer. This process of transfer creates opaque accountability where line of sight reporting over designated buckets of program funding becomes impossible. This may drive flexibility. Or it may permit cuts and growth in inequity of access.
Role of PHNs
A great deal of faith is being placed by the Federal government in the capacity of the new Primary Health Networks to lead and manage these mental health reforms. Across the thirty-one PHNs there is a wide range of skills and readiness.
Understanding of issues such as suicide prevention and stepped care vary markedly. The Coalition has pledged some $26m to support ten of these PHNs to become ‘lead agencies’ and show the others the way.
Some PHNs have established relationships with their local state and territory health district, in other places these relationships are yet to develop. These links are critical if Australia is to properly address the gaps which plague mental health, between primary, secondary and tertiary care.
We have divided responsibility for mental health between federal and state governments. Cooperation between federally funded and state funded services is patchy at best. A 5th National Mental Health Plan will be released shortly but there is no expectation it will be any more effective than its predecessors in driving national reform.
PHN-led regional autonomy sounds sensible and could lead to effective regionalism and tailored solutions for communities facing starkly different economic, demographic and service challenges. This kind of regional approach must be supported with strong central guidance, accountability, benchmarking and so on.
Failure to provide this support could instead reveal that the Coalition’s greatest achievement was to effectively abdicate the Federal Government’s role in national leadership in mental health, deferring control and responsibility to thirty- one PHNs with little regard to national consistency, quality or service improvement.
The aim here is to create more consistent and high quality mental health services, regardless of where you live in Australia. Currently the experience of care and the services available vary considerably depending on where you live. After dozens of statutory inquiries into mental health it is clear that without strong implementation support, policy commitments are meaningless.
National Mental Health Commission
Which brings us to the National Mental Health Commission. The Coalition has now promised a revamped independent Commission reporting directly to the Minister and Prime Minister, charged with preparing an annual report on the progress of reform.
The Commission cannot rely on existing data or processes for this report. It will need new data, collected in new ways. It will need information which reflects the actual impact of care: whether it results in young people being able to complete their studies; whether people with a mental illness can find and keep a job; whether the number of suicide attempts is decreasing.
These are true measure of the ‘mental wealth’ of Australia yet none of these things are currently reported. We know very little about the impact of large investments in mental health – we are outcome blind.
Both Labor and the Coalition have indicated their support for ongoing mental health reform. The Coalition’s approach has the potential for more profound impact. But it is now a question of implementation.
What powers and capacities does the National Mental Health Commission need to drive these reforms nationally? How can they create effective links to and between the PHNs, the headspace and early psychosis services, the NDIS, the states and territories, as well as into other key areas of necessary reform such as housing and employment?
This will need a new type of Commission, with new authority, access and resources. This Commission must be charged with supporting implementation of reform, helping people on the ground learn and change. This will need strong leadership and support.
Prime Minister Turnbull seems genuinely motivated to make a difference. Just as well because as the bitter experiences of the past two decades have shown, it is in this implementation where mental health reforms typically founder.