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What will it cost to move beyond “60 years of band-aids” for mental health?

Continuing the theme of recent Croakey posts on mental heath and the federal budget, John Mendoza argues that it’s well past time we moved past band-aid solutions. Instead, Australia needs to spend about $9-10 billion per annum on mental health services, or around 12% of current health care spending, he says.

John Mendoza writes:

In the past week there has been another round of calls from a variety of groups for major investments in mental health. These have in part being timed to influence the framing of the May Federal Budget. These have included calls for an extra $5 billion over five years from the Australian Medical Association and others.

A Blueprint to Transform Mental Health Services was also released and called for an investment of $3.5 billion over the same period. This came from an “independent mental health reform group” lead by Professors Pat McGorry and Ian Hickie and Monsignor David Cappo.

The latter are all members of the expert advisory group announced by Minister for Mental Health and Ageing, Mark Butler and the Prime Minister late in 2010 after a year of mounting calls for action on mental health. Minister Butler chairs both this group and the National Advisory Council on Mental Health.

Federal Labor knows that it must deliver a substantial boost to mental health funding come the May Budget after the chorus of criticism in 2010 and its oft stated pledges to make “mental health a second term priority”.

The “Blueprint” document released by McGorry and co has been largely positively received. Some criticisms – including the Croakey piece from Alan Rosen – from within the mental health sector have focused on the government’s piecemeal and confused approach to consultation (not the fault of the Blueprint authors I would have thought).

Rosen’s criticisms point to the omission of some evidence-based services including assertive community treatment teams, better forensic mental health care for the vast numbers of people with mental illness in corrections systems and the inadequate size of the investment.

Criticisms were also voiced by consumers at the ACOSS conference last week on the failure to advocate for the re-establishment of a national consumer representative body following defunding of the body by the Department of Health and Ageing in 2008.

In their defense, McGorry and colleagues say the 30 initiatives in the Blueprint are areas where the Commonwealth can act with or without state government cooperation and with a large dose of realism given the “tight Budget” rhetoric of the Government. They also believe that if the Commonwealth can get its act together, as it did under the leadership of Howard in 2006, then a commensurate investment could be forthcoming from the states and territories.

This would be a massive $7 billion over five years building on the $5 billion flowing from the 2006 COAG action plan.

The Australian public are entitled I would have thought for someone to tell them what amount of new funding is required to fix the seemingly contiguous crisis in mental health services.

Firstly, it’s important to understand no presently serving politician in either Federal or state governments created the shambles we now see in mental health in Australia. But all those First Ministers (i.e. PM, Premiers and Chief Ministers) and the respective state and territory Ministers have an opportunity to join a very small group of politicians who have taken bold and effective action in this area. To succeed, they will need to respect history in mental health reform efforts.

Australia has had a long history of responding to crises within mental health services. Indeed Prime Minister Menzies was forced to act following widespread and continuous public concern about the state of services in 1954. Somewhat reluctantly, Menzies and his Health Minister, Earle Page, appointed a Melbourne psychiatrist Allan Stoller, to review mental health care. Stoller was “shocked” by what he found – inhuman conditions, overcrowding, little or no therapeutic care, abuse and neglect. Menzies responded with a capital grants program to modernize the facilities. While some work was done, within six years, again public concerns forced the NSW Government to set up a Royal Commission into mental health services.

This cycle of crisis, review, government action and then within a decade another full cycle, has now characterized mental health reform in this country for close to 60 years.

There are a number of reasons for this, but a consistent one has been a failure by both state and Federal governments to ever undertake a systematic assessment of service requirements. No one has even taken up the challenge to fully scope requirements: the range of services based on available evidence, the scale of services to meet demands and then commit the funds to the development.

The consequence is that we have had 60 years of bandaids applied to mental health. We see dozens of excellent programs or small scale programs all round the country that have never been scaled up or linked with a spectrum of care to support recovery in the community.

The implementation of the policy of deinstitutionalisation from the 1960s to the so-called community based services of today, represents arguably the greatest failure of public policy in the post-war period.

The calls in the last week for major new investments in mental health, while they will improve the access to services and quality of some services, they will fall far short of providing people with mental illness with equality of care when compared with those experiencing physical health problems.

Both Pat McGorry and colleagues and the AMA have presented pragmatic proposals – proposals that take account of the political context. That’s fair enough, but it runs the risk that again we have another band aid – albeit maybe a full size plaster!

The question remains how much do we need to invest in mental health to end this terrible history of neglect? The Senate in 2006 argued that between 9-12% of health expenditure was required. The Mental Health Council of Australia has long argued for the 12% figure. Rosen is his Croakey article refers to 13% of health spending up from the current 7%. All of these are simply sound estimates.

Two health economists, Darrell Doessel and Ruth Williams have attempted to take a more analytical approach and they find that current resources and structures meet about 35% of the mental health needs of the community. They also find that significant resources go to those without a mental health need – in essence a wasteful use of scarce resources. Using their analysis and assuming one could significantly reduce the resources going to ‘non-needs’ as they define them, the funding required to provide for the mental health needs of the Australian community is in the order of $9-10 billion per annum. Maybe coincidentally, this is close to the 12% of current health care spending that many have called for and is almost double the current combined spending of all Australian governments.

This is an enormous challenge and one which will only be solved through a more strategic and sustained 10-15 year reform agenda. We also need to put in place as a first step, an appropriately empowered Commonwealth statutory authority to drive the restructuring of services and report to the Australian community on the progress and the outcomes from this investment.

• John Mendoza is Director, ConNetica , and Adjunct Professor, Health Science, University of the Sunshine Coast, and Adjunct Associate Professor, Medicine, University of Sydney

Comments 9

  1. Shooba says:

    I don’t want to hijack the conversation here, because I think “what portion of the budget should go to health” is a conversation worth having… but… surely bowel cancer screening is priority one? Croakey’s fixation on mental health and physician assistants recently has kind of duopolised discussion at the expense of topics like the FOB test and its glaring need for a full national program

  2. Shooba says:

    Awww shucks Croakey… you DO listen! 🙂

  3. Melissa Sweet says:

    Shooba, I was just about to comment and say: your wish is my command (well, at least sometimes).
    But you got in first…

  4. tamhss says:

    This is not a competition as to which illness is more deserving of funding – bowel cancer or mental illness. People living with mental health problems are deservedly receiving attention at long last. John Mendoza’s article and previous articles are very timely. The Blueprint is very timely – it aims to be transformative asking for real (though not enough) amounts of money for improving and enhancing Australia’s mental health services. The authors state: “the Blueprint does not make specific recommendations regarding other key services which are currently within state/territory jurisdiction, such as community mental health services, judicial and police services etc” as these are do not come under the Commonwealth jurisdiction. This perpetuates our existing, major, ongoing problems in this country. As John Mendoza has said, this is just another band-aid solution to the problem of providing integrated, comprehensive, innovative and collaborative mental health services in Australia. We must have a national approach that doesn’t set up a parallel system as happened under the Howard government. States and Territories must work with the Commonwealth towards a national system which therefore will include community mental health services and inpatient services and all other state/territory funded mental health services.

  5. Douglas and Milko says:

    John Mendoza, in case you read this post, I am concerned at how every article of yours I read seems to wax lyrical about the efforts of the Liberal party, and how much they have done for mental health over the years. Maybe I have been unlucky, but my father was floridly bipolar during the 1970s. It just about sent our family broke, as even in the early 1970s, admissions to mental health facilities were covered by neither private health insurance (which we did have) or any sort of government scheme.

    I now find that my son has the family illness, and nobody wants to know us, and that includes the Headspace centres that you are so supportive of. They seem to think that unless you are sane enough to know you need help, that you are not worth bothering with. Very hard when your son is psychotic, and you know he needs to go the Headspace, but he believes he is about to make a billion on his recording contract, and can’t understand what you are going on about. Even harder when the Headspace psychologist says, “he needs to do it for himself, he needs to get here, you should not help him, you are just enabling him”. So, taking the professionals advice, I do not help. All contact is lost with Headspace.

    Please forgive me for being cynical, but after trying Headspace, spending several millions on this program will not get us anywhere. Headspace is no more interested in genuinely psychotic people than any other program I have come across in trying to save my son’s life during this life-threatening illness.

    John Mendoza, if you are genuinely interested in helping the psychiatrically ill and saving their lives, perhaps you can start with my son. My email address is maria.cunningham@unsw.edu.au, and I would really like to hear, personally from you, why I have misunderstood what is going on around me, and just how your plans for Headspace will help people like my son, whose life currently hand on a thread.

    Also, re-reading this post. the “you wax lyrical about the efforts of the liberal party” needs explanation. From my perspective, we have only had help and empathy about getting or son into work programs, and getting some help with his very expensive medication, after the november 2007 election, when the Federal Government changed.

    So, John Mendoza, am I doing something wrong, or do you really believe that once people are too psychotic to engage with mental health professionals, that they are not worth bothering about?

  6. I have to agree with tamhss here- it not a competition for which illness is more deserving but the whole issue is that there is a vast inequality in the provision of services and funding that mental health receives compared to physical health.

    When we are talking about mental health I don’t think you can compare a particular disease with the whole spectrum that mental health covers. Better to compare mental health with physical health (every single disease and illness) and on that scale a few blogs hardly constitute a fixation. They are but a drop in the ocean of the discussion that would need to be had to even bring it on a par with the discussion that happens on physical health.

    I was very happy to come across Croakey and see that it was giving some attention to mental health- please keep it going

  7. John Mendoza says:

    Just a couple of comments on the comments.

    1) Funding for bowel cancer screening is a no brainer. the evidence is compelling and it shows how health policy has so little to do with evidence.

    2) “Waxing lyical” about Liberal Governments – on the contrary, this article like others makes it clear there have been inadequate responses for 6 decades. I have also consistently stated, that is 2006 Morris Iemma (Labor) and John Howard (Liberal) provided national political leadership and an acknowledgement that the COAG 2006 agreement was the first step to rectifying the wrongs. Regrettably, the Rudd-Gillard Governments have not taken the ‘second step” – as yet. They know they need to. There are over a hundred Parliamentarians in Canberra, on all sides of politics including all the current Independents, genuinely concerned about this issue and endeavouring to make a difference.

    3) I have voiced concerns on Crikey (just last month) about the dumbing down of the headspace model, the inadequate funding for the 60 proposed sites and the lack of transparency and accountability with the way headspace is now operating. I challenged the CEO, Chris Tanti, to release the evaluation and the data on numbers of clients now paying out-of-pocket expenses. Unfortunately there was been no response even though Chris accused me of inaccurancies in my statements about headspace.

    4) I am happy to be judged on my personal commitment to this issue.

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