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Thirty years, and counting

Jennifer Doggett writes:

Scott Morrison has called the final report of the Productivity Commission’s inquiry into the economic impact of mental ill health “the most comprehensive report of its kind” ever produced in Australia.

He’s probably right. This huge report draws on a record number of submissions, a series of roundtables and public hearings in all states and territories, and input from a range of eminent experts. It makes more than one hundred recommendations to help the one in five Australians experiencing mental illness every year. It provides a strong economic case for reducing the direct economic costs of mental illness — between $43 billion and $70 billion each year — and the additional $151 billion lost to disability and premature deaths.

So why do I have a feeling that the report’s recommendations might go nowhere?

The fact is that we have thirty years of evidence that official inquiries into mental health — thirty-two of them between 2006 and 2012 alone, according to one observer — rarely lead to major changes. The pattern goes something like this:

  • A new health minister recognises the need to do something about mental health but struggles to find a clear direction through the maze of conflicting viewpoints and previous reports. She or he does what any new minister would do in this situation and sets up an inquiry.
  • This inquiry takes up considerable time, energy and resources only to confirm the key finding of previous reports — that the problems in mental health are deep and systemic and have no easy solutions. The report recommends a level of spending that makes the treasurer of the day go weak at the knees.
  • The health minister is stumped by most of the recommendations in the report because they require feats seemingly impossible in Australian politics (upsetting doctors, working collaboratively with the states, coordinating action across portfolios). While she or he comes to terms with the fact that there’s no chance of getting enough money out of Treasury to implement the recommendations, stakeholders start competing for what they perceive to be a dwindling pool of new funding. The in-fighting quickly becomes personal and nasty.
  • To create the appearance of decisive action, the health minister sets up some sort of body with an impressive title to oversee the mostly doomed recommendations of the report (or perhaps to put some distance between the minister and the sector). She or he throws a bit of money at whichever stakeholder group is shouting the loudest and hopes for the best. By this time the government is near the end of its term and the minister is secretly gunning for a promotion to Treasury, or at least a portfolio where the issues are more straightforward and the stakeholders less toxic.
  • If the government wins a second term, the minister of the day realises that mental health is a political road to nowhere. She or he gives up on the idea of systemic reform and decides that the best strategy is to keep a low profile and focus on keeping the most powerful stakeholder groups onside so they don’t make trouble leading up to the next election.
  • Three years later, after a change of government, a new health minister arrives, recognises the urgent need to do something about the dire state of mental health, becomes confused by the lack of clear policy direction and stakeholder in-fighting, and sets up an inquiry…

And so the cycle continues, as it has many times over the past thirty years, both federally and in the states. Meanwhile, Australia spends more than ever on mental health services with no sign that outcomes are improving. A staggering one in eight Australians are now taking antidepressant medication (the second-highest rate in the OECD) and our age-standardised suicide rate has increased by 13 per cent over the past decade.

One way to read the Productivity Commission’s report is to treat it as a comprehensive record of the mental health system’s failure to fix policy and service-delivery flaws we’ve known about for decades.

Twenty-seven years after the release of the Burdekin report on the human rights of people suffering mental illness, hospitals and correctional facilities are still routinely discharging people with mental illness into homelessness.

Twenty years after the publication of the first National Suicide Prevention Strategy, half of all people discharged from a hospital after a suicide attempt don’t receive any follow-up.

Fourteen years after a Senate inquiry into a national approach to mental health found that “services have failed to meet the standards Australians should now, after many years of inquiry and reform, be able to expect,” mental health consumers still describe their experience of seeking treatment in hospitals as inefficient, traumatising, inadequate, stigmatising and distressing.

Key areas

If this latest report somehow defied the odds, we would all be better off. Its conceptualisation of the problems and its recommendations would dramatically improve how mental healthcare is provided across Australia. Its main focuses are worth highlighting:

Robust economic modelling: The report applies a sharp economic lens to mental health. Expenditure of $4.2 billion per year, it concludes, would deliver an annual $18 billion in benefits, mainly from improvements in people’s quality of life, plus a further $1.3 billion each year from increased economic participation and productivity.

Prevention: While prevention is not the report’s focus, the Productivity Commission goes as far as it can within its terms of reference to stress the need for more and better preventive health measures, including actions to reduce trauma in early childhood and tackle workplace stress and bullying.

A broader approach: The need to work across portfolios — including within the justice system, policing, housing, education and income support — is a key thrust of the report.

Shared responsibility: Another strong theme is the importance of distributing responsibility for mental health across the government and non-government sectors, with key roles for workplaces, educational institutions and the business community.

Aboriginal and Torres Strait Islander people: The recognition of the mental health impacts of racism and the emphasis on cultural competence across the mental health sector is a strength of the report. It supports the role of peer workers and makes clear that Aboriginal and Torres Strait Islander people should lead the development and implementation of an Indigenous-specific suicide prevention strategy. It also calls for an implementation plan for the National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing 2017–2023, which “was endorsed by the Australian Health Ministers’ Advisory Council and is highly regarded by both Indigenous and non-Indigenous peak bodies.”

Increased consumer focus: All mental health inquiries pay lip service to the importance of consumers and carers, but this report takes a more nuanced approach, recognising the complexity and diversity of these groups and the many ways they can engage with mental health policies, programs and services. It suggests tangible engagement strategies like co-design and co-production and recommends the funding of new national mental health consumer and carer peak bodies.

Technology: New modes for delivering mental healthcare are highlighted as a way of meeting increased demand for treatment by reducing the need for expensive face-to-face services.

Structural changes

The report also recommends structural changes across the system in two areas: accountability and governance. A lack of accountability was the major governance issue raised by participants in the consultation process, it says. The current mechanisms for holding jurisdictions accountable for mental health outcomes are “weak and poorly developed,” with poor integration of consumers and carers, and the absence of a “culture that requires demonstration of program impact and evaluation.”

In discussing the need for better evaluation, the report questions the value of big-spending mental health programs like the recently expanded MBS-funded Better Access program and the youth-targeted Headspace centres.

It also questions the consistency of GPs’ performance in providing mental healthcare. Some GPs do an excellent job, it says, but too many lack knowledge and skills in mental health, and rely too readily on medication as a treatment option. GPs need more competency in “identifying risks, diagnosing conditions, assessing and recognising the physical health consequences of prescribed treatments, and connecting people with other services (including online mental health services, allied health services and non-clinical services such as counsellors).” A “rigorous” evaluation of the Better Access program is “urgently needed.”

In relation to Headspace, the report finds a mismatch between the needs of consumers and the services provided by these centres. “About half of young people presenting at Headspace centres have either mild, moderate or no symptoms of mental ill health,” it says, “and about half have low or moderate distress — indicating that low-intensity services may well be suitable for a many of these young people.” But “among young people with mental ill health who received an assessment, four out of five went on to receive individual therapy (which is not a low-intensity service).”

To improve the performance of mental health programs and policies across the board, the report argues for a “culture of evaluation.” It recommends that the National Mental Health Commission should drive the dissemination of this culture, on the basis that it already has a mandate to work across all areas with an impact on mental health and that the cost of expanding its role would be lower than establishing a new body. To strengthen the independence of the NMHC, the report recommends making it a statutory authority.

In relation to governance, the report argues that “the scale and complexity of many mental health policy issues has thus far exceeded the design of national committee structures.” Distortionary and unclear funding arrangements are undermining the efficient use of resources and causing an overreliance on Medicare-funded and hospital-based services.

As well as recommending a new whole-of-government National Mental Health Strategy, the report recommends that federal, state and territory governments establish a Special Purpose Mental Health Council to facilitate mental health reforms across health and non-health portfolios. It suggests several strategies to improve cooperation between Primary Health Networks and Local Hospital Networks, including a requirement for comprehensive joint regional planning and formalised consumer and carer involvement, to be overseen by the NMHC. If that doesn’t work, the report recommends a more radical approach involving new Regional Commissioning Authorities to pool and administer the networks’ mental health funds.

As I said, these are all excellent ideas. But the question remains: does the current government have the appetite for what are major structural changes?

Based on previous form, it is unlikely that Scott Morrison and his colleagues will take on the report’s bolder cross-sectoral recommendations.

As Nicole MacKee points out in Croakey, recent government actions — including the $1.2 billion settlement of the robodebt case and the vote by Australia’s attorneys-general for the age of criminal responsibility to remain at ten, despite a 2019 United Nations Committee on the Rights of the Child recommendation of fourteen — demonstrate a lack of commitment to recognising the mental health effects of decisions made in other portfolios.

Break the cycle

But the Government might be willing to consider some of the more narrowly focused recommendations, and even to allocate significant funding if it is confident of success, both practically and politically.

The Prime Minister has committed to responding to the report in next year’s pre-election budget. With big spending measures needed to drag Australia out of a COVID-induced recession, some serious mental health funding could be on the agenda. But there is also a risk that this opportunity will be wasted and the fruitless cycle of failed reform attempts will continue.

It’s easy to point the finger solely at governments, and of course successive governments at all levels could and should have done more. But the mental health sector, particularly the providers of mental healthcare, also bears some responsibility for the repeated failures in this area. It’s hard for any government, no matter how committed, to make progress in a policy area in which the stakeholders are divided, disorganised and antagonistic and put their own interests above those of the sector as a whole.

This report and next year’s budget provide the best chance for decades to break the cycle.

With budget priorities for 2021–22 likely to be locked in around March next year, the sector has only three months to take advantage of the opportunity. Only if it comes together to agree on key priority areas, acknowledges the limitations of current programs and services, stops the in-fighting (or at least keeps it behind closed doors), and gives government a realistic plan for reform (and commits to backing it if the budget delivers most of the plan) is there a genuine chance to achieve generational change in mental health.

If not, then the Government’s only realistic option will be to make a tokenistic response to the report, set up another body with inadequate funding and insufficient support, and hunker down until a new health minister starts the doomed mental health reform cycle again.

Also see this Twitter thread by Jennifer Doggett, who is a Croakey editor and health policy analyst

This article was first published at Inside Story

Also at Croakey

Productivity Commission charts familiar course for mental health

Landmark mental health report urges reform. But we need more than Band-Aids

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Croakey Conference News Service 2013 – 2019
2013 conferences
Australian Centre for Health Services Innovation Forum 2013
Australian Health Promotion Association Conference 2013
Closing the Credibility Gap 2013
CRANAplus Conference 2013
FASD Conference 2013
Health Workforce Australia 2013
International Health Literacy Network Conference 2013
NACCHO Summit 2013
National Rural Health Conference 2013
Oceania EcoHealth Symposium 2013
PHAA conference 2013
2014 conferences
#IPCHIV14
AIDA Conference 2014
Congress Lowitja 2014
CRANAplus conference 2014
Cultural Solutions - Healing Foundation forum 2014
Lowitja Institute Continuous Quality Improvement conference 2014
National Suicide Prevention Conference 2014
Racism and children/youth health symposium 2014
Rural & Remote Health Scientific Symposium 2014