Note to readers: Please see author’s correction at bottom of the post.
At this time of year, there is always a lot of pre-budget jockeying. This year there is great expectation and also great apprehension about what the Federal Budget might hold for mental health.
Mental health advocate Professor Alan Rosen has been watching recent developments closely, and his analysis follows below (at the bottom of the post you will find an invitation to provide feedback to the Federal Government’s mental health advisors).
Professor Alan Rosen writes:
The bookies seem to know what every election result will be. So why did we bother having Saturday’s NSW election? Couldn’t we just extrapolate from where the odds stand at midnight on election day?
Then we could spend the Electoral Commission’s budget on our run-down mental health services. Maybe, on past disappointing form, we should not even wager our lunch on having much of a boost for mental health on budget night, despite Julia Gillard’s insistence that it is a 2nd term priority. (Perhaps it should be called budget-smugglers’ night, to celebrate that dark art of sleight of the contents of taxpayers’ pockets?).
But the longer the Government keeps postponing the crying need to reform Mental Health Services, the more that the growing affected community will keep raising the stakes. It is a dead-cert that it won’t just go away as an issue if ignored. In an international survey last year, foremost among all countries, the Australian public placed mental health services as one of its top 3 concerns, alongside the global financial crisis and climate change.
Sensing the disquiet and impatience of the burgeoning Australian mental health constituency, Mark Butler, the federal Minister for Mental Health, recently put out an update letter about his deliberations with his expert committee, which said next to nothing about what they might be proposing in their advice to him, about which they were all sworn to secrecy.
It may be that he is engaged in a delicate negotiating process to squeeze something substantial out of the tightening federal budget, but for what purpose?
It is a bad move not to take this seasoned network into your confidence on your way. It is laudable that early in his tenure, Mr Butler did a whistle-stop tour around Australia, running brief group consultations in urban and regional centres.
But that was before he installed his expert panel to develop these proposals. The fact is that he does not seem to have foreshadowed any wider consultation process, on any actual proposals. He has commissioned a separate kitchen committee, derived partially from his expert group, to develop a “blueprint”, published not as a draft out there for consultation, but as time is of the essence in the budget build up process, as a finished submission to be taken urgently to Treasury, hopefully for funding*.
There is a lot to commend in its striving for a transformative approach, and its shopping list of “evidence based best buys” for different age groups. So far so good.
However, many of its proposed structures for adults though possibly promising, are substantially untested. We need time to produce some evidence that they work, because we don’t want to repeat the blatant wastage caused under Howard’s CoAG initiatives like Better Access, perpetuated by Nicola Roxon.
Even more concerning is that the real firmly “evidence-based best buys” for adults with severe and persistent mental illnesses, especially with forensic, drug and alcohol comorbidities, have been left out. These include (acute) 7 day and night mobile crisis and continuity of care teams, assertive community treatment (rehabilitation) teams, and 24 hour residential respite households as an alternative to many admissions.
The Blueprint group can’t back this trifecta, we are told, because their riding instructions stated that these are viewed federally to be state responsibilities, particularly since the states wouldn’t relinquish that 30% share of GST. This could almost be construed as a washing of hands in retaliation.
At whose expense? These proven service delivery systems will become orphans, and many severely disabled clientele will continue to be clinically abandoned.
Most states squandered the resources allocated for them long ago, by diverting them to medical and surgical procedures, and by failing to complete the disgorging of stand-alone institutions, preventing the shift of some of their resources to community care. With few exceptions, this has resulted in stunted development or dismemberment of such evidence-based mobile community-based mental health services, and often the retraction of their rumps back onto hospital sites.
A little under $2 billion over 5 years is required to provide firmly tied funding to the states to restore these key teams, including rural adaptations of them Australia-wide, and to monitor, this time around, their outcomes and fidelity to evidence via a national mental health commission.
Either that or they will need a contractual arrangement with the states to meet them half way if they want the money, not just via another CoAG agreement, which is bound to be broken.
The AMA is completely right that we need at least a commitment of $5 billion over 4 years, partly to make up for lost time and lost people. Most in the mental health community would differ with some of the AMA priorities for this funding, however. By my rough reckoning we need at least $5.5 billion over 5 years to kick-start a national mental health program with reasonable expectations of success.
Professors McGorry and Hickie are overly modest in their estimates of what is required to deliver an effective transformation of the mental health service system, saying they will settle for around $3.5 billion over 5 years.
This government also needs to commit resources to:
Ö a widely consultative process, arriving at a rough consensus inside a few months, about priorities and a framework for a national mental health reform program for the next 10 years, integrating public, non-government and private, including fee-for-service sectors. By now, this national mental health taskforce should be out there seeking a broad consensus for this national mental health program. It must overarch the superficial revamps of the national mental health policy, plan and standards, all devoid of practical goals and timelines, which have been diluted and downgraded in political compromises between state and federal bureaucracies. Gillard & Butler & co, need to hunt the money, but they also should not waste this build-up of expectation, momentum and opportunity for really consultation leading to transformative reform. If we are really into social inclusion, we need to practice what we preach.
Ö a National Mental Health Commission, as also proposed in “the Blueprint” like New Zealand, Canada, and now Western Australia, and soon NSW too, which promotes the resourcing and monitors the implementation of the reform agenda at arm’s length from government, while constantly consulting with all stakeholder groups, and reporting on an all-of-government scorecard basis to the Prime Minister, Health ministers and parliament.(Link to Rosen et al 2010, International Mental Health Commission review).
Ö Regional integrative budget-holding commissioning authorities ( as established in New Zealand, the UK and now on a statewide basis in WA, and soon to be formed in NSW ) ensuring integration of all mental health and support services, by being able to purchase flexibly from all funding streams, public, non-government communally managed, and private health organizations if need be (Link to AHHA paper on Funding Methodologies 2008).
Ö We need government to find new resources to bring the mental health proportion of health budget, currently sinking from 8% to 6%, up to 13%, closer to the proportion of health burden due to mental ill-health, as most other developed countries have done.
As clinicians, we need to follow the form and play the system squarely in the interests of our clientele and their families, in every age group and phase of care.
And we don’t need yet another policy shoot-out between the parties to entertain the political punters.
We need a consistent tripartisan commitment to integrated collaborative mental health care for the whole Australian community.
So while we can’t yet bet safely on the fate of mental health in the federal budget, either way, let’s hope it romps home.
*However, the authors have placed it in the public domain, and Professor Ian Hickie of the Brain & Mind Research Institute, Sydney, has now undertaken to invite and collate comments by email. Contact:
Ian Hickie <ian.hickieATsydney.edu.au>
TAMHSS (Transforming Australia’s Mental Health Service System, tamhssATyahoo.com.au) will take and list comments publically on its blog from Monday 4th April 2011.
• Professor Alan Rosen holds positions with the Brain & Mind Research Institute, University of Sydney, and School of Public Health, University of Wollongong.