Tomorrow night (Tuesday, June 22), I have the opportunity to grill the Australian of the Year, Professor Pat McGorry, at an Australian Institute of Health and Welfare function.
I recently put out a call to regular Croakey contributors to ask for their suggestions about what I should ask. Their responses follow below.
But I’m also keen to hear from Croakey readers. What would you like asked? Please speak up asap…
And, while I’m busy picking your collective brains, two more questions. I will also be giving a talk to the AIHW function around the themes of equity and transparency.
I’d also like to hear your thoughts on what are the most glaring examples of inequity in health and the health system more broadly; and what are some concrete examples of where you’d like greater transparency from the health sector?
Meanwhile, here are some of the questions for Pat McGorry (I hope to report back on his answers later in the week).
Professor Philip Davies, Professor of Health Systems and Policy, University of Queensland:
Q: Two of the things we do really badly in health are mental health and Indigenous health. What they have in common is that progress relies on whole of government action. They will not be fixed simply by more money for health or medical services. What they need is coordinated and concerted action from health, housing, and employment and other areas of government – both State and Commonwealth. How can we get effective across-government action in mental health?
***
Ms Carol Bennett, Executive Director, Consumers Health Forum of Australia:
Q: It seems the government make the right noises on mental health but does not deliver. Â Is this because it is too hard, or the ask is too big, or because it is seen as an area that has been addressed a few years ago with the COAG Action Plan on Mental Health, or because State and Territories are not willing to come to the national mental health ball game?
***
Professor Alex Wodak, drug and alcohol physician
Q: Would Australia be better off investing more resources into the small minority of the mentally ill with very severe problems or the very large majority of the mentally ill with much less severe problems [don’t allow him to say both need more]
Q: The physical health of Australians is petty good by international standards – life expectancy, infant mortality, maternal mortality etc – how about mental illness?
Q: Given that so many mentally ill Australians also have an alcohol and drug problem and that so many people with an alcohol and drug problem are also mentally ill, could we also improve the mental health of Australians by improving alcohol and drug treatment? And if yes, how would we do that?
Q: What are the main things we should be doing to prevent mental illness?
Q: Prisons are wharehouses for mental illness, Aboriginal Australians and people with severe alcohol and drug problems. What can be done to reduce the number of Australians behind bars? What can be done to improve the mental health of Australians behind bars? Do we need to reform our drug laws so that we don’t have so many drug dependent people behind bars?
***
Professor Stephen Leeder, Menzies Centre for Health Policy, University of Sydney:
Q: You might ask him why psychiatrists are now seeing fewer patients and why they have given up bulk billing in any form. Have they become just money grabbers treating the vaguely ill and having long holidays?
***
Professor Lesley Barclay, Northern Rivers University Department of Rural Health:
Q: How can health professionals work to improve the transparency and equity of a health system that still appears to be built on too much privilege and political positioning rather than need? This is really pertinent to mental health services which have also been underfunded greatly as we ‘normalised’ mental illness, making this a community, primary health care-based concern.
***
Professor Simon Willcock, GP and University of Sydney academic:
Q: Young Australians (Gen Y if you like) are often criticised for being self interested and for not sticking to a job or task. Yet these criticisms are usually made by baby boomers who have all the assets (including the real estate and the superannuation investments) who seem reluctant to share their bounty with Gen Y, who have been described as the first generation who may never be as wealthy as their parents or own their own home. Is it time to challenge current concepts about young people and to start challenging the baby boomers about their need to control everything?
***
Anonymous
Q: Our son, now almost 30 years old and in good health, had about three years of severe mental illness in his adolescence – on several occasions close to suicide. We were impressed by:
• The five-day week, 9 – 5 attitude among private sector psychologists, psychiatrists, neurologists. The people who stood out in strong contrast were the public sector mental health crisis teams – there around the clock. The private sector people saw him by appointment, which, almost by definition, was not when he was demonstrating psychotic behaviour – almost useless.
• The lack of integration of records between different professions and different individuals, at times leading to conflicting possible therapies.
• The lack of data capture. Our son, fortunately, had a quick and unexplained recovery. There could be several causal factors, but apart from some anecdotal guesswork, no one will ever know why.  Maybe his progressive easing off drugs and eventually going cold turkey, maybe a change of social surroundings that occurred at the same time, perhaps even a change in diet. Data capture and consolidation for research may reveal some patterns, and save many lives (and dollars). But everyone concerned had no interest – just relief at another case off their hands. And even if they were interested, there was no database to which they could contribute.
***
Professor Glenn Salkeld, Sydney School of Public Health, University of Sydney:
Q: Where do kids (and their families) with mental illness find hope?
***
Professor Gavin Mooney, health economist:
Q: Why does the AMA seem so uninterested in mental health?
Q: I did a questionnaire survey of participants at a mental health conference in Perth. One question asked: if one more person could be recruited to the mental health team you are most familiar with, from which discipline would that be? The least votes went to psychiatrists. How do we change the dominance of the ‘medical model’ in mental health?
***
Prue Power, Australian Healthcare and Hospitals Association:
Q: What are the most important strategies we should be implementing to reduce preventable presentations to public hospitals for mental health conditions?
***
Barbara Hocking, Sane Australia
Q: What community-based services would he like to see for people who become too old for the Orygen/Headspace program and who, in spite of the program, still struggle with a mental illness?
Q: How does Pat address the criticism that there is lack of evidence of any demonstrable longer term benefits from early intervention in psychotic patients?
***
John Menadue, health policy expert
Q: How is it possible to reduce the dependence of the media on hand-outs and briefings by special interests/providers. Do you think that the Australian community has a quite unrealistic expectation of what health services can provide?. Are there effective lobbyists for mental health and who are they?
***
Associate Professor Gawaine Powell Davies, UNSW Research Centre for Primary Health Care and Equity:
Q: How can we get health reform to go beyond reform of the system to reform of health care?
Q: What would the health system look like if we had a more accepting approach to the inevitability of ill health and death?
Q: How can the medical profession become a stronger force for social progress?
***
Liz Harris, Centre for Primary Health Care and Equity, UNSW:
Q: What are the values and beliefs of Australian society that you feel work against greater investment in early intervention programs and services for young people?
Q: How can we inspire young people to want to work in this area? How do we provide them with the working conditions and support that will protect their own mental wellbeing?
***
Associate Professor Nicholas Wilcken, cancer specialist, Sydney:
Q: Can he make a philosophical/semiotic connection between our obsession with sport and our treatment of people arriving in leaky boats?
***
Update, 22 June. Some more questions have landed:
Professor Judith Dwyer, Flinders University:
Q: How can parents and other carers of young people with mental illnesses be better incorporated in the care team for their children, while still recognising the rights of the young person?
***
Professor Ian Olver, Cancer Council Australia:
Q: The main question is how to raise the Government’s interest in mental health initiatives.
***
Dr Tim Woodruff, Doctors Reform Society:
Q: Given that  a huge burden of mental illness is dealt with by GPs in daily practice often dealing with comorbidities, is the push for separate mental health funding the best way to go or would it be better to have proper funding especially at the primary care level, on the basis of need which would inevitably require addressing mental health funding requirements. Ie isn’t separate funding just a second best way of getting mental health recognised with the potential to create other silos of health care rather than an integrated system?
***
Dr Ruth Armstrong, medical editor:
“I’d like to know how much he thinks the field of mental health can contribute to the wider concept of preventive health. It seems to me that mental wellness if going to be an essential element in motivating people to look after all aspects of their health.”
There seems to be very little happening by way of supporting young males to develop coping strategies and that inner-strength referred to as ‘resilience’. Once they leave school, many are also directionless in terms of finding something meaningful, or even enjoyable, in life. It seems disturbingly common for adolescent and young adult males to resort to physical and/or verbal abuse when faced with challenges and disappointments, rather than learning how to accept life’s setbacks and working out more constructive ways forward. What approaches do you believe should be implemented to better support young males, especially given that what I have described is not generally acknowledged as a problem by the young males themselves?
Does he feel there is a danger of ‘over medicalisation’ of youth mental illness within current treatment models in Australia, and if so how should we be changing services and healthcare access to avoid it. (Perhaps this is better asked as ‘Does he feel the present medical model for treatment of illness is suitable for treatment, especially early intervention, for youth mental health?)
As for inequity, my bugbear is the inequity between the physical health of people with severe mental illness, and those without. Specifically the inequity in healthcare access, referral and treatment patterns and thus outcomes (lower life expectancy being the biggie).
Thanks for asking!
Equity as a rallying call is a general principle that few would question, and is based in clinicial codes of conduct – to treat everyone equally regardless of age, gender, ethnicity, religion, socio-economic status, geography. But our delivery of care is clearly at odds with those priniciples – there is an ageism, there is bias towards WASP wealthy males, there is a bias against ATSI people, the mentally ill, those living in rural areas have lesser health status. So, is this an issue of clinician bias at an individual level or a bias at a higher system level? Where is the need for transparency – at individual access or collectively at a system level in choosing between types of service or care? The manner in which resources are allocated and policy developed needs to integrate the health care provided to communities rather than protect silos of care. If we need to move towards multi-disciplinary models of care and focus on outcomes then where is the leadership for that? Should it arise from grassroots clinicians or should it come from professional and political leaders?
If we have a hospital and medical centric model of illness care then equity and transparency won’t be addressed until we accept that our infrastructure as currently configured cannot deliver what we apparently expect of it. The current health reform proposals, focussed as they are on funding, will do little to change the entrenched culture that professes equity and transparency as principles but delivers little that can be objectively evidenced.
A doctor who wishes to remain anonymous has asked that this comment/question be posted:
“The system of lobbying government for pet projects creates lumpy funding for the disease/ disease category du jour at the cost of more sensible resource allocation. To take Professor McGorry’s field, he lobbies for sharp end mental health services, yet the greatest area of mental health morbidity in the adolescent age group is not diagnosable depression/ schizophrenia/ anxiety disorder etc which are the focus of his attention. The greatest burden of mental health disorder (over 95% I would contend) in this age group in the community lies in behavioural problems such as ADHD, school non-attendance, interpersonal violence, emerging personality disorders. Also, for reasons one can’t explain, the mental health system has dropped the ball on eating disorders and I don’t hear anything from Professor McGorry about this awful field which has a mortality of 3-5%, which is higher than depression/ schizophrenia/ anxiety disorder. The focus on diagnosable depression/ schizophrenia/ anxiety disorder shouldn’t be but is at the expense of these other more common, serious morbidities.”
Missing from the debate about mental health reform in Australia is the essential role played by primary prevention. That is hardly surprising, since primary prevention, supporting the health and well-being of all citizens across the lifespan through general and targeted strategies, would greatly reduce the incidence of mental ill health in the community. However, it would also greatly reduce the reliance we currently have on big pharma and big psychiatry. Addressing known causative factors like child abuse, domestic violence, workplace bullying, unemployment and poverty is a far preferable approach to the elusive quest of post-event, reactive pharmacological interventions. Such interventions at best have null clinical efficacy and at worst, typically come with a raft of serious, iatrogenic side effects. It is time that the mental health reform debate moves out of its timid, positivist shell and into the light of rigorous, evidence-based critical analysis. We could pour half; even a billion dollars a year more funding into meds and beds, and it would have no positive influence whatsoever on prevalence or recovery rates.
Treatment for early psychosis in most of the Scandanavian and Western European countries includes not only effective medication, case managment and family support, but also comprehensive, extended individual and family psychotherapy.
In the Australian model for treating young people with psychosis, how is family therapy and extended individual psychotherapy included along with medication, case management, and psychoeducation?
Another doctor who wishes to remain anonymous has asked for this comment to be posted:
Is there any evidence that the Better Access program, i.e Medicare funding for psychologists, counsellors, etc, has been money well spent? And if not known, too early, etc – is anyone evaluating this intervention (or likely to do so) in a manner that is independent and rigorous?
As a follow-up question to the question asked by ‘Anonymous Doctor’ about evidence in support of the Better Access program:
If the question is regarding the existence of randomized controled trial evidence for the efficacy of psychological interventions, then the answer of course is that generally there is as much evidence in support of psychotherapy as there is for psychiatric medication.
If the question is regarding specific community effectiveness evaluation in the Australian health care context, then the same question should also be asked about effectiveness evaluation for psychiatric medication funded by Australian Medicare and state expenditures. Where are the Australian outcome studies showing effectiveness (and safety) for use of psychiatric medication in Australia?
Another important point that should not be overlooked when evaluating Better Access, is that recent expenditures on psychological services are a small percentage of total mental health spending, which goes predominantly to hospital services, psychiatric and GP visits, and prescription costs.
If the concern is about reducing costs, why isn’t there more focus on expanding availability of psychiatric nurse practitioners?
Matt, if you put the doctor’s and nurses’ awards side-by-side you will see that there is a large overlap. Especially as NPs may (not unreasonably) expect a pay-supplement for their extra responsibility, it is unlikely to save much money. Also it contradicts your earlier statement: NPs are trained to prescribe, but you presumably don’t want more prescribers in the mental health system, you want more psychotherapists, who can be from a range of disciplines.
Bit of a follow-up comment — and I admit to having to read this twice, because I didn’t quite believe it — but this is from an interview with a GP, Dr Steve Wilson (Chair of the Council of Gen Prac for AMA WA), which appears in the 25.6.10 issue of Australian Doctor:
Q: “The condition I love to treat is…”
A: “…depression or anxiety to relieve people of the destruction of mood disorders.”
I wonder how many GPs would give a response like that?!
Ultimo167…Very well said
Where are the Preventative methods in all of this???
Psych/Pharma have only caused more distruction through their treatment methods and throwing more $$$ into this area WILL only cause more problems… eg. un-necessary medicating of children and teens before they even have a diagnosed condition, adverse & long term side effects, a higher % of medicated youth than the already too high rates… etc. etc.
Dealing with the issues in the state of youths issues within their environment such as low socio-economic conditions, drugs & alcohol abuse, child abuse, poverty etc. etc., would certainly see reduced rates of youth despair and would increase the rates of young people who are more informed…