Inside Story

“It’s like when a patriarch dies, and the will is read, and everyone starts squabbling”

Mental health had a big win in this year’s budget – and that’s when the fights began, writes Melissa Sweet in this joint investigation with Crikey

Melissa Sweet 29 November 2011 7426 words

Sweeping changes: Dawn O’Neil (above) speaking at a TED conference in Canberra last year. TEDxCanberra

BEFORE we dive into the murky, tumultuous waters of the present-day debate about mental health, it’s worth pausing for a quick trip back in time. Our destination is Roma, in the Darling Downs of southern Queensland, almost thirty years ago.

At the local hospital, a long search is ending in a bittersweet meeting. An idealistic young woman called Dawn O’Neil has tracked down a woman she had long thought dead — her father’s mother — who has been resident at the hospital for many years. Julia Mant had been admitted to institutional care when she became unwell after the birth of one of her children, and was moved to Roma after the Brisbane asylum closed. As so often happened, her family connections had been lost, no doubt reflecting the shame and stigma surrounding mental illness.

O’Neil grew up believing her grandmother was dead, and only discovered otherwise when she met an aunt in the United States in the early 1980s. “My grandmother had spent her whole adult life after the birth of her third child in various asylums, and the family didn’t want to know her. They wrote her off,” says O’Neil. “My dad was told when he was little, when he was naughty, that ‘you’re mad like your mother.’ Now, on reflection, I can see that my own father had a mental illness that was never diagnosed.”

By the time O’Neil found her grandmother, decades of institutional living had left their mark. There was no chance of rehabilitating her into the community, and she died just a few years later. Her grandmother’s history became part of O’Neil’s career choices, though, and she set about striving to improve community understanding and responses to mental health.

Through her work over more than fifteen years with Lifeline, Beyondblue, the Mental Health Council of Australia and other groups, O’Neil has developed a keen understanding of the complexities of mental health reform. She also has a broad perspective on the interests at play in the acrimonious debate triggered by the reforms announced in the May federal budget.

While a five-year commitment of $2.2 billion was seen as a significant win in tight financial times, praise for the package quickly dissipated, and since then there have been more negative than positive headlines. The concerns largely centre on cuts to rebates for general practitioners and a reduction in sessions funded under the Better Access program, which provides referrals from GPs to psychologists and other health professionals under Medicare. (About a quarter of the budget’s mental health package was funded by Better Access savings.) Some critics have also questioned the expansion of the youth mental health service, Headspace, and programs for early intervention in psychosis.

Other elements of the budget — accommodation and employment initiatives, new support measures for people with severe mental illness, more funding for carer respite services, and funds for a ten-year Roadmap for Mental Health Reform — have received far less attention. Indeed, one of the least-noticed elements of the budget is potentially the most exciting: support for developing online treatments for depression, anxiety and related disorders.

Dawn O’Neil believes that much of the post-budget critique is being driven by professional self-interest, but says the contretemps needs to be seen in the context of sweeping changes in mental health in recent decades. It is easy to lose sight of the fact that the federal government was perceived to have no role in mental health until about twenty years ago — that it was seen as strictly state business.

O’Neil refers to a 2009 World Health Organization report, Improving Health Systems and Services for Mental Health, which includes a deceptively simple pyramid-shaped diagram showing the optimal mix of services. At the pointy end are long-stay and specialist psychiatric services, the most expensive options. At the bottom are informal community care and self-care, the least expensive but most widely needed. In the middle are psychiatric services in general hospitals, community mental health services and primary care mental health services. With Australia continuing to spend a large chunk in the pointy end, the diagram represents a tremendous challenge to current practices.

“We’re slowly unpicking that and trying to turn the whole thing on its head,” says O’Neil. “That’s a big change. There are a lot of people who built their careers and their reputations on doing that acute end very well. For many of them, this other paradigm threatens their income, their livelihood, their nice lifestyle.” She adds that it’s not surprising that the journey from a system centred on the interests of services and professionals to one focusing on the needs of patients and the broader community is going to be “painful and rocky.”

O’Neil presents a picture of mental health reform that has many resonances for health reform more generally — the need to reorient complex systems in the face of a mire of resistance from professional, bureaucratic and institutional interests. Another view of the post-budget bunfights comes from health policy analyst Jennifer Doggett, who observes: “It’s partly a function of what happens when you get a win. It’s like when a patriarch dies, and the will is read, and everyone starts squabbling.”

Given the size of the Better Access industry — the program is worth around $10 million a week in government funding to psychologists, GPs and other health professionals (and that’s not including patient co-payments, which are often significant) — the squabbles are not surprising. Indeed, the recent Senate inquiry into the budget reforms revealed some rather poisonous divisions between registered and clinical psychologists over whether there should be differential rates for their services under the program. Psychologists who made submissions to the inquiry faced intimidation from colleagues, including threats to report them for ethical breaches.

The inquiry report noted: “The committee wishes to place on record that the actions of numerous parties within the psychology profession caused considerable frustration for the committee, anxiety for submitters, and reflected poorly on most of the professional bodies involved.”

IT’S not only psychologists who have been tearing each other to shreds. Considerable vitriol is also being directed at two of the country’s most prominent psychiatrists, Ian Hickie, executive director of the Brain and Mind Research Institute at the University of Sydney, and Patrick McGorry, an Australian of the Year and executive director of Orygen Youth Health in Melbourne, a mental health service that includes the Early Psychosis Prevention and Intervention Centre.

For years, Hickie and McGorry have worked closely as prominent advocates, not only calling for more funds for mental health but also pushing for changes to the way funders, services and professionals operate. They have argued for new types of services to meet the needs of young people, who often fall through the gap between child and adult services despite being at a stage of life when many mental health problems develop. They have also stressed the importance of issues like education, employment and social inclusion.

Hickie and McGorry were instrumental in developing Headspace, also known as the National Youth Mental Health Foundation, and are directors of the not-for-profit organisation. Headspace aims to deliver comprehensive care to those aged twelve to twenty-five by bringing together specialist and primary health services to provide general health and mental health services, alcohol and drug counselling, and education, employment and other assistance.

That there is now tripartisan support for mental health reform is at least partly a reflection of the pair’s sustained engagement with the media and politicians of all persuasions. Yet since the budget they have come under fire from a wide range of critics. They have been accused of having undue influence on policy, of feathering their own nests, of being in the pockets of the drug industry, and of failing to bring the wider sector with them. (It’s worth noting that the expansion of Headspace and early psychosis intervention services was recommended in the 2009 National Health and Hospitals Reform Commission report and by the Mental Health Council of Australia.)

At least some of the ill will is explained by the fact that funding for the Better Access program, of which Hickie in particular has been a longstanding critic, was cut while Headspace and early psychosis intervention services will be expanded. Some see this as a case of the government converting former critics into supporters. Others note that one motivation for the cuts to Better Access was to allow an expansion of a more equitable system of access to psychological care via the Access to Allied Psychological Services program. The pity, as the Senate report pointed out, is that these other services were not rolled out before the cuts took effect.

The attacks on Hickie and McGorry can be viewed through multiple lenses. They are tall poppies whose strong advocacy is bound to create professional jealousies. “It’s the peril of being a public health advocate,” says Wayne Hall, a professor in the Centre for Clinical Research at the University of Queensland. “You do get a high profile and there will be plenty of people to shoot you down. The only thing that surprises me, having been in the drug and alcohol field, is that it’s taken so long for Pat and Ian to cop the criticism they have.”

The backlash against the pair also reflects professional demarcation disputes. Creating a new type of youth service means stepping on the toes of the professionals who provide existing child and adult services, and some child psychiatrists view Hickie and McGorry as intruding on their turf. And there are inevitably tensions between proponents of prevention and early intervention, and between those who are focused on the needs of the patient in front of them and those considering the broader population’s needs — including people unable to get access to existing services.

Then there are the tensions between those professionals who deal with less common but more severe disorders like schizophrenia and those advocating for less severe but more common disorders like depression and anxiety. There is also competition for funds between services and professionals focused on different stages of the lifespan. One of the more astute observations in the Senate report came from the Australian Counselling Association, which commented that “the problem is the siloing of professions. Every profession wants the dollar for their profession and every peak body wants the money for their members...”

But Louise Newman, professor of developmental psychiatry at Monash University, says competition for funding in different areas is not so much about professional infighting as a result of long-term underfunding of mental health. “It’s the starving dogs with their bone,” says Newman, who argues for far greater focus on early childhood and family support. Or as another senior psychiatrist puts it: “It’s all about dividing a cake. Everything is at the expense of somebody else.”

Some of the frustration also reflects wider disappointment with health reform. So much more was promised than has been delivered — funding and services will still be fragmented — and so much remains unclear, especially about the future of community services and how mental health will fare under casemix funding for hospitals. There are also real questions about the logistics of the national roll-out of Headspace and the early psychosis intervention centres, and whether funding, workforce, bureaucratic and federal–state political processes are up to the task.

And while Hickie has been critiquing the Better Access program, others have been raising questions about the effectiveness of Headspace and the Early Psychosis Prevention and Intervention Centre. One of the people raising questions is Jon Jureidini, a child psychiatrist in Adelaide and member of Healthy Skepticism, an organisation that monitors inappropriate pharmaceutical marketing and influence. He argues that the evidence supporting these approaches has been over-sold, and he also raises broader questions about whether a medical response is appropriate for the many problems affecting young people that are social in origin.

“This is not to say that Headspace and EPPIC” — early psychosis intervention — “are without merit,” he says. “Both of these models warrant further exploration and evaluation but they certainly aren’t of the quality that we should give over the vast majority of the new money.” One of the reasons for divisions within mental health, Jureidini adds, is the lack of firm evidence about the merits of various interventions. “We’re working in an area of uncertainty. There’s very little concrete evidence to separate one person’s idea from another in terms of their effectiveness.”

John Mendoza, whose high-profile resignation last year as chair of the federal government’s National Advisory Council on Mental Health has consigned him to the political sin bin, has a different perspective, expressing frustration at the preoccupation with the new services and corresponding lack of scrutiny of existing services. “Total federal and state mental health funding will come in at just under $6 billion in one year. This year we will spend $60 million on early intervention through EPPIC and Headspace,” he says. “Our state governments will spend over $500 million on stand-alone psychiatric institutions, and we still have 2100 beds in such institutions.”

As Mendoza points out, the broad consensus that these institutions should close dates back as far as 1992. “At the moment we are still spending over 50 per cent of our total resources on our acute-care beds and our stand-alone beds,” he says. “They’re not well-based interventions. The acute-care beds in general hospitals should make up about 10 per cent of our general mental health investment.” The critics of early intervention, he says, “should focus on where the big problems are.”

NO DOUBT the backlash against Hickie and McGorry also reflects broader community suspicion about psychiatry, which is perhaps not surprising given the profession’s history of attracting royal commissions and other inquiries. There are also concerns about medicalisation of health problems more generally — the inappropriate use of psychiatric medications is a genuine concern, particularly in nursing homes — and about overly close ties between the psychiatry profession and the pharmaceutical industry.

“Our college of psychiatry, among other medical and surgical colleges in Australia and elsewhere, became addicted to drug company money — not just for running conferences, but to meet the bottom line,” says Alan Rosen, a psychiatrist who has been a strong advocate for community mental health and works with the Brain and Mind Research Institute at the University of Sydney, and the University of Wollongong. “They are at different stages of painfully weaning themselves off this formerly bountiful teat.”

Rosen says he generally supports the work of Healthy Skepticism, but thinks the focus by some members on Hickie and McGorry is misplaced, given the pair’s emphasis on a psychosocial model of healthcare and their focus on social justice rather than narrowly clinical approaches. “In this case, I think Jureidini et al are criticising a movement” — early intervention into psychosis — “that is actually trying to persuade other clinicians to lower anti-psychosis medication to often very small dose levels, only if and when it is necessary,” he says.

McGorry himself says he has much in common with the broader concerns of Healthy Skepticism, having devoted much of his career to trying to reduce the adverse impact of medications and traumatic systems of care on young people. “My whole career has been trying to reduce reliance on antipsychotic medications,” he says. “I’ve done most of my research on psychosocial treatments.”

The backlash against Hickie and McGorry is also being fed by the extreme end of the anti-psychiatry lobby, including scientologists who have been lodging freedom of information requests targeting their research projects at the universities of Melbourne and Sydney.

Powerful personalities are another factor. The pair may have different personal styles — McGorry being a quiet, restrained presence in contrast to the voluble, high-energy Hickie — but they share an absolute faith in the rightness of their causes. They are “true believers,” say some colleagues. Years ago, Hickie’s mother told me that her son can be argumentative: “If he thinks he’s right, heaven help you.”

It’s not surprising that when Hickie and McGorry loudly highlight the failings of existing services, those working in these services, often under difficult circumstances, take offence. Indeed, it seems that the major protagonists in recent debates all feel, to some extent, that they have been victims of personal criticisms or slurs. According to Wayne Hall, “There’s an even-handedness in the personal attacks.”

For John Mendoza, the divisions reflect a sector in crisis. “This infighting is typical of a bottom-dweller, dog-eat-dog world where there are so few resources that it breeds this sort of behaviour.” Indeed, a cynic might think that the post-budget schisms represent a convenient outcome for a government previously facing an effective and united lobby with massive public support fanned by the activist group GetUp.

As another mental health policy insider puts it, “As far as the sector goes, we always used to bitch and complain but we did it behind closed doors. Now we’re having an open civil war. That just allows government to say, ‘They don’t know what to do, what the priorities are, they can’t agree. And if the experts can’t agree, then why should we throw public money at mental health?’”

Jennifer Doggett also sees the division as destructive. “I wouldn’t have thought there are going to be any winners from trying to discredit what [Hickie and McGorry] have done. A more constructive approach would be to say that these initiatives can achieve some gains and this is what else needs to be done.” She says that when groups ask for funding, political advisers want to anticipate the likely political fallout. “You can never give them everything they ask for,” she says. “You ask, if we give them 80 per cent, are we going to get beaten up for the 20 per cent we don’t give them? If that’s the case, we may as well give the money elsewhere.”

For those who have followed the longer history of mental health reform, the personalisation of the backlash is not unusual. Over the years, many of those associated with challenges to the status quo have come under bitter attack. On occasions, this has escalated into personal threats and acts of intimidation and violence.

Dawn O’Neil sees the backlash against Hickie and McGorry as in part a reflection of their role as change agents. “I know them both very well,” she says. “I have found them to be incredibly passionate, committed, smart and… I would call them revolutionaries really.”

ON THE wall of Ian Hickie’s office in inner Sydney is a large whiteboard covered with a sprawl of writing, graphs and diagrams that is almost impenetrable to a casual observer. Hickie enthusiastically launches into a vigorous, detailed explanation of the research, clinical and policy questions outlined on the board, despite having just talked almost non-stop for more than two hours.

You don’t have to spend too long with Hickie to understand that “revolutionary” tag. The qualities that make him “good talent” for journalists — someone who speaks his mind without worrying whom he might upset — can also make him unpopular. Or as Hickie himself puts it, he is “disruptive,” “impatient” and a “permanent irritant.”

He doesn’t confine himself to advocating for more money for his sector, but engages in broader health system and societal debate. Much of what he says challenges entrenched interests and the power of groups like the Australian Medical Association and the Australian Psychological Society. He is no fan of fee-for-service healthcare, which he has long argued contributes to inequities; he is a critic of private health insurance incentives, which he says mean “half of Australia gets a much better deal”; and he calls health reform “a damp squib” that has failed to tackle fundamental structural inequities. He offers many examples of the resistance of self-interested professions to change, and says, “Whoever really reforms Medicare, it will probably cost them their political careers.”

Hickie says he can take the heat that is being sent in his direction, but is outraged at the “unsubstantiated personal abuse” being directed at McGorry. “The failure of people to line up behind him like they line up behind Fiona Stanley or Ian Frazer”— both medical researchers and former Australians of the Year — “is disgraceful,” he says. Hickie advised McGorry to take an impressive job offer in the United States a few years ago, warning that he would inevitably face a backlash in the “small pond” of Australia because his ideas were “so transformational.”

While McGorry has been feeling the personal heat in recent months, he says he won’t be deterred from advocacy, and holds with the sentiment that when you engage with the media “you’ve just got to take the rough with the smooth.” He adds that he doesn’t enjoy having a high profile. “I was always a very shy person,” he says. “It wasn’t until later in life I would have been able to do anything like this. I don’t like being the centre of attention; to me it’s a necessary evil to get these messages across. I had to really work at it.”

Hickie says he first began to develop an appreciation for the revolutionary nature of McGorry’s work while running Beyondblue. It was also around then, when I was researching a 2001 profile of the new organisation’s CEO for Australian Doctor magazine, that I first came to know Hickie.

At that time, Harvey Whiteford, a former director of mental health in the federal health department, told me the beyondblue selection panel had been impressed by Hickie’s ability to think outside the clinical box. Harvey told me that Hickie “had a vision for population level mental health, for people who weren’t patients. He had a perspective of mental health beyond the specialist sector.” Hickie suggested that I interview another psychiatrist, Margaret Tobin, who was then director of mental health in South Australia, and used to be his boss at St George Hospital in Sydney.

That connection was one of the reasons I was prompted to write a book about Tobin after her murder in 2002. Inside Madness was also about the difficulties of mental health reform. As I wrote in the epilogue: “Margaret’s life also told a larger history, of the changes that have occurred in mental health care and of the struggles faced by change agents in deeply conservative health systems.”

I mention this to declare a longstanding association with Hickie (who wrote the foreword to my book), and also because researching it helped me to understand how media reporting often favours sectional interests that are resisting change. As well, I think it almost impossible to make sense of the messy, complex state of mental health reform — for which Hickie’s whiteboard seems the perfect metaphor — without some understanding of history.

IN AUGUST 2006, Rob Knowles, who was chair of the Mental Health Council of Australia, wrote to Christopher Pyne, a parliamentary secretary to the Minister for Health and Ageing, about plans to open up the Medicare Benefits Schedule to psychologists. The council had been campaigning for increased access to psychology and other allied health services, but Knowles warned against creating a fee-for-service model that, he said, was likely to result in inequitable access and high out-of-pocket expenses for patients.

He said the reforms should focus on disadvantaged areas and groups, and warned against mirroring the inequity of psychiatry, which he described as one of the most poorly distributed specialist services. He pointed out that the annual per capita rate of Medicare funding on psychiatry varied from 0.31 cents in rural north-west WA to $73.79 in inner southeast Melbourne (while these rates may have since increased, the relative gap is very likely unchanged).

“The current model of fee-for-service payments of psychiatry has led to a situation in Australia where unless you live in the inner metro suburbs of our major cities, access to specialist psychiatric services is extremely difficult,” he wrote. He recommended building incentives into the Medicare reforms to encourage mental health professions to see the most needy clients, and providing incentives to encourage organisations to hire psychologists. “The time-based fee-for-service model remains very popular with many health professionals,” he wrote, “but it does not deliver more services particularly to vulnerable groups and it does not foster a role of consultant physician among mental health professionals.”

Tellingly, many of the letter’s themes were later echoed in the 2009 World Health Organization document, which notes the importance of incentives to ensure that mental health services are distributed equitably and says that systems that result in out-of-pocket payments are likely to particularly disadvantage mental health patients.

Faced with concerted lobbying by medical and psychology groups, the Howard government ignored the Mental Health Council’s advice. Once the program was introduced, demand soon outstripped government projections, with the scheme costing $1.45 billion between November 2006 and June 2010, about 2.5 times more than expected.

The legacy is explored, to some extent, in the recent Senate committee report, but reading between the lines makes two things evident. The first is the power of the professional lobby, whose claims seem to have been accepted by the Senate committee without, it appears, any rigorous analysis of the self-interest involved. To give some context, there are currently 24,000 GPs, 14,800 psychologists, almost 2000 other allied health professionals and 1700 psychiatrists using Medicare items under Better Access. This may represent a lot of patients getting care, but it also represents a sizeable industry.

The second observation is that the evolution of Better Access and the Access to Allied Psychological Services program, or ATAPS, as revealed in the report, neatly illustrates both the competing priorities of efficiency and equity, and the principles of the “inverse care law,” which holds that those most in need of healthcare are least likely to receive it.

ATAPS was established to provide care to the most needy with minimal out-of-pocket expenses. People on low incomes receive two-thirds of all services delivered through the program, and 45 per cent go to rural areas. ATAPS funding is distributed via divisions of general practice and capped, whereas Better Access funds are distributed according to the distribution of providers and uncapped. Under Better Access, 25 per cent of services are delivered in rural areas and the richest one-fifth of Australians receive 2.5 times the number of services and three times more in Medicare rebates than the poorest fifth.

But because it is so much larger than ATAPS, Better Access has provided many services to rural and other historically under-served areas. In the three years from 2007, more than two million people received more than 11.1 million services under Better Access, with costs projected to continue rising. By contrast, ATAPS provided a little over 600,000 mental health services between 2003 and 2009 for a total outlay of $80.7 million (although the budget promised that funds would be increased to $205.9 million spread over the next five years, with a focus on reaching disadvantaged patients).

Not surprisingly, the professional chorus of support for Better Access is deafening compared to that for ATAPS. Even so, the redirection of funds from Better Access has more supporters than the headlines suggest. The authors of the much-disputed evaluation of the Better Access program, Jane Pirkis and Meredith Harris, are on the record as supporting the changes, writing in the Medical Journal of Australia: “We believe the budget reforms have struck an appropriate balance between retaining the core features of a program that appears to be working well while at the same time providing additional resources for important existing and new initiatives.”

Gavin Andrews, a psychiatrist who was on a committee advising the Department of Health and Ageing about the Better Access evaluation, believes the changes to the program are well justified and quite “moderate.” He says GPs had been “on a bonanza,” getting up to $165 per mental health plan, often for minimal effort. Helen Keleher, the head of the Public Health Association of Australia, also supports the reforms. “We do need to rationalise and work out where we do need to put scarce resources,” she says.

Dawn O’Neil believes the government made the right decision on equity grounds, and says psychologists and doctors campaigning against the cuts are not being upfront about their financial interests. “I hope the government doesn’t buckle,” she says. “I would much rather see the saved money go into developing services in the country and rural and regional areas where there is still so little available.” Barbara Hocking, executive director of SANE Australia, adds: “I support the notion of improving access for groups who did not benefit from Better Access. The strong professional groups have been very effective at jumping up and down.”

ONE of the clear messages from the Better Access fracas, however, is that there remain huge gaps in systems of care. While 87 per cent of Better Access patients receive fewer than ten sessions and will not be affected by the session cutbacks, some high-need patients will be hit. Jane Ralls, a GP who is president of the WA branch of the Doctors Reform Society, has a strong professional and personal commitment to equity, and is no fan of fee-for-service. She works in a well-to-do area of Perth but many of her patients struggle financially.

As she describes the plight of several patients who will be hard hit by the Better Access cuts, distress and frustration are evident in her voice. She believes some will be at high risk of suicide. The argument that Better Access was never intended to support patients with complex, long-term problems is no comfort to Ralls when there are no other systems her patients can access.

“What they’ve done is radically reduced a functioning, not-brilliant but reasonably supportive system. They’ve chopped it right back before they’ve made another system available,” she says. “If I had a roof that was structurally unsound, I would not remove it years before I could put in a good replacement. I would patch it while I was waiting.”

Ralls argues that the uptake of Better Access reflects a huge community need, and that it is a mistake to cut one area of mental health to fund another. She also describes young children who are waiting two and three years to be assessed for suspected autism. “We are a really rich country,” she says. “We have lots of money floating around and there is no need to take money out of mental health to put it back into mental health.”

It is impossible to listen to Ralls without feeling concerned for her patients. When I visited a Headspace centre in Campbelltown in western Sydney and an early psychosis intervention centre in eastern Sydney I heard similar stories. But one of the troubles with any debate driven by service providers is that you tend to hear only about the needs of those receiving their services, and not those who, for a whole host of reasons, aren’t. Earlier this year, for another story, I spoke with Anne Chirnside, a GP in Geelong who has been working with young people for many years and is a huge fan of the local Headspace facility where she works.

Chirnside says that young people with chaotic, stressful lives are unlikely to visit a GP, and that the Better Access program has struggled to serve those who need help the most, including those grappling with mental health problems, poverty, drug and alcohol issues, violence and abuse. “Those people are still not getting psychologists because they can’t afford a gap payment or don’t have the level of functioning to get to a private psychologist,” she says.

Chirnside says the integrated care model of headspace is far better for helping people with complex needs. “It’s almost impossible to do this work on your own,” she says. “You need a team to do it well. You need a GP but you also need a drug and alcohol worker, a youth worker and possibly a psychologist.”

She has found Headspace extremely helpful in providing infrastructure to bring together services and to support a team-based approach. “It’s not about tearing down what’s there and building a new thing, it’s about bringing services together, identifying gaps and putting people in those gaps.” But she says Headspace centres will continue to struggle to attract GPs unless better remuneration is on offer. Headspace told the Senate inquiry that the Better Access cuts to GP rebates will make it even harder for them to recruit GPs.

One of many lessons from the post-budget fallout 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, 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 a number of departments now working to tackle issues beyond health, including social and housing support.

The Minister for Mental Health, Mark Butler, says that the main thing he has learnt in 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 and Equity at Flinders University, who is studying how social factors are reflected in national mental health policy, says it is a challenge for policy-makers 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 policy-making 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.’”

If you ask people with psychosis to prioritise, clinical services are not among their top priorities. 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, their main concerns are inadequate incomes, loneliness and social isolation, poor employment opportunities and poor physical health. Mental health comes in fifth.

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 per cent of children 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 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.”

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 for regular, population-based studies of children’s health and wellbeing. “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 wellbeing 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 talking 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 eighty-year-old psychiatrist 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 around 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 or bipolar, or to 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 per cent 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.”

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 very hard 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 for policy-makers 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 1 January 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 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.” •