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More comprehensive analysis on mental health and the budget (it’s complicated)

There are many question marks over the likely impact of the budget’s mental health announcements, says psychiatrist Professor Alan Rosen. A particular concern is the lack of clear support for public, evidence-based, community mental health services, he says. But the formation of a Mental Health Commission should prove useful.

The news on mental health: encouraging, worrying, disappointing, and promising

Professor Alan Rosen writes:

Of course we should be grateful for any increase in targeted mental health funding, however delayed, and yes this budget allocation looks like real money, though the Treasurer, Mr Wayne Swan, certainly did not come up with enough to do the job.

I  strongly support some of the initiatives funded,  but my concerns in a recent piece on the “independent blueprint group” recommendations, some mysterious variations of which are partially funded here, have not yet been assuaged.

Over time, this budget commitment will begin to enhance some very well-researched or promising  programmes:  youth mental health “headspace’ and early intervention, early childhood programmes,  suicide prevention, and e-health strategies, more housing with regular support for adults with longer-term conditions, and more integrated mental health care for the elderly.

In primary care, it is hoped that the blow-out in Better Access counselling can be more effectively contained and targeted to those with defined mild to moderate mental health conditions, and that ATAPs funding and CoAG support worker programs will be expanded to reach and coordinate the care for people with more complex conditions. This is supposed to include Aboriginal communities and those in rural and remote areas.

However, it is notoriously difficult for inexperienced non-professional or sessional staff to herd seasoned clinical cats. Fee-for-service professionals consider that they are not paid sufficiently for the time it takes to do so, so many won’t prioritise these functions.

Basing these support and coordination services with Medicare Locals may allow better linking in with physical care, but could tempt primary care centres to go up-market, to direct these support resources to people with milder conditions, and to favour sedentary clinic-based medical over psychosocial interventions for mental disorders severely affected by social conditions.

Tendering out the proposed “flexible care” packages and coordination teams for extended mental health care to Medicare Locals, NGOs  or private interests provides a fascinating  exercise in contestability, and may end up being  a good idea, but they are largely untested in effectiveness, and will need extensive trialling over a longish period before we should consider wider implementation.

However, they have already been given a very substantial allocation in the budget ($343.8 million) for a national roll-out, with no stated prior requirement  for evaluation and rigorous research.  Compare this to the considerable research evidence-base for modules of public community mental health services which will remain as abandoned orphans, sinking  still in the wake of this budget. So what will be left of sound mental health services to coordinate?

Maybe “putting new money into old systems” doesn’t work where the systems have been shown to be ineffective, like institutionally based care, but  provision of well tested 7 day and night mobile mental health teams, with adaptations for regional populations,  has not yet been tried consistently and equitably across this country. One state, Victoria, is an exception, and even the resourcing there is now fraying.

These teams only don’t work where they have never been tried. Or when their resources are withdrawn due to managerial expediency or loss of a clinically informed culture. However, there is little encouragement for public mental health services in this budget, except a pious hope that at the next CoAG meeting, the Commonwealth will be able to convince the states to match this investment.

But, as ever, funding signals shape practice, and there are no clear funding signals from the feds to the states for public community mental health services.

We need these to concentrate their minds on meeting their obligations to restore evidence-based services like mobile crisis and assertive community care teams. Such public community mental health services should be complementary to and the backbone of all the important NGO support services. The former should be available to reach out to all in need of mental health care and to support NGO facilities too, around the clock, largely with on-duty staff  in urban settings, and on an on-call basis elsewhere.

But many have been allowed to shrivel. There is very little in this budget that can be used as real leverage or incentives to the states to reinvest in public evidence-based community mental health services.

These have been so eroded since the end of the 1st National Mental Health Plan in 1997 when the incoming Howard government stopped the virtually contractual funding signals to the states. Consequently both the national strategy and state efforts became diluted, too thinly spread, and lost their momentum and focus. These signals need bringing back for services to become effective again.

This budget allocation will only keep mental health’s head barely above water by still struggling to stop a decline below  the habitual 7%  of health expenditure, even when funding eventually fully kicks in towards the end of  5 years.

If there was any justice for our clientele,  it should have moved up in stages by then to 13% of the national health spend to more closely match the proportion of health burden due to mental illness, and to bring us into line with comparable OECD countries.

Government has only just started to show some leadership, and yes the providers  and the consumer and carer movements do need to get behind this belated encouragement, uniting to make these initial steps work, with a willingness to test new delivery systems, as well as to continue to pressure government to develop their commitment further.

That is why the Mental Health Commission as recommended to government by many stakeholders over many years, and most recently by the mental health minister’s expert advisory panel and the “independent blueprint group”, is the key to the fuller realization of the national reform agenda.

It should ensure that evidence based care is equitably implemented, integrated  and systematised, and that accountability mechanisms are much more arm’s-length and transparent (for more background, see here and here).

Only then, if the Commission is allowed to be sufficiently expert, well-informed, independent, and continuous in tenure,  will it be able to ensure that services actually do reach those in need consistently, and make a real difference in their lives, particularly to individuals with severe and persistent mental illness and their families.

So far, the good news about the National Mental Health Commission, is:

1.     that it is tripartisan, now being integral to the mental health policies of the Labor government, the federal Coalition and the Greens;

2.      that it will complement in some way yet to be defined, the state mental health commissions which are now  developing in Western Australia and New South Wales, and hopefully other states in the future, which may also function as  or devolve integrative regional funding/commissioning authorities.

3.     that it will be located within the prime minister’s portfolio, which should provide for added independence from the Commonwealth health bureaucracy,  and making it explicit that mental health should be an all-of-government enterprise. It must however report not only to the prime  minister as stated, but to parliament and the public if it is to fulfil its promise of transparency.

So all this could either be a good start towards a happier ending – or an uncontrolled  descent into more disconnected fragments of service, unless  more balanced  investments and strong monetary signals to the states to deliver evidence-based care for all age-groups and phases of care can be made to follow this up in the next chapter.

Professor Alan Rosen holds positions with the Brain & Mind Research Institute, University of Sydney, and School of Public Health, University of Wollongong.

Comments 4

  1. jillian Horton says:

    As a practicing Clinical Psychologist who sees many people via the Better Access Scheme, I am shocked and very concerned about the cuts to the number of sessions people can be supported by Medicare to engage in. As a specialist, along with many, many of my colleges who have contacted me today, we are outraged that the people we see have been classified as having “mild to moderate” mental health problems, almost implying that they just need a supportive chat and a bit of advice! The people I see have eating sidorders, suicidal and self harm issues, depression where they cant function, high anxiety leading to loss of work time or considerable emotional disablilty, children who have disfunctional families or have considerable problems coping with the school system, and I could go on. Our ability to assess and treat the people we see was already difficult under the restrictions of the Medicare scheme and the current cuts to the Medicare support will place many people in a situation where they cannot obtain adequate or completed therapy. What does Professor Hickey and his colleagues think psychological therapy is?? What information does he have about the sort of people we actually see?? Whatever it is, it is clearly wrong and for him and others to support the shift of funding away from a highly used and successful program is a huge backward step for the community and is outrageous. To also suggest that the ATTAPS scheme did or does, see more complex cases is unbelieveable. I know many colleagues who worked in the ATTAPS Scheme when it was established and they said it was difficult to work within, underqualified and trained people were seeing complex cases and they did not find it resonable in terms of working conditions and admininistration structure. The cases were not more complex than those we see in private practice.

    Please government rethink the reduction of session for people to see specialist Clinical Psychologists in the Better Access scheme, and assit those with complex issues to get proper assessment and therapy inhterventions.

    Dr. Jillian Horton
    WA Clinical Psychologist in private practice

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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
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AIDA Conference 2014
Congress Lowitja 2014
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Cultural Solutions - Healing Foundation forum 2014
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National Suicide Prevention Conference 2014
Racism and children/youth health symposium 2014
Rural & Remote Health Scientific Symposium 2014
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Population Health Congress 2015
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