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Will the Budget mental health package deliver for the "missing middle"?

On the Budget and mental health, what are the experts saying?

Melissa Sweet
Tuesday, May 11, 2021

Federal Budget 2021-22, Social determinants of health, Mental health, Suicide, Youth health, Nursing and midwifery, Telehealth

Croakey readers can download the Department of Health Budget Briefing Pack here.

This post wraps reaction on the mental health announcements from the National Mental Health Commission, mental health experts, the Australian Medical Students Association, the Royal Australian and New Zealand College of Psychiatrists, the Youth Health Forum and the Australian College of Mental Health Nurses.

A genuine shift

National Mental Health Commission

National Mental Health Commission Chair, Lucy Brogden AM, has described the 2021-2022 Federal Budget as “a genuine shift in our national response to mental health, wellbeing and suicide prevention.”

Today’s $2.3 billion budget announcement presents a commitment to a more preventive, compassionate and person-centred mental health and suicide prevention system.

“In 2021, more Australians than ever are recognising the importance of seeking help for their mental ill health, and governments and the sector are united in their commitment to meet this need,” Mrs Brogden said.

“To achieve this we need both system reform and additional services. This budget addresses both. We also need an ongoing commitment to building our evidence base to enhance knowledge, services delivery and outcomes.”

The Budget commitment leads a shift to:

Focusing on the value of investing in mental health and wellbeing for all Australians, not just how much we spend on mental illness.
Significantly increasing accessibility to services online and in communities where people live, learn and work. A new network of community-based mental health hubs for children and those who care for them, young people and adults that will ensure those services are age and needs appropriate.
Supporting our mental health workforce, across multiple disciplines, to deliver compassionate evidence based quality care.

“The Budget creates a universal approach to suicide prevention, spearheaded by a National Suicide Prevention Office. It will enable suicide prevention care – coordinated with the States and Territories – to be delivered where people live,” Commission CEO Ms Christine Morgan said.

“Importantly, the Budget recognises that to achieve coordinated integrated services we need to adopt a coordinated way of doing things, across all jurisdictions and in partnership with all stakeholders.”

This is the first budget that responds to the recommendations from the Productivity Commission and Suicide Prevention Final Advice.

“The budget has drawn on the research and outcomes from those landmark reports, which included the lived experience voices of consumers, carers and those providing support within the sector.

The 2021-2022 Budget provides five pillars for change that will help Australia achieve systemic reform.

$248.6 million for early intervention and prevention.

“Investment in mental health and wellbeing requires a new focus on prevention of mental ill health and early intervention – in life, in illness, in episode of illness, and in relapse. It recognises the importance of the social determinants of health such as employment, economic security and education, as well as the role of workplaces and communities. It works with the challenges of the justice system. It works with the challenges of the justice system. It recognises the importance of a whole-of-person, whole-of-life, whole-of-system approach to mental health and wellbeing, and it needs to be accessible via integrated and easy to use digital services, channels and infrastructure for all Australians regardless of where they live,” Ms Morgan said.

$298.1 million for suicide prevention.

“This commitment presents a shift towards early intervention at times of suicidal distress. It recognises the imperative of providing evidence-based universal aftercare to anyone who has been in the suicidal crisis, and for those who have been bereaved. It shifts towards a provision of suicide prevention services that address the needs of those who are disproportionately impacted by suicide. It establishes a national suicide office to ensure a national approach is adopted across all jurisdictions.”

$1.4 billion for treatment.

“Such a significant investment delivers on the need to bring more service options into community settings, across the spectrum of children, young people and adults. By establishing a network of hubs, a new approach is being taken to bring into effect a more coordinated approach that is provided by multidisciplinary teams – across GPs, mental health professionals and allied health services. Australians will have a network of new mental health service centres that respond to them as a whole person regardless of their life experience and their needs. It responds to the needs of the missing middle – those missing out on services due to lack of services, lack of accessibility, or because they are too unwell for primary care but not so unwell as to require going to hospital. It is a significant shift towards the goal of a universal mental health care system providing affordable, accessible, evidence based care to Australians when and where it is needed.”

$107 million to support priority populations.

“Mental health services need to be accessible to priority population groups, recognising that a one size fits all approach is not suitable. The provision of equitable access to services by creating additional support for particular groups recognises the experience of each person is different.

“The particular needs of Aboriginal and Torres Strait Islander communities, Culturally and Linguistically Diverse communities, LGBTIQ+ communities, those who live in regional and rural Australia and those who are going through a transition in life, including veterans must be considered in services and system reform.”

$202 million for workforce and governance.

Ensuring our mental health workforce is supported to provide compassionate, safe care is a critical enabler for our system and service reform.

By offering over 1,000 scholarships and clinical or training placements, and further training opportunities and incentives, this component of the Budget seeks to broaden our mental health workforce, increase capacity and improve capability.

It recognises the importance of our GPs, psychiatrists, psychologists, nurses and allied health professionals. Most importantly it recognises and supports investment in our peer workforce.

A whole of government approach:

Finally, and crucially, the budget commits to making the National Partnership Agreement a reality. Key to achieving lasting reform will be strong collaboration across all governments, the sector and communities, and a commitment to co-designing solutions with people with lived experience.

The implementation of cross-portfolio responsibility will see improvements in data collection, outcomes measurement and the capacity to provide support to people at all stages of their life while addressing the social determinants that influence mental health and wellbeing.

“The Commission welcomes the continued investment and improved data, and the steps towards delivering outcomes and results for all Australians. We welcome investments in research and outcomes, and data collection, because we see these as essential for continued reform.”

“Today’s Budget lays the foundations for the national mental health and suicide prevention reform that is required. It reflects a genuine commitment and presents the sector and government with an opportunity to take a unified approach to building a strongly coordinated mental health system. This opportunity also includes the potential to fully realise a whole-of-government and whole-of-governments’ approach, that is coordinated, connected and compassionate.”

“This budget lays the foundation for a truly integrated national system,” Ms Morgan said.

Welcome investment

Australian Medical Students’ Association

Australian Medical Students welcome the Australian Government’s record-breaking mental health investment as an important first step in meeting the Productivity Commission’s mental health report recommendations.

“Whilst we welcome tonight’s mental health funding announcements, higher investments will be necessary to achieve the benefits associated with the priority reforms as recommended by the Productivity Commission’s 2020 mental health report,” Sophie Keen, Australian Medical Students’ Association (AMSA) President, said.

“The allocation of $2.3 billion in funding the National Mental Health and Suicide Prevention Plan will be instrumental in designing a sustainable and effective mental health care system as outlined by the Productivity Commission.

“We are also pleased to see the Federal Government intends to establish a number of new adult and child mental health centres that focuses on providing care to Australia’s vulnerable populations including our First Nations and LGBTQIA+ populations.

“In the context of spikes of mental health access during 2020, it is vital that the Federal Government continues to support those who have had their mental health severely impacted by the pandemic.”

AMSA provided two recommendations in their Pre-Budget Submission to the Federal Government relating to mental health. These recommendations focused on investment in mental health care access for the general population, and training medical students to identify and respond to mental health care crises in themselves and others.

The Better Access initiative allows eligible people to access up to 10 individual mental health service sessions each year, with the availability of 10 additional sessions being made available from October 2020 until June 2022. An additional $111.4 million was allocated to the Better Access initiative in tonight’s Budget.

Support for overall direction

Dr Sebastian Rosenberg, Senior Lecturer, Brain and Mind Centre University of Sydney

Working with the mental health sector, we have established that for mental health to begin to gather the resources required to address demand, around $1bn is required each year for several years.

This budget provides around half this, an improvement on recent more meagre years.

The budget also focuses on the development of regional and digital solutions, using new centres and services. A national and universal aftercare service, following an attempted suicide is both sensible and welcome.

How all these models evolve needs close scrutiny.

A full Government response to the Productivity Commission is yet to emerge.

However, and while the scale of the investment is not optimal, the overall directions and key themes are to be supported.

The mental health budget papers refer to ongoing work to establish a new agreement between the federal and state governments.

While this is welcome, Minister Coleman referred to the need for structural reform in mental health.

For me, this means revisiting the intent of the very first national mental health strategy, back in 1992.

Specifically, it means diminishing the ever-increasing role (and cost) of hospital-based mental health care, instead shifting our collective focus and investment on alternatives, earlier intervention, psychosocial care, hospital avoidance and genuine accountability for progress.

Don’t stop now

Professor Ian Hickie, Co-Director, Health and Policy and Professor of Psychiatry at NHMRC and a Professor at University of Sydney’s faculty of Medicine & Health

The Government’s $2.3 billion investment in mental health and suicide prevention is the first-phase of a much larger and more complex deal that is yet to be done with the states and territories and the private sector. This is due to be completed by November 2021 and will cost many more billions.

However, this investment is targeted and does respond to the big items that should be at the front of the federal government’s response – suicide attempt aftercare, digital transformation, expanded treatment centres, reaching regional areas.

The big question is then whether Prime Minister Morrison will next take the really hard political steps to lead genuine national reform that provides more complex care for those who will never receive that help from the states and territories.

It’s in that classic ‘missing middle’ that there is the greatest opportunity for saving lives and seeing the biggest social and economic return on investment.

Telehealth and other initiatives welcomed

Royal Australian and New Zealand College of Psychiatrists

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has welcomed the confirmed extension of the COVID-19 telehealth psychiatry items announced in the Federal Budget 2021-22.

The President of the RANZCP, Associate Professor John Allan, has said it brings relief and certainty to both the patients and their doctors.

‘The COVID-19 telehealth items under the Medicare Benefits Schedule (MBS) have been integral in allowing us to continue to provide mental health services to users and for them to be able to continue using those services, as uninterrupted as possible.

‘We’ve seen from the latest outbreaks and cases of community transmission that the threat of COVID-19 is not yet over, and therefore provision must still be made for those unable to attend regular mental health services due to being high risk.

‘The extension of these MBS items is a positive step for those in mental health and health in general as telehealth has provided access to regular service users as well as opened the door for those who previously may have not been able to access our services.

‘Consumer feedback received by psychiatrists in relation to the use of telehealth for their psychiatry consultations has also been positive.

The RANZCP strongly encourages the Federal Government to commit to the continuation of telehealth to further enhance Australia’s mental health service system and support those who have significantly benefitted from telehealth.

‘We are pleased that telehealth has been made available until the end of the year, however, there is not only great potential, but an even greater need for telehealth to exist beyond 2021.

‘It is integral to our country’s mental health that we invest in long-term access to assessment and treatment by telehealth to enhance person-centred care and go some way to compensating the shortfalls in psychiatrists, particularly in rural and remote areas.

‘Flexible access to all types of consultations should be a priority.

‘This will serve to enhance service provision by providing cost-effective delivery of services to people who already have mental health conditions or who have developed them during the pandemic.

‘The RANZCP looks forward to being actively engaged with the Federal Government in their planning for the future of telehealth, as we work towards a longer-term transformation of telehealth services beyond 2021.’

The College has also welcomed the Government’s announcement of $288.5 million to list Repetitive Transcranial Magnetic Stimulation (rTMS) therapy for patients with medication-resistant major depressive disorder.

Associate Professor John Allan supported the announcement that patients will now have access supported by Medicare to a wider range of treatments, specifically rTMS, for people for whom other treatments have not had the effect hoped for.

‘rTMS is a therapeutic, well tolerated, and safe, medical procedure for the treatment of psychiatric disorders, especially episodes of major depression’, explained Associate Professor Allan.

‘There is a good evidence base for the therapeutic efficacy of rTMS in major depressive disorder. Those with treatment resistant depression who respond to rTMS treatment will subsequently experience a lower burden of disease.

‘We strongly support the introduction of this service to the Medicare Benefits Schedule (MBS) following the recommendations from the independent Medical Services Advisory Committee (MSAC).’

Chair of the RANZCP Section of Electroconvulsive Therapy and Neurostimulation, Dr Salam Hussain, echoed the welcoming of the announcement including rTMS on the MBS.

‘Given the significant evidence for rTMS as an effective treatment for depression, and the clearly defined standards for the delivery of rTMS, we are pleased that it will now be accessible to more people through the MBS’, said Dr Hussain.

‘This is an important treatment that should be affordable and, where appropriate, offered as a therapeutic option for the treatment of major depression.

‘The Budget’s inclusion of rTMS to the MBS has provided many Australians, who are battling major depressive disorders, an affordable and accessible treatment pathway for those who have tried antidepressant medications or psychological therapy and remain unwell.

Budget moves for youth health welcome as a first step

The $2.3 billion investment in mental health and suicide prevention is a welcome first step on the road to much needed mental health system reform, the Youth Health Forum says.

“It is promising to see a number of the Productivity Commission’s priority recommendations addressed in this budget,” the spokesperson for the Youth Health Forum, Roxxanne MacDonald, said.

“For young people in particular, this includes the $158.6 million investment in care for people discharged from hospital after a suicide attempt, investment in developing the peer workforce, and targeted funding to involve family and carers in treatment provided under Better Access.

“While the budget talks about mental health care reform, it largely invests in strengthening current models of care for young people. We know that headspace is a great doorway to mental health care, but its only meeting the needs of a handful of young people, with many of the most vulnerable falling through the gaps. For the young people who fall into the ‘missing middle’ we often talk about, this budget is more of the same.

“It is time to look at how we can get maximum benefits from the current headspace model and invest in more sophisticated solutions to address the complexities of rising youth mental ill-health rates, such as digital platforms and ensuring headspace and state services are well-integrated.

“With such significant investments into current mental health structures, we will be looking at how these services are integrated into mental health system reform without further fragmenting an already difficult-to-navigate system.

“Once again, the focus remains on clinical care with little attention paid to social determinants of health. We know how important financial stability and a sense of belonging are in preventing and treating mental illness in communities.

These things must be at the centre of mental health care for young people if we are to achieve our goals for mental health system reform.

“We welcome the investment in the Head to Health adult mental health treatment centres. Many young people who need ongoing mental health care but are unable to cover the cost themselves are often left high and dry when they age out of youth-specific services like headspace.

“Expanding adult mental health treatment centres will ensure continuity of care for young people as they transition out of youth-specific services.

“Suicide is the leading cause of death for young people. The measure to provide every Australian who is discharged after attempting suicide with appropriate ongoing care in the community is very welcome. Suicide is the leading cause of death for young people and we know that the risk in the first month after discharge from hospital is especially high. If effectively implemented, ensuring the young people are provided appropriate care in their community will assist in reducing these rates.

“The lack of funding for climate change is disappointing, particularly given the impact of last year’s bushfires. We know it is affecting the physical and mental health of Australians now, and addressing the causes of climate change remains a top priority for young people.

“Ensuring these initiatives are implemented effectively and with consumers at the heart of decision-making will be crucial in their success. Young people must be involved in all levels of this implementation, from having a seat at the decision-making table, to co-designing the services and how they’re delivered,” Ms MacDonald said.

Mental health nurses sidelined

Australian College of Mental Health Nurses

With the Budget published on the eve of International Nurses day, Australian College of Mental Health Nurses (ACMHN) president Dr Mike Hazelton said that now was the time to recognise the extent to which nurses everywhere have ‘answered the call’ during this global pandemic.

“This has been especially so for Mental Health Nurses (MHNs) and it is likely we will need to keep doing so well into the future, given the mental health impacts of COVID-19. The ACMHN looks forward to working with the Government to build high quality mental health care available to Australians living with mental illness.”

Whilst the College welcomed the Federal Government’s funding boost for mental health and nursing, the vulnerable and underserviced ‘missing middle’ – those too unwell for primary care, but not unwell enough for state-based services – has not been given enough attention, and the important work MHNs do for these people continues to be overlooked.

“This is a major omission that needs to be addressed in government initiatives to rebuild the Australian mental health system from the ground up,” ACMHN president Dr Mike Hazelton said.

“I would like to join others who have commented on the very poor state of mental health care in Australia and acknowledge the importance of the $2.3 billion allocation to mental health in the budget. I take this as an expression of good will by the Government heeding the recommendations that many reports and individuals in the mental health sector have been putting forward.”

Within this large spend, the ACMHN welcomed the $27.8 million allocated to increasing the number of nurses, psychologists, and allied health practitioners in mental health settings.

The College was pleased to see support for the development of and access to services for people with eating disorders and their families and the allocation to enable Repetitive Transcranial Magnetic Stimulation (RTMS) to be included on the Medicare Benefits Schedule (MBS) for people with medication-resistant major depressive disorder.

The College also acknowledges the substantial allocation of $1.1 billion to battle domestic violence.

“We welcome the spend, as much of the work that MHNs do throughout the mental health service sector is in relation to caring for and supporting individuals and families that have been the victims of violence,” Dr Hazelton said.

“MHNs are the only mental health professionals who also deal with physical health, so let us be front and centre in providing help to tackle issues such as suicide, domestic violence, and COVID-19.”

Not enough

Professor Henry Cutler, Macquarie University Centre for the Health Economy

In mental health care, Budget funding is piecemeal, mostly allocated to service expansion. But the primary problem is service fragmentation, poor navigation, and intractable governance. These have not been addressed.

The Budget has allocated some funding to the mental health workforce, but it’s not close to what is required to ensure the workforce is appropriately skilled.