Announcing the federal government’s response to the National Mental Health Commission’s review of mental health services today, Prime Minister Malcolm Turnbull emphasised the concept of patient choice.
The commission’s review was the latest in a long line of reports showing that for many Australians needing mental health care, their current choice is between getting no care or getting poor care.
The reforms announced today have the potential to change this appalling situation. But ultimately they should be judged on the outcomes they achieve for patients.
Poor access to care
Mental health is the third-biggest chronic disease in Australia behind cancer and heart disease, affecting 4-5 million people each year.
Access rates to care are low. And once a person has seen their general practitioner or psychologist, if their condition deteriorates, they have few options but to seek care from their local hospital emergency department.
Following deinstitutionalisation 30 years ago, which overturned the practice of sending people with severe mental illness to asylums, Australia largely failed to invest in a genuine system of community mental health care.
The bar for entry into the state-run hospital system rose, so you must be sicker and sicker to qualify for care. Rates of access to state and territory mental health services have not changed in some years. Yet spending has increased by more than 50%.
We are, in fact, over-reliant on hospitalisation and there is waste. An unpublished survey by state governments indicated that more than 40% of all hospital mental health beds were occupied by people who would be better off in other settings if there was anywhere to send them.
Mental illness also has a colossal impact on productivity and economic participation. The OECD estimates the average overall cost of mental health to developed countries is about 4% of GDP. In Australia, this would equate to more than A$60 billion or about A$4,000 a year per individual taxpayer.
The federal government’s announcements have the potential to address these problems by presenting two key structural changes.
The first is the decision to use the new Primary Health Networks (PHNs) to keep people with mental health problems out of hospital, by building new, integrated and stepped approaches to primary and community mental health care. Under the Abbott government, PHNs replaced Medicare Locals. PHNs’ role is to both plan and commission (fund) primary and community care.
This means having the capacity to respond to all the problems a person might have, including not just their mental illness, but drug and alcohol issues, physical problems, homelessness and other problems. It also means having a range of services available to match the intensity of the person’s needs.
PHNs will be tasked with properly planning to meet the mental health needs of the regions they serve.
Given the size of the PHNs, some may require multiple plans to ensure they understand and can respond to locals’ needs. One of the PHNs in Western Australia covers an area the size of much of Western Europe, so plans will need to cater for diversity within regions.
The second key structural change offered under these reforms is to end the dependency on simplistic fee-based services. The government has recognised that just sending people off for a set number of psychology sessions is an inadequate response, particularly for people with more complex conditions.
The suggestion is that people with less complex problems should access evidence-based mental health therapies and services online.
For others, a continuation of the Better Access program, which subsidises ten sessions with a psychologist or psychiatrist, may be entirely suitable.
For people with more complex problems, however, the government has flagged its intention to permit PHNs to cash out some of their Medicare Benefits Schedule payments into new pooled funding arrangements to meet locally identified needs. PHNs would have the capacity, for instance, to build further on successful programs such as headspace or the Mental Health Nurse Incentive Program.
These reforms suggest that better understanding individual needs can lead the PHN to more intelligently plan individual responses, bringing together clinical care and social supports such as living skills, vocational training and education.
The government’s changes to mental health are not without challenges. It’s unclear whether PHNs will be up to the job, and what support they need to make the scheme work.
The changes don’t appear to be supported with any new funding, yet we know the mental health system is under-funded. Mental illness accounts for 13% of the burden of disease but receives only around 6% of the total health budget. It should be noted that the “cashing out” arrangements are uncapped, opening up the potential for new funding under Medicare.
Most importantly, we need to ensure these changes marry up to commensurate reforms by the states and territories. The fifth national mental health planning process now underway has proven ineffective in joining up mental health approaches between governments. The Commonwealth has pledged new leadership and it is here that it is needed most.
Finally, the Commonwealth must establish a new and robust approach to accountability. Regionalism cannot mean we let myriad programs start and go unevaluated. Instead we need strong and consistent approaches to data collection, providing real information about things that matter.
Rather than reporting on bed numbers, these processes need to reveal the extent to which PHNs are actually working to help people with a mental illness stay out of hospital, recover from their illness, complete their education, resume employment, avoid homelessness and become healthy and productive members of the community. None of this information is currently available.
Prime Minister Turnbull stated that these changes were about trying to make the most of Australia’s mental wealth and human capital. His goal is laudable. But the work starts now.