Further to a recent Croakey post comparing election mental health policies, here is a far more indepth analysis.
Sebastian Rosenberg, Senior Lecturer, Brain and Mind Research Institute, University of Sydney, writes:
“The recent high profile resignation of the chair of Minister Roxon’s own expert committee, John Mendoza, and the profile of the Australian of the Year Patrick McGorry have created a crescendo sufficient for mental health to register on the political Richter.
Mental health has moved out of the policy shadows and into the election spotlight. Labor and the Coalition have laid out their election policies with regards to mental health and these can now be compared.
Relying on the always sophisticated approach of the ‘spendometer’, the comparison has been reduced by some to Coalition good, Labor bad because the former promises spending of $1.5bn, the latter a mere $277m.
Labor counters this by referring to the 1300 sub-acute beds it promised at April’s Council of Australian Governments meeting.
But in mental health, which represents some 13% of the total burden of disease, but attracts only some 6% of the total health budget, there can be no denying that money talks.
On closer inspection, the policies of both parties are largely focused on expanding investments in existing programs such as the headspace youth mental health service.
The Coalition is to be commended for pushing more and new services, particularly through the establishment of a new network of 20 evidence-based early psychosis intervention centres. Australia currently has only one specialist centre of this type, servicing a population of about 700,000 people in inner west Melbourne. A commitment to expand this type of care surely rates as one of the ‘best buys’ in mental health service spending.
Labor, by contrast, has backed a significant increase to Lifeline which does amazing, largely unsung work, providing telephone crisis counselling services to people at risk of suicide. New funding will allow Lifeline to manage up to 700,000 calls per year, up from 450,000.
On one hand this is a welcome boost to a critical service. On the other hand, why must we wait until a person is in crisis before any kind of mental health care is available? A well organised and properly funded mental health system should have a diminishing rather than increasing need for services such as Lifeline.
The rest of Labor’s policy is a frugal spend on programs such as KidsMatter, Respite Care and the Activities of Daily Living Program. Some of the programs supported by Labor have not been independently evaluated. Evidence-based funding remains an elusive dream.
By far the most contentious aspect of the election policies of both parties is their headlong rush towards sub-acute mental health care. But what exactly is this?
The evidence is thin. There are a handful of nascent services in Victoria. These offer short term transitional accommodation for people no longer requiring acute hospital care but not quite ready to go home. This care is now commonly called ‘step down’, and involves a mix of clinical and psychosocial support services. Vitally, these services also provide a ‘step up ‘component, with people able to secure a period of lower level care early in their illness, designed hopefully to stop things getting worse and obviate the requirement for an acute hospital admission.
This all sounds good but in reality is largely untested. The evaluation that has been conducted on the few services in operation in Victoria was supportive but not without criticisms.
Advice from people running these centres is the integrity of the model of care relies on maintain the ‘step-up’ component of the service, so that these sub-acute units do not become merely dumping grounds for acute ward bed managers keen to address bed block.
And bed block was clearly a concern driving the state and territory leaders when they met at CoAG in April. A national snapshot survey of acute mental health wards in 2006 indicated that 43% of all patients could be discharged from public mental health inpatient services if suitable services and supports were available.
NSW is particularly worried about bed block and has already moved to establish romantically-titled Non-Acute Inpatient Units or NAIPUs. Unlike the Victorian models, at this stage it is understood that these new units will operate without any step-up facility and will not link up with psycho-social support services.
With $1.6bn, the ALP has pledged to build 1300 sub-acute beds, to be shared between mental health, rehabilitation and other services, while the Coalition has promised 800 new mental health beds to be split between acute and sub-acute. The psychiatric institutions have been shut and people with a mental illness have few options to pursue care other than to go to hospital.
Now they face the prospect of being shunted into sub-acute services with little evidence to support this as an effective model of care.
Neither party is promising much in terms of building the range of community-based psycho-social support services specifically designed to keep people living well in the community, in their own homes. Home-based care is not being offered. Unless sub-acute services sit clearly as part of a suite of services and support, then these significant new investments in mental health could merely establish new dumping grounds for people with a mental illness.
The other election promise of note is the $9m promised by Labor to establish a National Mental Health Report Card. The states and territories have in fact already received over $50m over the past few years to build information systems and improve reporting.
After this, it is still not possible to tell if someone is alive or dead within three months of being treated by a mental health service.
The suicide rate is also unclear with national reporting problems unresolved as recently illustrated by the South Australian coroner. We also know nothing about the homelessness rate of people with a mental illness, the employment rate or the extent to which people with a mental illness are completing their education. Australia also lacks a national system for the validated collection of the experience of care for consumers and their carers.
But perhaps most fundamentally, we know almost nothing about whether, with the $5bn we currently spend on mental health, people are getting better. A new commitment to a national report card, provided it is prepared and managed independently and transparently, is long overdue.
Mental illness is the leading cause of death for all Australians under 45, more than road trauma and more than binge drinking. It is the leading cause of disability in Australia across all demographics. Mental illness affects over four million Australians every year and is estimated to cost the Australian economy around $30b each year.
Every day 330 Australians who present to emergency departments with serious mental illnesses are turned away. Less than 1 in 15 are referred to any other service. Every day over 1,200 Australians are refused admission to a public or private psychiatric unit. Every day, at least seven people die as a result of suicide, with more than a third involving people who were discharged too early and/or without care following hospitalisation.
To address this situation will take more than a commitment to maintain or even expand existing programs. It will require sustained effort and investment, married with root and branch analysis and redesign of the programs and services needed to keep people with a mental illness living well in the community.
No other area of Australia’s health system needs the type of fundamental investment and reform as needed in mental health.
Vote for any party promising that.”