In this edition of The Health Wrap, Associate Professor Lesley Russell provides a detailed overview of mental health spending and policy challenges, investigates the wide-ranging health impacts of inflammation, and also dissects an important question about private health insurance.
Lesley Russell writes:
The media focus this past week has been on the new outbreak of coronavirus infections in Melbourne and how this has highlighted the failures in hotel quarantine and the appalling slowness of the vaccine rollout. I’m hopeful that yet another lockdown for Melbourne will highlight how vulnerable Australia is and will continue to be, especially with the spread of the much more infectious Indian variant of the virus, unless and until Australians are vaccinated.
These few articles sum up the issues:
ABC News has done an excellent summary of the confusing history of Australia’s vaccination targets and the waffle from senior Morrison Government people on this. It really is shameful that promised timelines have not been met, especially for the most vulnerable Australians in aged and disability care.
An article on the Pearls and Irritations blog highlights that encouraging COVID complacency is a dangerous political game.
A terrific, in-depth piece from my Croakey colleagues highlights the importance of effective and accurate communications in these pandemic times – this is something that has been conspicuously absent and is not helped by the obtuseness of responses from the Prime Minister and his Cabinet. See, for example, this interview by Leigh Sales on ABC TV with Health Minister Greg Hunt.
The Project’s aim is to create clear, understandable information about coronavirus in more than 40 languages. The group’s fact sheets, vetted for accuracy and readability are being shared internationally; they have so far been downloaded in over 150 countries.
The biology of grief
The coronavirus pandemic has brought death and grief to so many people. A study published last year in the Proceedings of the National Academy of Sciences estimated that each American COVID-19 death leaves, on average, approximately nine close relatives bereaved.
For some, their grief for a life lost, whether by COVID-19 or any other cause, never diminishes and is so intense they are unable to function normally. An article this month in Scientific American states that COVID-19 has put the world at risk of prolonged grief disorders.
A recent article in The New York Times about the biology of grief caught my eye and provoked me to look further into this issue.
Grief isn’t just psychological, affecting the mind and the spirit, it is also physical, affecting the body in ways that are not well understood.
In the early stages of grief, people have increased heart rates, higher blood pressure and may be more likely to have heart attacks. Studies show bereaved spouses have a higher risk for cardiovascular disease, infections, cancer and chronic diseases like diabetes. Within the first three months, research on bereaved parents and spouses shows that they are nearly two times more likely to die than those not bereaved, and after a year, they are 10 percent more likely to die.
Researchers have shown that grief causes the brain to send a cascade of stress hormones (cortisol and epinephrine) and other signals to the cardiovascular and immune systems that can ultimately change how those systems function. Over time, chronic stress can increase the risk of cardiovascular conditions as well as diabetes, cancer, autoimmune conditions and depression and anxiety.
A 2019 study shows that people who experience higher levels of grief and depression after bereavement also have higher levels of immune system markers for inflammation. Inflammation also contributes to cardiovascular disease, Type 2 diabetes, and some cancers and has a role in depression and fatigue.
There is also a link between depression (and perhaps other mental health disorders) and inflammation. People with depression have higher levels of inflammation in their bodies than those who don’t have the condition, but it is unclear whether this is due to genes that indicate a predisposition for depression, or because depression can lead to behaviours that trigger inflammation.
It seems there are strong links between physical and psychological stress, inflammation, mental health disorders, dementias, obesity and a range of chronic illnesses. That begs the question of what do we then do about what has been called “an epidemic of inflammation”?
Physical activity is one way to tackle this. A large, long-term study done back in 2007 that sought to understand why physical activity is beneficial found that about a third of the benefit of regular exercise is attributable to reduced inflammation.
In 2017, cardiologists at Brigham and Women’s Hospital in Boston published the results of a clinical study, with 10,000 patients in 39 countries, that showed an anti-inflammatory drug, by itself, could lower rates of cardiovascular disease. They also discovered that lung cancer mortality dropped by as much as 77 percent and reports of arthritis and gout also fell significantly.
There is also data to suggest that diet may play a role with excess body fat now seen as a risk factor for inflammation.
Finally, there may also be a role for sleep. The immunological mediators of inflammation are altered by sleep loss.
Why is sleep so important?
I’ve set up the perfect segue into this topic – sleep – which is increasingly seen as an issue in improving physical and mental health. The report “Sleep Matters: the impact of sleep on health and wellbeing” from the UK Mental Health Foundation does a good job of explaining why (although it is dated 2011).
The amount of sleep doesn’t just affect the risk of developing chronic illnesses (as outlined above) but also influences the magnitude of specific immune responses to infections. There is a good, up-to-date summary of the issues here.
A recent paper in The Lancet looks at a possible role for sleep in individuals’ immunological responses to coronavirus vaccine. The data are not definitive, and uncertainties remain, but I did note one issue I thought deserves further attention: how to determine the appropriate time of vaccination for night-shift workers. This group often has chronic circadian disruption and exhibits a markedly greater risk of COVID-19 diagnosis.
Deep sleep has been shown to “flush out” the brain with restorative effects on cognition and brain health (or damaging effects from poor sleep patterns). An article this month in JAMA Network summarises what is known about brain “waste management” during sleep.
Mental health and the budget tasks ahead
Here’s a quick summary, including some points taken from Dr Rosenberg’s tweets:
- Total expenditure on mental health in 2018-19 was $10.6 billion. Of this, $6.4 billion was spent by the States and Territories (includes $2.8 billion on public hospitals); $3.6 billion by the Australian Government; and $584 million by private health insurance and other third-party insurers.
- Interestingly, I can find no mention anywhere in this report of payments by patients or out-of-pocket costs.
- In 2019-20 $1.4 billion of federal expenditure was in Medicare-subsidised services and $566 million on Pharmaceutical Benefits Scheme medicines.
- In 2019-20 10.7 percent of the Australian population accessed Medicare-subsidised mental health services. People receive these services were more likely to be young, female, and live in major cities.
- 11.8 percent of these mental health services were delivered by telehealth.
- The average number of services per patient in 2019-20 was 4.5 nationally. This varied by State and Territory, with the highest average number of 4.8 in Victoria and the lowest of 2.9 in the Northern Territory.
- Of the Medicare mental health services delivered, 45.3 percent were provided by psychologists, 30.6 percent by GPs, 20.3 percent by psychiatrists.
However, most of the people getting Medicare mental health services received them from GPs. In the majority of cases this involved the prescribing of medication.
While GPs have seen significant increases in mental health services over the decade 2009-10 to 2019-20, the number of services delivered by psychologists has not significantly increased and the number of services delivered by psychiatrists has remained constant.
There were 310,000 mental health Emergency Department presentations in 2019-20. This is more than double the number from 2006 (when COAG provided its National Mental Health Action Plan).
Of the 735,554 people receiving services provided by registered psychologists in 2019-20, only 599 were recorded as being provided to Indigenous Australians.
The take-out: Virtually all of the Medicare-subsidised mental health services are provided under the Better Access program.
The data cited above lead to the critical question – Better Access for whom?
As we see every time this mental health program is analysed, all the evidence points to the fact that people most in need are least likely to get the care they need; when they do get it, it is most likely to be from a GP or in the Emergency Department and these parts of the healthcare system are bearing an undue load.
See this October 2020 article on how AIHW data show the growing role of GPs in the provision of mental health care and this May 2020 article by Dr Simon Judkins on mental health presentations in Emergency Departments.
Sadly the AIHW report has no information about out-of-pocket costs and the role these play in ability to access care. So it’s not possible to say if the low rate of increase in services provided by psychologists and psychiatrists over the past decade is due to financial barriers or workforce numbers (or both these factors).
The mental health data that are collected are limited in their usefulness. The most recent data from Bettering the Evaluation and Care of Health (BEACH) on GP encounters has not been updated since 2015-16 (when around 12.4 percent of all general practice encounters were mental health-related) because the Government withdrew its funding in 2016 and the AIHW only collects data for Medicare’s specific mental health items, so many GP consultations that involve mental health go uncounted.
There is also little meaningful evaluation of Better Access. We know, from the Productivity Commission report, that the mental healthcare system isn’t meeting demand and services are not meeting community expectations. And while governments have been increasing expenditure on mental health support through the Medicare system, outcomes for patients haven’t improved.
Despite the significant new mental health funding provided in this year’s federal Budget, much of the detail about how this will be committed is yet to be revealed.
To quote Mental Health Australia:
The key details regarding the most significant structural Budget items are not yet clear and will form part of the critical negotiations between the Australian Government and state and territory governments as they move towards a new National Mental Health and Suicide Prevention Agreement, due for completion in November 2021.”
The Morrison Government will be significantly challenged to both do more and do this in partnership with the States and Territories because of the substantial investment in mental health made in the recently-presented Victorian Budget in response to the Royal Commission into Victoria’s Mental Health System ($3.8 billion over the next four years – 65 percent more than the Morrison Government).
Victoria will, controversially, seek to partially fund this new spending through a new levy on big business, arguing that mental health is a workplace and productivity issue. Victorian Treasurer Tim Pallas has revealed that the State has asked the Commonwealth to expand the Medicare Levy to better provide for mental health but was rebuffed.
Rosenberg has asked the pertinent question in a recent article he wrote for Croaky entitled “Will Canberra and Victoria work together to make the most of record mental health spending?”
He concludes: “The danger is that as both State and Federal governments now make welcome moves to fill the community mental health void, they do so in the absence of common philosophy, approach or model of care. This is a recipe for fragmentation not continuity of care.”
A paper from researchers at Systems Modelling, Simulation and Data Science at the Brain and Mind Centre at the University of Sydney just out in Nature Scientific Reports also looks at this issue. It finds that Federal and State cooperation is necessary but not sufficient for effective regional mental health systems.
The paper states: “… competing priorities between Primary Health Networks and Local Hospital Districts can undermine the optimal impact of investments for suicide prevention and that the Productivity Commission’s recently recommended pooling of national and state funding for mental health under new Regional Commissioning Authorities is neither necessary nor sufficient to prevent ongoing policy resistance.”
It is exciting to see that the Victorian Budget includes $36 million for new Hospital in the Home services. This has been welcomed by mental health experts. Professor Ian Hickie and Rosenberg wrote recently for MJA Insight that “the best place for mental health care is in the home”.
More 2021-22 Budget analyses
There are more #Budget2021Health analyses out:
Mental Health Australia: 2021 Federal Budget Analysis
National Foundation for Australian Women: Gender Lens on the Budget 2021-22.
Australian Council of Social Service: Post-Budget Gender Analysis – single mothers, older women left behind.
Croakey colleague Linda Doherty did a great summary of women’s issues in the Budget: “Glossy” women’s Budget statement fails to deliver for those in poverty and at risk.
Chris Atmore from Allied Health Professions Australia, writing in Croakey: Allied health is a litmus test for the 2021-22 Federal Budget.
In case you missed it
The importance of Patient-Reported Outcomes
Professor Afaf Girgis, from the University of New South Wales, in an editorial in the Journal of Medical Radiation Sciences, makes a compelling case for health services to consider implementing patient-reported outcomes (PROs), including determining the respective roles of different health professionals in supporting routine PRO implementation and identifying local barriers to implementation.
Hospital in the Home in north west Queensland
ABC News reports on the success of a Hospital in the Home program in north west Queensland, based in Mt Isa. This is the most recent of a number of programs run across the state by the Queensland Government. The state guidelines are here.
Telehealth keeps a remote Aboriginal community safe and healthy
Some good news on the successful application of digital technology, telehealth and My Health Record in keeping a remote Indigenous community safe and healthy during the coronavirus pandemic is outlined here.
The pandemic and resulting border closures meant no doctors or healthcare workers were able to visit the 160 people who live in Tjuntjuntjara (650 kilometres north east of Kalgoorlie in the Great Victoria Desert in Western Australia) for more than ten months, from March 2020 to January 2021.
However, with broadband service and telehealth (and a doctor who has been going to Tjuntjuntjara for more than a decade) the clinic was able to continue to have a high level of health care for chronic conditions, preventive activities and mental health issues.
“In many cases, and despite the reduced face-to-face encounters with visiting medical specialists, the increased use of telehealth sessions improved care.”
Why do Australians buy private health insurance?
A very interesting piece on the Pearls and Irritations blog presents the results of a survey (done in April) by the Melbourne Institute on why people buy PHI hospital cover.
Key points from the survey:
- Respondents who have a job, live in metro areas and are financially comfortable are more likely to buy private health insurance.
- High insurance premiums and out-of-pocket costs are the most common reasons given for not having private health insurance.
- More people are happy to use public hospitals instead of purchasing private cover compared to six years ago.
- Reasons to buy private hospital insurance differ substantially by age, employment and financial status.
The most common reason given for purchasing PHI is peace of mind. This suggests people are looking to avoid financial risk and catastrophic health costs, but that doesn’t make sense when all Australians have free access to public hospitals, and those who use private care are the ones who face out-of-pocket costs. So the conclusion is that people with PHI are worried about wait times in public hospitals.
The Morrison Government has been noticeably quiet on PHI recently. Perhaps they are (finally) wondering if the $11 billion spent annually on propping up PHI and private hospital services is good value for the government and for taxpayers?
Croakey has recently published several articles on PHI, including some that relate to the provisions in this year’s Federal Budget. You can access them here.
The best of Croakey
At Croakey, we were delighted to see the global media collaboration Covering Climate Now recognise the importance of this recent article by Dr Amy Coopes, reporting from the Royal Australian and New Zealand College of Psychiatrists conference.
The good news story (X 2)
Some weeks I struggle to find a good news story. But this week I have two stories that both focus on successful initiatives in Indigenous communities.
This story is headed “How a town that Tony Abbott described as having the worst housing in Australia is changing the game” but that doesn’t reflect the account of the wonderful Indi Kindi, an outdoor walking-learning early years program that is led and taught by local Aboriginal people. You can follow Indi Kindi on Twitter at @Indi_Kindi – the tweets are guaranteed to make you smile.
This program and others like are sponsored by the Moriarty Foundation. A review finds it has found it has bridged the gap in early childhood education by reaching 80 percent of Indigenous preschool-aged children in Borroloola and nearby Robinson River on the Gulf of Carpentaria.
ABC News has a great story about how an outback school in Queensland is reviving the Gunggari language, bringing back an endangered dialect once on the brink of extinction. Local elders are in the process of compiling the first Gunggari dictionary, which is expected to be completed by the end of the year.
Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow her on Twitter at @LRussellWolpe.
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