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Urgently needed: health equity responders to Productivity Commission on mental health

The Productivity Commission’s draft report on mental health stretches to 1,238 pages and two volumes. It is wide-ranging – making recommendations beyond the health system, including for housing, policing, workplaces, prisons, workers compensation and schools – as well as detailed assessments of the evidence base for particular programs, from social prescribing to Justice Reinvestment.

It represents an enormous body of work, with 80 draft recommendations informed by more than 550 submissions, 300-plus meetings, and consultations in all states and territories, including visits to regional areas. The inquiry has also received 185 brief comments from individuals and organisations.

While the Commissioners acknowledge that they are treading a well-worn path, they claim their report is different to the many reviews, reports and inquiries that have gone before because they consider in detail how reforms outside of healthcare can improve mental health.

And yet…

Despite its terms of reference giving clear permission to examine how sectors beyond health can contribute to improved population mental health, the draft report has not seized this opportunity as fully as it might.

It does make some related recommendations, including calling for a new whole-of-government National Mental Health Strategy that aligns collective efforts of health and non-health sectors to improve mental health outcomes.

Mind the gaps

But there are so many glaring gaps in the analysis and recommendations, with no mention of the climate crisis despite the obvious implications for mental health (as recognised by groups such as the Royal Australian and New Zealand College of Psychiatrists and the Australian Psychological Society), and no explicit proposals for addressing poverty or other forms of structural disadvantage that are recognised in the report as important for mental health.

Even when the report grapples with issues such as homelessness, racism and determinants of poverty, such as the low rate of Newstart allowance, it fails to grasp the nettle and respond with commensurate recommendations.

The report makes clear the impact of housing unavailability, both upon peoples’ lives and on acute care systems that end up as defacto accommodation, citing evidence that roughly 30 percent of mental health inpatients could be discharged if appropriate clinical and accommodation services were available (this translates to about 2,000 people in hospital beds when less intensive care is more appropriate).

However, it says fixing the “broken” social housing system is beyond the scope of inquiry. Nor does it address wider housing concerns affecting the community’s health and wellbeing.

The bigger context (perhaps better described as the interconnected upstream determinants) is often missing. For example, when discussing schools as a site for mental health intervention, the report fails to grapple with systemic inequalities that mean some schools will be far better placed to respond to the recommendations than those whose children are most likely to be in need.

Likewise, when considering the role of employment and workplaces, where is the all-important context about the changing and increasingly insecure nature of work and the mental health issues associated with the urgent need for rapid transitioning to a low carbon economy?

Beyond scope?

Perhaps the Commission simply saw the task as too big, as suggested by this observation: “addressing the social determinants of mental illness —such as inequality and entrenched disadvantage —requires a very large scale government response, far beyond the scope of any one provider or organisation within the mental health system”.

If this had been a Productivity Commission inquiry into Health Equity, perhaps we would have ended up with a bigger picture vision and a more useful plan for influencing some of the upstream determinants of mental health and wellbeing.

While the report does suggest some significant system reforms, such as a move towards regional pooled funding for mental health, there is always a risk when considering such big changes to one part of the system in isolation.

Perhaps an optimist might see this as an opportunity for re-invigorating wider discussions about regional funds holding; a pessimist might see the potential for big changes focused on mental health to undermine efforts to better integrate physical and mental healthcare.

However, the good news is that this is a draft report and the Commission clearly is hoping for extensive feedback – holding more public hearings, and accepting written submissions until 23 January 2020.

This article aims to give Croakey readers a brief overview of key recommendations, and to identify some areas of opportunity for readers interested in making further submissions.

See a more detailed account of the report in this 58-page compilation of a tweet-a-thon by Marie McInerney and I last week, tweeting as we read the report.

Overview of key issues and recommendations

The Commission said overarching themes raised in consultations included:

  • under-investment in prevention, early intervention
  • difficulty of finding/accessing suitable support
  • focus on clinical services often overlooks other determinants of mental health
  • the support people do receive is often well below best practice, sometimes causing harm
  • stigma and discrimination
  • fragmented responsibilities and funding, and
  • limited accountability mechanisms, such as public reporting.

The three key principles guiding the Commission’s draft recommendations:

  1. The mental health system should be people-oriented, putting the consumer, carers, their family, and their kinship group at the centre. This involves meaningful use of co-design, culturally responsive care and understanding of the importance of lived experience.
  2. The mental health system should prioritise prevention and early intervention. Prevention of mental illness involves schools, workplaces, communities, homelessness services and prisons.
  3. The mental health care system should be adequately funded to eliminate service gaps; services should make efficient, effective use of taxpayer funds. Governance and funding structures should enable people-oriented systems, rather than being supplier-centric.

The Commission puts forward two options for structural reform, making it clear that it prefers the second, more transformational option:

  1. The Renovate model, largely a continuation of the current approach, with some changes that would give more flexibility to PHNs by relaxing centrally imposed restrictions on their funding pools
  2. The Rebuild model would have most mental health funding held in regional funding pools controlled by each State and Territory Government and administered by Regional Commissioning Authorities (RCAs). RCAs would aim to create a seamless mental healthcare system with continuity of service, and to address duplication and gaps that would otherwise persist at the interface between Federal, State and Territory Govt responsibilities. The Commission envisages RCAs as be best located with State/Territory governments due to their hands-on role in health, housing, education & justice.

Points of interest

The Commission says the Government should relax requirements for Primary Health Networks (PHNs) to direct funds to headspace centres (which aligns with its push towards regional decision making), and also calls for reform and rigorous evaluation of the Better Access program.

The COAG Health Council should agree on a set of targets that specify key mental health and suicide prevention outcomes that Australia should achieve over a defined period of time. Targets should be developed in consultation with consumers and carers.

The National Mental Health Commission should be made an interjurisdictional statutory body, and charged with systematically evaluating mental health and suicide prevention programs, and driving a long term stigma reduction strategy. The Commission also stresses the importance of ensuring the NMHC’s independence, so it is not beholden to the Department or Ministers in reporting evaluations of programs.

The Government should strengthen systemic advocacy by providing more support for mental health advocacy groups and extending funding cycle length for peak bodies to at least five years.

The Government should resource and expedite the development of an implementation plan for the National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing 2017–2023. The Commission notes: “There is little benefit in not implementing a strategy that Aboriginal and Torres Strait Islander peoples regard highly and that the Australian Health Ministers’ Advisory Council has endorsed.”

Tweets by The Centre of Best Practice in Aboriginal and Torres Strait Islander Suicide Prevention

The report explores the impact of out-of-pocket costs in some depth, estimating that 44 percent of Australians with mental ill-health stated that they skipped healthcare treatment as a result of these.

It backs expansion of online treatment for mild to moderate symptoms, and says the Federal Government should instigate an information campaign to increase awareness of the effectiveness, quality and safety of government-funded clinician-supported online therapy for treatment of mental ill-health for consumers and health professionals.

The Commission seems impressed by impact of care navigation platforms such as HealthPathways, and recommends expanding their use to beyond health – to schools, maternal/child health nurses, tertiary institution counselling services, Centrelink social workers, and public housing tenancy managers.

The report also recommends the Government fund a national clinical trial network in mental health and suicide prevention, and that Federal, State and Territory Governments should actively address barriers to implementing service provider public reporting and benchmarking.

“The Commission has concluded that national benchmarking and public monitoring and reporting at the service provider level would improve service quality and outcomes for consumers and carers,” the report says.

It identifies a stack of data gaps, and says: “A lack of outcomes data, particularly for MBS-rebated mental health services was a key issue raised by consumers, peak bodies and service providers”.

The report includes considerable discussion of workforce issues, making it clear that the mental health workforce extends beyond health system to include police, lawyers, librarians and teachers.

However, it doesn’t address issues such as cultural safety in these workforces or the wider implications of increasing police involvement, especially for the wellbeing of Aboriginal and Torres Strait Islander people.

(from p. 604)

For the health workforce, it recommends “shifting to a more efficient allocation of skills” which would mean “more people can be treated within the resources available to the community” (ie, bigger roles for nurses and cognitive behaviour therapy coaches).

It considers a range of mental health nursing workforce issues in detail, and says the benefits of adding a specialist Mental Health Nursing category to nursing registration are very likely to outweigh the costs, and there’s “a strong case for introducing a 3-year specialist degree in mental health nursing and recognising this as one of the pathways to being registered as a specialist MHN”. Meanwhile, it notes that the Government has not released the final report of a broader review of nursing education led by Emeritus Professor Steven Schwartz.

The report makes several recommendations to strengthen the peer workforce, and raises the possibility of governments providing seed funding for a professional organisation to represent peer workers.

It recommends improved mental health training for doctors, noting the Commission heard many cases of  “GPs not assisting their patients as well as they could to manage the side effects of mental health medications”.

The Commission wants to see more psychiatrists but “has not seen convincing evidence of a pressing need to significantly increase the supply of psychologists, especially compared with mental health nurses and psychiatrists”. However, the Commission does not appear to address the issue of whether more Aboriginal and Torres Strait Islander psychologists are needed.

On justice-related issues, the Commission says the Australian Commission on Safety and Quality in Health Care should review the National Safety and Quality Health Service Standards to ensure that they apply to mental health service provision in correctional facilities.

State and Territory Governments should ensure Aboriginal and Torres Strait Islander people in correctional facilities have access to mental health supports and services that are culturally appropriate, and designed, developed and delivered by Aboriginal and Torres Strait Islander organisations where possible.

As well, State and Territory Governments should work with Aboriginal and Torres Strait Islander organisations to ensure Aboriginal and Torres Strait Islander people with mental illness are connected to culturally appropriate mental healthcare in the community upon release from correctional facilities.

Opportunities for advocacy

The draft report presents health equity advocates with some clear opportunities for suggestions for the final report, including:

1. Tackle racism

The report cites a range of evidence on the harmful impacts of racism, especially for Aboriginal and Torres Strait Islander people, but makes no specific recommendations for addressing this critical determinant of mental health and wellbeing, or for embedding cultural safety across the various workforces and workplaces (referring largely to ‘culturally appropriate’ or ‘culturally capable’, which are quite different concepts).

The report also cites an Australian Law Reform Commission finding that discrimination and racism are among the drivers of incarceration of Aboriginal and Torres Strait Islander people. Tackling racism and reducing police involvement and incarceration are key areas for further recommendations.

2. Address poverty and wider inequalities

The report does acknowledge the importance of poverty as a determinant of health:

700,000 people in Australia have been in income poverty for at least the past four years. Unemployed people, those with disability and Aboriginal and Torres Strait Islander people are at higher risk of income poverty and deprivation.

People experiencing financial stressors, such as low income or poverty, and/or compromised financial security, such as being unemployed or having excessive debt, are at increased risk of developing a mental illness.

Data shows that people living in the most relatively disadvantaged areas of Australia reported significantly higher levels of psychological distress and mental illness than those living in the least disadvantaged areas.”

For health equity advocates wanting to shape some related recommendations for the final report, the Croakey archives have some leads, eg:
To reduce suicides, boost social payments and supports
Global health expert calls for an end to punitive controlling policies
Calls to boost Newstart and address health inequalities.

Also, read the Central Australian Aboriginal Congress submission to the Senate inquiry into Newstart.

3. Address the climate crisis

With health authorities from the World Health Organization to the Australian Medical Association sounding the alarm on the climate crisis, let us have no more health reports or inquiries that do not address this public health emergency.

If the Productivity Commission’s final report does not address the climate crisis, from its consequences for the community’s mental health and wellbeing, to its impact on health and social services, and its implications for all the wider determinants of health (including the economy, employment and social cohesion), then the report deserves a big F.

4. Government policies contributing to ill-health

The final report should squarely address the mental health toll that arises directly from government policies, such as Centrelink’s automated debt recovery system, the ParentsNext program and soaring rates of removal of Aboriginal and Torres Strait Islander children.

At the very least, the findings should be laid out so clearly that governments can no longer get away with suggesting that the country’s mental health would be so much better if only we stopped holding ourselves back from seeking help (as Health Minister Greg Hunt did yesterday on ABC TV’s The Insiders).

Governments need to be held to account for their contributions towards mental ill-health.

5. Other paradigms

The Commission’s terms of reference are embedded in the current economic paradigm: “an inquiry into the role of improving mental health to support economic participation and enhancing productivity and economic growth”.

But many public health thinkers – from Kate Raworth and her Doughnut Economics, to Professor Fran Baum’s Governing for Health and Professor Sharon Friel’s call to address consumptagenic drivers of poor health – are questioning the capacity of current economic systems to sustain health and wellbeing.

Perhaps the Productivity Commission could be persuaded to at least interrogate some of these other paradigms.

And, finally

In its draft report, the Commission states:

…there is no clear national vision for mental health.

Although the National Mental Health Policy declares it ‘provides a strategic vision for further whole-of-government mental health reform’, there is little evidence its development involved collaboration with non-health portfolios.”

If those with a concern for health equity respond to the draft report, and the Commission takes on board their feedback, then there is hope of developing a true national vision for mental health and wellbeing.

Whether the Government will have the will to enact is another matter altogether. And so the need for health equity advocacy will continue…

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