After years of neglect the federal government has shovelled billions of dollars into the mental healthcare system — but the debate on how best to spend it has just begun. In the final chapter of a four-part joint investigation with Inside Story, health journalist and Croakey blogger Melissa Sweet reviews the lessons learnt and the future for reform …

One of many lessons from the post-budget fallout in mental health is that clinical clout wields far more political power than any other interest involved in health. The lack of pressure for governments to fund programs that deal with the broader social determinants of mental health, for example, is inadvertently illustrated by the WHO diagram (shown in part one of this series), which doesn’t mention them at all.

Yet this is an area crying out for attention. A recent report highlighted the fact that Australia ranks poorly on many social justice indicators that affect mental health, including child poverty and educational equity. The report, Social Justice in the OECD — How Do the Member States Compare?, found that Australia “is struggling with larger problems in poverty prevention and educational justice, and is therefore lagging behind in terms of creating a sound framework for social justice”.

It’s true that there is a growing focus on broader support for people who already have a mental illness. One of the more encouraging recent developments has been the emergence of a whole-of-government approach to mental health, with several departments now working to tackle issues beyond health, including social and housing support.

In an interview for this story, the Minister for Mental Health Mark Butler said the main thing he had learnt about his portfolio “is that good supports for people living with mental illness in the community and their families need to be well integrated across a whole range of services, including but not limited to health, that take in housing needs, employment and training needs, and general social inclusion needs”.

Matt Fisher, from the Southgate Institute for Health, Society & Equity at Flinders University, who is studying how the social factors are reflected in national mental health policy, says it is a challenge for policymakers to balance people’s immediate need for help with policies to prevent mental health problems developing.

“There are some immediately available things that could be done that would have positive benefits, such as tighter regulation around alcohol laws,” he says. “We know alcohol is a strong contributor to domestic violence, which flows on into impacts on mental health for families and for children.” Fisher’s research suggests that mental health policymaking is dominated by clinical perspectives, and so “there is an underlying interest in saying, ‘what we need is more and more medical services and psychiatrists and psychologists’.”

But if you ask people with psychosis to prioritise, their top concerns are not clinical services. According to Vera Morgan, a research professor at the University of Western Australia who was involved in the second national survey of psychosis for the Department of Health and Ageing, the main concerns are inadequate incomes, loneliness and social isolation, poor employment opportunities and poor physical health. Mental health comes in fifth (more details in this Croakey post, including a personal response to the findings from someone with schizophrenia).

The Public Health Association’s Helen Keleher, another advocate of greater focus on the upstream determinants of health, says mental health would benefit from a much greater emphasis on intervention in early childhood, particularly among the 15% to 20% who live in poverty, and on supporting parents. “If we could do anything for mental health, it would be free, early childhood centres. Preschool should be free, and the therapeutic interventions like speech therapy, occupational therapy, podiatry and vision, should be free and universally available — which they’re not currently,” she says. “We need to be intervening as early as we can, within a social model of health.” (More on these matters in this Croakey post.)

Keleher cites a report released earlier this year by a British MP, Graham Allen, Early Intervention, the Next Steps, which makes detailed recommendations for ensuring young children have “the social and emotional bedrock they need to reach their full potential”. According to the report: “Many of the costly and damaging social problems in society are created because we are not giving children the right type of support in their earliest years, when they should achieve their most rapid development. If we do not provide that help early enough, then it is often too late.” It goes on: “Especially in a child’s earliest years, the right kind of parenting is a bigger influence on their future than wealth, class, education or any other common social factor.”

Mark Butler says he is well aware of the need for a greater focus on early childhood. He points to plans for early childhood checks and budget funding regular, population-based studies of children’s health and well-being. “I would really like to see over the next five years that investment into children start to build an evidence base that sees a much more proactive approach to the emotional and social well-being of children and toddlers,” he says.

“At the end of the day interventions for children are largely through family and education policies. You need well targeted services for children and youth and if you’re taking about prevention, it’s got to involve and include families and learning environments, not just the family GP.”

My search for leads on the future of mental health eventually takes me to Gavin Andrews’s office in a smart new building alongside St Vincent’s Hospital in Sydney. The 80-year-old is another of mental health’s fearless revolutionaries. But his revolution has been happening much more quietly than some others. As he remarks a number of times, with a twinkle in his eye and a dry delight in his voice, he has managed to “fly under the radar”.

Andrews shows me the results of research demonstrating impressive results for online cognitive behaviour treatment programs for depression, anxiety and related disorders. His clinic has now provided online treatment to about 7000 people, with an over-representation from rural and remote areas. The treatment is not offered to people at high risk of suicide, or with schizophrenia, bipolar, or those taking antipsychotics. “We now see 750 new referrals a year, we are by far the biggest anxiety and depression clinic in the country,” says Andrews. Other centres, notably at ANU and at Swinburne University of Technology, have also been developing online mental health programs.

Asked about the common argument among health professionals that such programs can’t replace face-to-face contact, Andrews says bluntly: “That’s bullshit. When asked, would you like to come here for treatment or do it on the web, 97% of people say they will do it on the web. We’re a free clinic. The average cost of someone to see us is $29 per visit in transport, parking, babysitting, time off work. Of course they’d like to do it at home in their own time, when it is convenient and private.”Psychologist Peter Cotton believes the resistance among many mental health professionals largely reflects a lack of knowledge and a fear of change, and sees e-health as the way of the future. “I predict that within five years, mainstream mental health professionals, psychiatrists, psychologists, everyone will be using this stuff and integrating it with their face to face practice,” he says.

If that’s the future, what can be learnt from recent history in mental health reform?

A glaring lesson is the immense challenge of developing integrated team-based systems of care within a system built largely on fee-for-service and entrenched professional and funding “silos”. Another is about the need to tread carefully when setting up new programs. Once professionals have sunk their teeth into a cash cow they will fight tooth and nail to retain it. This is a useful lesson that should inform efforts to provide fairer access to dental care. Another clear message is the need for much better evaluation of all programs and services, and not only in mental health. For all the concerns about the Better Access evaluation, it provides more detailed information than is available for many other programs and services.

For Tony Hobbs, a rural GP who led development of the national primary health care strategy and is a supporter of the ATAPS model, one lesson is the need to be politically savvy. The timing of the Better Access cuts to GP rebates has been disastrous, he says: “What it did was to make resistance to the establishment of Medicare Locals more problematic. People became suspicious of Medicare Locals and also the rollout of headspace.”

For Gordon Gregory, executive director of the National Rural Health Alliance: “One of the broader lessons is if you advocate for money be clear as a sector how you’re going to spend it.” Or as another health policy insider observes, mental health people “are good at getting the money but they’re not good at dividing up the money and working out what to do with it”.

With relations so poisonous in the sector, another lesson is for policymakers and advisers is to be more transparent and to develop mechanisms to ensure wider engagement, and particularly to empower a community voice. Allan Fels who begins work on January 1 as the first national Mental Health Commissioner, also stresses a commitment to cross-sectoral action and accountability. And he believes it is significant that the commission is located in the Department of the Prime Minister and Cabinet.

For Professor Stephen Leeder, a public health expert who is charged with overseeing health reform at the Western Sydney Local Health District, recent mental health debates illustrate a need for far more investment in change management, an area he says is too often neglected. “The PM or the minister for health or whoever is in charge of this enterprise should,” he says, “take advice from the captains of industry or people in the public service, saying we want to bring about quite radical change in delivery of mental health services, we’ve got a lot of money to do it, how do we go about managing the process?”

Dawn O’Neil (who, as we featured in part one, has worked with Lifeline, beyondblue and the Mental Health Council of Australia) wants to see far greater attention to developing effective leadership for the sector, given the obstacles that inevitably confront reform. “We have come a long way, that was in my lifetime,” she says. “We still have a long way to go but it will be painful; I’m ever idealistic that we will get there but it’s going to take strong leadership.”

**Declarations: The Croakey health blog, which Melissa Sweet moderates, has received funding from the Brain and Mind Research Institute and the Public Health Association of Australia. The author has also been paid for research (not related to mental health) through the University of Melbourne centre involved in the Better Access evaluation, and the lead author of the evaluation, Jane Pirkis, was interviewed for this article.

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