Introduction by Croakey: The Labor Federal Budget provided just $114 million in new spending on mental health programs, focusing on restoring psychiatry telehealth items, supporting headspace and creating a new network of perinatal mental health centres.
When asked to explain this modest investment, Minister Mark Butler explained that the message he got from the mental health sector is that it was already dealing with considerable new funding and lots of new programs and initiatives, arising mostly from the 2021 Morrison Budget.
This was a $2.3bn package that the previous Coalition Government then organised to distribute via a series of bilateral co-funding agreements, signed with all the states and territories just prior to the last Federal election. It may well be that Butler’s comment reflects justifiable confusion about how all this is actually playing out on the ground.
Below Dr Sebastian Rosenberg, Senior Lecturer at the Brain and Mind Centre, University of Sydney, argues that one reason for this confusion is that mental health lacks the architecture to organise its national reform effort. He discusses the lack of commitments in the Budget for mental health planning, regionality, workforce, funding and accountability, which he says should be a priority before the Government considers new spending on programs or services.
Rosenberg makes the case that without this “architecture of reform”, it is impossible for any government to direct mental health resources to the programs and services which will make the most impact on the lives of people with a mental illness and their families, and to end Australia’s fragmented and piecemeal responses for people with mental illness.
Sebastian Rosenberg writes:
Nobody was expecting that this Budget would contain much in relation to mental health. And that is how it panned out. $114m in new spending was provided with key initiatives including:
- Restoring loading to Regional Psychiatry Telehealth Service – $47.7m over 4 years from 2022–2023
- Expanding and Strengthening the headspace Network – $23.5 million over 5 years from 2022–2023
- National Network of Perinatal Mental Health Centres – $26.2 million over 4 years from 2022–2023.
And of course, people with a mental illness may well benefit from other Budget measures, in relation to social housing and cheaper medicines in particular.
However, given this Budget outcome, the broader task of national mental health reform remains undone. It is timely to take stock and consider some issues untouched by the Budget.
It is remarkable how fast the issue of mental health has disappeared from the public consciousness. The Lancet has just published the findings of its Commission on ending stigma and discrimination in mental health. Despite considerable advances in this country, it is likely these issues remain a concern, particularly among decision-makers who might question the merit of the spend – after all, if people with mental illness aren’t seen to get better, what is the value of investment in their care?
Whether or not such attitudes fuel political neglect is unclear.
What is clear is that mental health has failed to garner durable political support for systemic change and reform. Mental health’s record in this regard is poor, achieving substantial new funding about every five years.
John Howard and Morris Iemma coaxed the artist formerly known as CoAG into substantial new funding in 2006. Wayne Swan made mental health a centrepiece of one Budget, Josh Frydenberg another.
But, as Howard said, mental health needs more than ‘a quick fix’. It requires enduring stewardship of strategic change, engaging all governments as well as regional leadership. Mental health has failed to engender this stewardship.
Despite the new investments made by governments in mental health, overall funding remains largely unchanged. Mental health received 7.25% of total government expenditure on health care in 1992 and 7.57% in 2019-20. But mental health contributes around 12% of the burden of disease. This gap does not explain everything, but it highlights something.
The proportion of the population receiving state or territory clinical mental healthcare was 1.6% in 2009-10 and 1.9% in 2018-19.
Boosts to mental health funding have been irregular and piecemeal. The exception here has been the Federal Government’s willingness to invest in mental health services provided under Medicare, which has grown considerably. The AIHW report that the impact of spending more than $26m per week has lifted the percentage of the Australian population in receipt of Medicare mental health services from 6.9% in 2010-11 to 11.2% in 2020-21.
The impact of this spending on the community’s mental health is not clear. The lack of clarity leaves mental illness vulnerable to the stigma mentioned earlier. It also renders hollow the ambit industrial claims for simply more Medicare funding by the various professional groups.
Governance and policy
The Productivity Commission inquiry report initially proffered two models of future governance for mental health services in Australia, but finally opted for neither. This leaves mental health awkwardly split, with the Federal government’s Medicare services largely directed towards people with depression or anxiety, while state services respond more often to people with rarer illnesses, like schizophrenia. This demarcation suits separate funders and service providers. It does not make for integrated care.
Unlike the previous five national plans, at the heart of this current ‘national’ mental health plan are the bilateral agreements entered into by the previous Coalition Federal government and each state and territory. A header agreement sets out some shared principles but with few details. No mention is made of a formal Sixth National Mental Health and Suicide Prevention Plan, nor are national goals or targets set.
Planning and design
The approach taken to governance does not lend itself to national consistency, but rather to a situation where a person’s access to mental health care varies depending on where they live. Does their jurisdiction provide community housing support options, step up/step down care or low intensity services? It depends.
One of the governance models suggested by the Productivity Commission called for the construct of new regional models of governance, designed to supplant the current demarcation between federal and state funders. The explanation for this model was incomplete, which is perhaps why it has not been pursued.
But the primacy of regional thinking and planning remains. Geelong probably has more in common with Newcastle than with Melbourne. But that is not how we plan. Rather, mental health resourcing is determined by the health departments in each capital city. The specific needs of rural and regional areas are often poorly understood or not addressed. One size does not fit all.
Health department ownership of mental health planning processes probably also explains the historical reticence to invest in community-based mental health services, rather than hospital-based inpatient and outpatient care. It currently makes more sense for the states and territories to attempt to manage the unsustainable pressure on their hospital services than it does to shift the balance of system towards earlier intervention and prevention in the community.
The hospital-centric nature of our system, together with the governance issue raised earlier, also explains the reluctance of all governments to invest in the community-based psychosocial services typically provided by non-government organisations.
Despite good evidence for these services and a desire from consumers for non-clinical support in areas like housing, employment, education and social connection, they have always been a peripheral element of Australia’s service system, never receiving more than about 7% of the total national mental health budget. This leaves mental health dependent on medical and clinical interventions, without a psychosocial partner.
Tools to enable this regional planning are in their relative infancy and require development and implementation support.
Workforce and models of care
The rapid take-up of telehealth services during the pandemic has challenged the traditional paradigm of face-to-face care and it has done so organically, without pre-meditated structures or boundaries.
These organic characteristics in fact apply to mental health more broadly, where role delineation between general practitioners, psychologists, mental health nurses, social workers, occupational therapists, peer workers, psychiatrists, psychosocial workers and others is quite blurred. This makes it difficult for consumers and their families to identify the help they need. It makes it difficult too for service providers. A national mental health workforce strategy was due by the end of 2021 but has not been delivered.
There are few if any clear models of care in mental health to follow. This isn’t like cancer, where patient options are carefully calibrated against the evidence gleaned from registry information and other sources, leaving families generally well-equipped to make difficult but informed choices. Where there are mental health services available, they are often fragmented and disjointed operations, not cooperative systems.
Another example of disorganisation pertains to the plethora of e-mental health services that have blossomed over recent years. How these services fit together and fit in with other mental health services is not clear. What exactly we expect consumers to do is not clear: if they feel better or if they feel worse. What should happen next?
Recent calls by general practice for more support may be worthy, but this should be part of a much broader discussion about the shape and nature of primary mental health care in Australia and how we shift towards early intervention, prevention and multidisciplinary team care.
Accountability and architecture
The attractive notion of shifting to a Wellbeing lens in this Budget should not distract us from the frank realisation that, despite it being at the heart of the 1992 National Mental Health Strategy, accountability for mental health really does not exist.
We are outcome blind. We can count beds and services in hospital settings. But not much more.
The implications are profound. Providers cannot assess the impact of their care. Consumers cannot track their recovery and report their experiences. Communities cannot assess the performance of their local health services. Taxpayers cannot assess value for money. Decision-makers cannot allocate resources fairly. Our mental health system cannot learn and improve. This is how stigma manifests.
Politically, the priority for mental health reform seems to have slipped way behind other (related) reforms in areas such as disability, aged care and housing. National mechanisms to stimulate reform, under National Cabinet arrangements, seem weaker and more remote than they did even under CoAG.
When Minister Butler was asked during the online Department of Health post-Budget briefing about the mental health Budget outcome generally, he stated that the message he had heard repeatedly from the mental health sector was that it was overloaded with new programs, services, reforms and other challenges arising from recent inquiries, unable to absorb significant further investment or action.
It is certainly true that the 2021 Morrison Budget provided considerable new funding into mental health and that a series of deals around co-investment were made with each state and territory, just prior to the last election. How all this is actually working, where money is flowing, is not clear and this may explain Butler’s response.
However, what is also missing now is the architecture of reform. Rather than focusing just on new programs, or on payment systems which have become detached from models of effective mental healt care, we urgently need to organise reform efforts around a set of agreed principles and processes, starting by addressing the key issues raised here.
The tweet above is from a @CroakeyNews thread from the budget briefing.
See here for Croakey’s archive of stories on mental health
Many thanks to Dr Sebastian Rosenberg for a comprehensive and informed critique of the current situation regarding mental health reform. Here’s hoping it is read by the various interest groups, and leads to significant further work to improve services and outcomes.