The long-withheld National Review of Mental Health Programmes and Services proposes a fundamental overhaul of the systems in place to address with the massive cost of mental illness in Australia, as the current framework is “not cost-effective”, “does the wrong things” and fails to deal with “the dire status of the mental health and wellbeing of Aboriginal and Torres Strait Islander people”.
The report, by the National Mental Health Commission, chaired by Allan Fels, was provided to the government in November but remains officially unavailable. A part of the report has been leaked to the ABC, and a full copy of the four-volume report has now been leaked to Crikey.
The commission’s core finding is that current mental health funding arrangements are too skewed to treatment within the hospital system rather than focusing on prevention and care within the community. It finds:
“The status quo provides a poor return on investment for taxpayers, creates high social and economic costs for the community, and inequitable and unacceptable results for people with lived experience, their families and support people.”
The review complains of being hampered in its assessment of existing programs by the lack of reporting information, or information focused on activities rather than outcomes. “There is nothing efficient about funding activity-based programmes when there is no way of measuring the impact of those programmes,” it says. The commission wants to shift Commonwealth resourcing — currently around $10 billion, spread around 16 agencies, in addition to $4.5 billion in state and territory spending — toward prevention and early intervention, to fix a system “driven by supply (what providers provide), rather than by demand (what people want and need)”.
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The commission states:
“At present, our programmes and services across sectors are not set up to promote early intervention. For example, sometimes people need to inflict serious physical harm to gain access to support… in mental illness, late intervention is too often the norm … For example, for people with complex needs, such as a person with severe bipolar disorder, optimal care (based upon greater GP contact, increased support from community mental health teams and continued access to care coordination and psychosocial supports) can yield savings over nine years of $323 000, with about half of that saving being directly to the states through reduced acute care costs (admissions).”
Moreover, the commission finds, Aboriginal and Torres Strait Islanders bear the brunt of current inefficiencies given the far higher rates of mental health problems in those communities.
Programs are often poorly co-ordinated as well, the commission finds, with different agencies administering short-term, sometimes duplicative programs with poor evaluation mechanisms and no links to other programs or programs addressing non-mental health issues that can play a key role, such as housing. And “the Commonwealth’s major programmes reward volume of activity and funding of one-off patient interactions, with no accountability for effective achievement of outcomes”. Worse, states and territories had been withdrawing specialised community mental health services, creating a “missing middle” between GPs and hospital care, especially in regional areas which already face poorer access to health services.
The person-focused “architecture” proposed by the National Mental Health Commission is based on a “stepped care” framework designed to address different levels of intensity of need with greater choice and responsibility, with resources — it does not propose an increase in funding — shifted “upstream” to primary and community care and non-clinical services, overseen by renamed “Primary and Mental Health Networks” (which have replaced the Medicare Local network). This is the basis for the $1 billion shift in funding from hospitals that has been widely reported, which has already ruled out by Health Minister Sussan Ley. GP incentive payments would be structured to strengthen the role of GPs, and pharmacists would be included “as key members of the mental health care team.”
The commission also wants to expand full-time mental health and social and emotional well-being teams for Aboriginal and Torres Strait Islander people, reflecting the need to take a broader approach to mental health among indigenous communities.
The report leaves the Commonwealth in a difficult position, and to an extent it’s understandable that the government has sat on it for months trying to work out a way forward. The status quo is simply not an option in the wake of this report, given the inefficiencies, lack of performance information and patchwork nature of our current approach to mental health; apart from anything else, a greater focus on prevention and community care represents an opportunity for substantial savings that can in years to come be reallocated to other priorities in mental health or the health system more widely. But the alacrity with which the government ruled out shifting $1 billion from state and territory-run hospitals to Commonwealth-funded GP and community services reflects the political problems inherent in such a recommendation — especially as the government is already facing a huge fight with the states and territories tomorrow over its massive cut to hospitals funding in coming years.
In short, if a more efficient, effective mental health system is to be found, the government may have to be prepared to invest up front in order to obtain savings down the track — but any “savings” in the health portfolio will always come with a political price tag.