1 Boring Old Man

BUILDING A NATIONAL MENTAL HEALTH SYSTEM:
A 21st Century Engineering Challenge
Croaky: The Crikey Health Blog
by Jennifer Doggett
September 5, 2011

^{Professor Pat McGorry, Executive Director, Orygen Youth Health Research Centre, will appear today from Europe via videolink to provide evidence to the Senate Inquiry into the Budget mental health initiatives.  Here is a summary of the main points of his presentation:}

^{One of our greatest symbols of nation-building is the Sydney Harbour Bridge.  Construction lasted nearly a decade through a series of carefully planned and executed stages.   One of my favourite photographs is of the incomplete arch being built simultaneously from opposite shores.   Planning, precision and cooperation were essential if the two ends were to meet in alignment.}

^{Mental health reform is a 21st Century opportunity for nation building that requires cooperation between State and Territory governments building mental health services from one shore and the Federal government building from the other.   Up to now we have had two sets of engineers, eight sets of plans and nowhere near enough money for the task.  The chances of the two sides of the system aligning or indeed ever meeting will be slim indeed unless these issues are addressed. State governments have financed their construction from the proceeds of deinstitutionalisation in the 1980s and began building the first section of the arch.  This included general hospital inpatient units, assertive community treatment teams and generic case management.It was poorly designed, not built to scale and could not withstand the strain of unmet community need.  Much of it has buckled or actually been dismantled, with ongoing cuts to State funded community mental health services.   The Federal government has been building multidisciplinary models of primary care such as Better Access and headspace to respond to mental ill health in its early stages, and of mild-moderate severity and briefer duration.}

^{The gap between Federal and State funded systems has been sharply revealed by community concerns about the May budget’s reduction in the maximum number of sessions of allied health care under Better Access.   The Federal side of the community care arch has been scaled back with the government arguing that it was veering off course and that finite funding could be better targeted to other mental health investments. The State side has been eroding for years and is not up to bearing additional strain.  People are genuinely suffering as a result. Who are these people stranded in the middle of this construction zone?   They are a spectrum of Australians from all walks of life and all age groups, though the disadvantaged, the young and those in rural and regional Australia are especially excluded.  At one end they are people who despite the primary care experience of Better Access have a need for more specialised and sustained multidisciplinary care.  They are people with genuine need who need more expert help.  They suffer from a variable mix of persistent mood and anxiety disorders, eating disorders, post-traumatic stress, complex personality problems, substance use and psychotic disorders.} 

^{This group of people need access to more specialised forms of care than a basic primary care approach can provide.  This means a secondary model, involving many different types of expertise ranging from clinical psychology, psychotherapy, psychiatry, addiction medicine through social programs for housing, further education and employment. Even further along the spectrum are people with more severe forms of these illnesses, usually in combination, and who are or may become socially excluded and homeless.  People with severe and enduring mental illness. The people that deinstitutionalisation failed. The needs of these people lost in the middle requires a substantial and systematic solution, one that not only restores access to those whose ongoing care has been restricted, but goes much further and provides access to care of a more specialised nature to the much greater number of Australians with more complex and persistent mental ill health needs who have never had such access in the first place.}

^{However, efforts to find a comprehensive solution are frustrated by the inevitable fighting over scraps that will probably continue so long as mental health remains so desperately underfunded. The $1.5b over five years of new investment pledged by the Australian Government in May, though a welcome and important step in the right direction, was able to allocate just under half of the amount that a number of mental health leaders, including myself, had identified as immediately required. As a result, current discussion of the needs of the people lost in the middle is seen as a zero sum game.  As framed by some commentators, the zero sum policy choice is either restoring funding for an unchanged Better Access program or building the new supports pledged in the mental health reform package – such as the $205m boost to the Access to Allied Psychological Services program, the $571m to improve care for people with severe and persistent mental illness or the $419m expansions to primary and specialist youth mental health care. Either way there are losers as well as winners. In physical health care we rarely see positive new investments criticised on the basis that there are other areas that also need urgent attention or funded by restricting access to other popular programs.  Unfortunately, in mental health care the investment case on behalf of one group of people is often made at the expense of the care needs of another people.}

^{To liberate mental health policy from such zero sum thinking all Australian Governments must respond to the scale of the unmet need and commit to steadily increasing the share of the health budget allocated to mental health over the lifetime of a ten year reform process.Ultimately, mental health spending needs to double so that the resources allocated to mental health care match the burden of mental ill-health on Australian society. Mental health reform therefore needs a sequential plan tied to an investment schedule in which every budget makes further progress towards completing this massive nation-building project.  We must pursue transformational change and not be seduced into patching up a system that has been failing.  Because unmet need abounds, notwithstanding the National Health and Hospital Reform Commission’s recommendations, debate continues about where to start.   While there is no doubt that all these needs must ultimately be met, the sequence for investment must follow principles of capacity to benefit, cost effectiveness and social inclusion.  We need a much more unified and professional approach to this, which transcends vested interest.  Our whole sector needs to behave in a more mature manner, eschew public conflict and partner better with the community, including the business community.}

^{The August 19th meeting of the Council of Australian Governments in Canberraat least committed all Australian governments to developing a Ten Year Road map for Mental Health Reform. However, this road map will only be meaningful if it is developed  with clear unifying purpose and creates an engineering blueprint supported by sufficient collective will, expertise and funding. The National Disability Insurance Scheme initiative, which has tripartisan support, contains some important lessons that may be applied to developing aspects of this road map.}

^{When David Cappo, Frank Quinlan and myself presented to first ministers at the COAG meeting this month, our central recommendation was that the ten year road map endorse what the mental health sector last year identified as its core goal – that all Australians should have the same access to quality care for mental ill-health as for physical ill-health. Making substantial progress towards achieving this goal should be the unifying purpose of the ten year road map and the measure of its success. Like the Sydney Harbour Bridge, the construction process to transform mental health care into a system fit for the modern era depends on a unifying vision and the skill and resources to achieve it.   The people currently lost in the middle are relying on the mental health sector to represent them in a mature and effective way and all Governments to step up and make it happen.}