This month has seen announcements of record Budget allocations for mental health from both the Federal Government and the Victorian Government.
Will these begin to deliver the mental health reform and support required across Australia or do we face the prospect of competing, unrelated reform processes?
That’s one of the questions posed by Dr Sebastian Rosenberg, Senior Lecturer at the Brain and Mind Centre at Sydney University and head of the Mental Health Policy Unit at the Australian National University’s Centre for Mental Health Research, in his analysis below.
Sebastian Rosenberg writes:
The Federal and Victorian budgets have delivered new resources but also new challenges for mental health.
This article explores how some of the main features of these budgets now serve to highlight the key challenges facing national mental health reform.
The budgets shared very high expectations from stakeholders they would address respective statutory inquiries that had recently reported.
The Federal Government needed to respond to the Productivity Commission which provided its report on 30 June 2020. The Victorian Government needed to respond to its Royal Commission which reported on 4 March 2021.
How much is being allocated?
The Federal Budget provided a total of $2.3 billion, spread over five ‘pillars’ as follows:
- Prevention and early intervention — $248.6 million
- Suicide prevention – $298.1 million
- Treatment — $1.4 billion
- Supporting vulnerable Australians — $107 million
- Workforce and governance — $202 million
This means 11 per cent of total funding was directed to prevention and early intervention.
The vast bulk of funding is directed towards addressing mental health problems once they are manifest – a more difficult and expensive prospect. Five per cent of total spending on vulnerable populations also seems low, particularly when spread over four years.
The Federal Government was keen to trumpet this expenditure as a record.
And indeed this Budget is marginally greater than the 2011-12 version, when the Gillard Government provided $2.2 billion over five years, making mental health the ‘centrepiece’ of that budget.
However, the Federal Government’s largest single contribution to mental health was in fact in 2006, when it provided $3.3 billion of federal spending over five years as part of the 2006-11 Council of Australian Government (COAG) National Plan on Mental Health. That included new programs such as Better Access, Personal Helpers and Mentors, Day to Day Living and Mental Health Nurses, among others.
There are two other measures against which we can now assess the 2021 Federal Budget outcome for mental health.
The first is the Productivity Commission Inquiry itself which suggested that mental health required additional investment of $2.4 billion.
The second is now the colossal $3.8 billion mental health spend just announced in Victoria. To put this into perspective, in 2018-19 (the most recent year reported by the Australian Institute of Health and Welfare), Victoria spent $1.6 billion on mental health care. Put another way, Victoria’s 2021 mental health budget commitment represents more than the total contribution made by EVERY State and Territory under the CoAG National Action Plan (around $3.5 billion).
How the funding is being spent
The main method the Federal Government is using to implement its Budget is through national programs and services it already funds.
There is more funding for Medicare (around $400 million) and headspace ($278.6 million), as well for national organisations like Beyond Blue, ReachOut, Lifeline, Perinatal Anxiety and Depression Australia (PANDA), Head to Health, Black Dog, the Program of Assistance for Survivors of Torture and Trauma, DRS4DRS and so on.
While this expenditure may all be worthwhile there is an element of ‘business as usual’ about it. However, Mental Health and Suicide Prevention Minister David Coleman has stressed how the aim of this budget was more ambitious, striving to promote enduring structural reform in mental health.
There are two elements of the budget that appear quite ‘structural’ in nature and appear to signal the Federal Government’s willingness to engage in serious reform.
The first is the commitment to a new, universal national aftercare service ($158.6 million), drawing on a recommendation made by the Productivity Commission, designed to address Australia’s persistently high rate of suicide and with an eye on any increase due to the broader social and economic impact of COVID-19.
The second overtly ‘structural’ element is the commitment to establish a new suite of community mental health treatment hubs ($541 million). The budget specifies funding for:
- eight new adult Multidisciplinary Mental Health Treatment Centres, plus ongoing funding for the eight Head to Health Multidisciplinary Mental Health Treatment Centres originally funded ($114.5 million over five years) as part of the 2019-20 Budget as a trial, with one Centre to be established in each state and territory — in a recent interview on ABC Radio, Minister Coleman acknowledged that, so far, only one centre was open with the others scheduled to be operational by the end of 2021
- 24 new satellite centres
- 15 new Head to Health Kids Centres (aged 0-12 years).
But an important point is that neither of these structural elements will deliver fundamental mental health reform without new, strong coordination between the federal and state governments.
Aftercare services require whoever is providing this follow-up to be working closely with the state-run services which are discharging clients following an attempted suicide. Lifeline has estimated 65,000 people attempt suicide annually, so the task is large.
But this need for coordinated action is perhaps more starkly illustrated by the new centres. Only days after the Federal Government announced its hubs, Victoria’s budget announced the first tranche of funding for:
- 50 to 60 new Adult and Older Adult Local Mental Health and Wellbeing Services
- 22 Adult and Older Adult Area Mental Health and Wellbeing Services
- 13 Infant, Child and Youth Area Mental Health and Wellbeing Services.
The Victorian method of investment seems designed to rebuild, or build anew, a state-run community mental health infrastructure, providing sophisticated clinical (and possibly other) services.
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.
Another area of unfortunate confusion concerns the mutual neglect by state and federal governments of the psychosocial sector, which received minimal support in the Federal budget ($171 million over two years).
The sector provides the skills and support people need to live well in the community, housing, employment, education, peer support and living skills. The mostly non-government agencies that provide these psychosocial services were badly damaged by the advent of the National Disability Insurance Scheme. The sector’s role and potential to become an active and respected partner with clinical care remains unexplored by all governments.
More generally unexplored is the terrain of the ‘missing middle’. Exactly who are the clients needing care and missing out now, how many of them are there? Harking back to when it had strong ‘secondary care’ services, Victoria’s new centres would presumably link up clearly with existing state-run mental health services but their links to primary care are less obvious. How the Federal centres will work, where they will be located and who will run them is still in the design phase.
What comes next?
It is a confusing and complex picture. In the space of one Productivity Commission Inquiry, the guiding philosophy for mental health planning in Australia has shifted from stepped care to person-centred care.
We now face the prospect of competing, unrelated reform processes.
The Federal Government has criticised the Victorian Government already for its decision to deploy a new levy on big business to help fund its massive mental health program.
In his response to this critique, Victorian Treasurer Tim Pallas revealed that Victoria had previously approached the Commonwealth to incorporate necessary new mental health spending into the Medicare levy, given mental health is a “national problem” but “(t)hey had very little inclination in that regard. So we were left, once again, to our own devices”.
What does this reveal about the prospects of coordinated state and federal action?
Moreover, such actions in fact must enable effective reforms to be undertaken not in Canberra, Sydney or Melbourne, but locally in each region.
This kind of joined up approach could focus, as a start, on agreeing where new services might be best located. For example, governments could agree to locate new treatment hubs in regions where existing access to either Medicare or hospital-based services is low – new services where they are most needed, rather than in the leafy eastern suburbs of our major cities.
Minister Coleman has placed considerable store on governments working together to deliver a new mental health and suicide prevention agreement.
Mental health has already had five of these, plus a couple of roadmaps and action plans – and that’s just nationally.
New Federal attention to mental health is most welcome, as is the recognition of the need for structural reform.
Victoria has recognised the scale of investment needed and set a bar for every jurisdiction.
But what comes next is critical, determining if Australia proceeds towards a joined up mental health system offering genuine continuity of clinical and psychosocial care, or if we sacrifice exciting new funding opportunities due to prevailing fragmentation.
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