To call the nation’s mental health system “fragmented” would do disservice to a dusty hard drive. Actually to call it a “system” is even a bit of a stretch. Everyone, from patients to the policy class, is agreed that Australia’s mental health services are in need of urgent reform. Well, everyone but Mark Latham, who is of the minority view that mental ill health is a fiction written by “worried well” lady writers he doesn’t like. Most other commentators, peak bodies and politicians accept the evidence: people are sick and services are scant. “Chin up” is no longer a recognised strategy.
There may be consensus that something significant needs to be done, but that doesn’t translate to the view that something needs to be spent. There are few signs from Health Minister Sussan Ley that funding to the sector is likely to increase. While the mental health envelope has been a little more generously stuffed in recent years, data sets show that relative to other OECD nations, our own spend on mental health relative to the health budget falls far behind.
There are probably no prominent mental health advocates who would say “no, we don’t need any more money”. But in our local climate of austerity-lite, such people are required to adapt to the prevailing tone of “agility” and accept the terms of lean spending, usually by arguing over which under-funded part of an under-funded sector gets most of it.
When the National Review of Mental Health Programmes was leaked earlier this year, the advice that funding be moved from hospital services and into preventive, community-based strategies was criticised by The Royal Australian and New Zealand College of Psychiatrists. When the Gillard government cut the scope of the Better Access program that permits Medicare subsidy to psychology services in favour of other programs, disagreement was widespread and public.
This week, the Australian Psychological Society (APS) revived that debate last heard in 2011 with its submission to the 2016-17 federal budget. The organisation is seeking to restore the pre-2011 Better Access sessions available to us to 16, instead of the currently available 10.
This morning by telephone, APS executive director Lyn Littlefield said that the perception, often reflected in media, that different organisations were fighting for different professional interests was false. “I’m really not fighting for psychology” she said. She is fighting for better outcomes that psychology, along with a range of other services, can deliver.
There is some evidence that the Better Access program, introduced by the Howard government in 2006, has improved health outcomes. Since its inception, a greater number of Australians are addressing their mental health concerns with a registered or clinical psychologist. But an unintended outcome of the scheme is that these subsidised sessions tend to be accessed by the most advantaged Australians. Ebullient critic and frequent policy adviser Professor Ian Hickie was unequivocal in his criticism. Better Access, he said, did not uphold the Medicare principle of universality.
Littlefield concedes that this is a problem, but she explains the unintended consequence is not down to a fundamental failure in Better Access policy but to uneven distribution of psychology services. Psychologists, unlike many other professionals in the business of doing social good, have no incentives and few programs to lead them into the regions that need them the most.
Professor Patrick McGorry, another prominent advocate known for his work with the ABC’s Mental As week and his collaboration with Hickie, told Crikey that he would like to see a scheme where “clinical psychologists are more incentivised and rewarded”. He does not support further cuts to the Better Access program, but like Hickie, he sees the value in a more integrated approach to mental health care. He consistently campaigns for “multidisciplinary teams rather than isolated office based practice or silos of either psychologists or psychiatrists, as is currently the case”.
The APS represents a slightly different view, which holds that there are many kinds of mental illness, particularly high-prevalence disorders like anxiety and depression, which can be meaningfully addressed in a “silo”. Sometimes 16 psychology sessions are alone enough to help a patient out. Sometimes that won’t even touch the sides and a more team-based approach that addresses the many causes and effects of a mental illness is truly needed.
Just how broad the social and medical contexts should be in considering treatment of mental illness is a really interesting question; it’s one we lay folk have often. But this era is not one in which lobbyists have the luxury of discussing different models of understanding. It’s one that demands statements about outcomes. Discussion of an integrated approach in such an atomised time is difficult.
In many sectors, not just mental health, it seems Ley and Turnbull are committed less to funding services than they are to speaking the language of Uber. We’re not going to spend our way into better health. We’re going to innovate!
This is not to suggest that abandoning red tape or unproven therapies in favour of genuinely clever solutions is a bad idea. It is, however, to say, as the Croakey blog often does, that different fragments of a very fragmented mental health system are left fighting for funds while Mal bangs on about innovative approaches. While professionals and patients wait for the Uber of Anxiety, divisions emerge to produce, in the words of John Mendoza, former chair of the National Advisory Council on Mental Health, a “dog-eat-dog world where there are so few resources that it breeds this sort of behaviour”.
Differences in theoretical positions on mental health are not just bred by schools of thought. They are also bred by hunger. Whatever divisions there are on the correct approach, these are enhanced by need. “The big problem,” said Littlefield “is that there is not enough money.”