Inside Story

The personal and the political

Why do we find it so hard to direct mental health spending to the people who most need it?

Jennifer Doggett 15 June 2019 3989 words

Powerful interests: health minister Greg Hunt speaking at a mental health forum in Adelaide last July. Kelly Barnes/AAP Image

Reappointed to the job he held before the election, Greg Hunt has nominated mental health as a central priority and set an ambitious goal of reducing the youth suicide rate to zero. The health minister’s commitment is longstanding and partly personal, informed by his mother’s bipolar disorder and the suicide of a close friend’s brother.

But his success will depend on a willingness to challenge the way mental healthcare is funded and delivered. Australia’s provider-centred, episodic model of healthcare needs to be abandoned in favour of a coordinated, consumer-focused system that works across jurisdictional and sector boundaries and prioritises patients with the greatest need.

To understand why this must happen, the minister need only look at Australia’s mental health statistics over the past ten years. With an unprecedented, decade-long investment by both sides of politics, the mental health sector should be thriving. Spending by governments in all jurisdictions has grown steadily and is expected to hit a record $9.8 billion next financial year.

The result has been an explosion in certain kinds of mental health services. Between 2006–07 and 2016–17, the number of Australians receiving Medicare-subsidised mental health services doubled from 1.2 million to 2.4 million. In each of the five years to 2016–17, the rate of overnight mental health–related hospital visits increased by an average of 3.9 per cent, four times the rate of physical health admissions.

Medication use has also increased significantly. Around one in every twenty people received a prescription for mental health medication in 2004–05; by last year the figure had quadrupled to almost one in five, or 4.2 million people.

Never before have so many Australians been counselled, medicated or otherwise treated for mental health problems. If increased funding and greater access to care delivered better outcomes, then Australians would be enjoying better mental health than ever before. Yet our performance seems to be stagnating or even going backwards.

In 2004–05 around 5 per cent of the population reported experiencing either anxiety or depression; the most recent National Health Survey, for 2017–18, put the figure at 10 per cent (for depression) and 13 per cent (for anxiety). One reason for these findings, of course, may be that reduced stigma has resulted in an increased willingness to report these illnesses. But other signs suggest that Australians are experiencing unprecedented levels of mental illness.

Australia’s suicide rate has increased over the past decade and is now among the highest in the OECD. More than 3100 died this way during 2017, an average of almost nine deaths per day. The rate among Aboriginal and Torres Strait Islander Australians is double that of non-Indigenous Australians.

More broadly, both consumers and providers report that inadequate community-based mental healthcare is leading people to present in crisis at hospital emergency departments. Even within dedicated mental health facilities the rate of restraint, seclusion and other forms of coercion is unacceptably high.

People with experience of mental illness also report discrimination and barriers to gaining access to basic services. Rates of homelessness and unemployment are high among people with more severe mental health conditions, and those with a range of mental health conditions continue to die around ten years earlier than those without, frequently from physical health problems only indirectly related to their condition.

At the heart of the problem is a failure that, on the face of it, seems quite simple. Current mental health policies and programs have proved unable to target services to those with the highest level of need. While they have unquestionably helped more people get access to psychology services and reduced discrimination and stigmas, former NSW mental health commissioner John Feneley tells me, the focus has mainly been on the more common but less severe mental illnesses, such as mild depression and anxiety.

As a result, Feneley believes, and despite the enormous efforts of front line staff and some isolated examples of improvement, most people with more severe and persistent illnesses, such as psychosis, bipolar disorder and eating disorders, have not benefited from the record increases in spending. And if we aren’t improving outcomes for this group of people then we can’t claim that our overall approach is working.

Reorienting the system to prioritise the needs of people with more serious problems would mean reassessing big-ticket mental health initiatives like the Medicare-funded Better Access program, and challenging some of the basic principles of our health system, such as fee-for-service funding.

By making mental healthcare accessible to a much wider group of consumers, Better Access has been a game changer. But it operates within a traditional private medical model, with providers free to practise wherever they wish and set their own fees. Doctors and psychologists are concentrated in more affluent areas, where co-payments of around 25 per cent are considered acceptable. Barriers of both cost and geography face people in lower socioeconomic and rural areas.

Monash University’s Graham Meadows has mapped the distribution of services provided under Better Access. He found that, per 1000 population, Better Access funded sixty-eight clinical psychologist consultations each year in the wealthiest one-fifth of areas, and twenty-three in the least wealthy. The pattern of need is the other way round.

Meadows — a professor of psychiatry who directs Southern Synergy, the Monash Health Adult Psychiatry Research, Training and Evaluation Centre — describes Better Access as “basically government-funded private mental healthcare which encourages practitioners to practise in more affluent areas, because that is where they are financially rewarded, rather than where they are most needed.”

Even apart from economic and geographic disadvantage, many people with complex mental illnesses and cognitive impairments find mainstream services difficult, if not impossible, to access. The system relies on individual consumers identifying their need for care and independently contacting the relevant service providers and managing their treatment. Better Access funding is limited (in most cases) to six psychology sessions, and lacks scope for team-based, multidisciplinary care.

Other experts identify the therapies provided under the program (mainly cognitive behavioural therapy and “talking” therapy) as having inherent class and social biases that make them less attractive to many groups, including men. (About 60 per cent of all services under Better Access are provided to women.)

For Sebastian Rosenberg and Ian Hickie, writing in the Medical Journal of Australia, the program highlights “Australia’s willingness over the past two decades to ‘fix’ mental health by prioritising increased access over systems that promote enhanced quality or monitor health or functional outcomes.” They point out that the program operates with little or no accountability at the practitioner or national policy level, and ignores recent evidence of the importance of patient-centred measures of quality, multidisciplinary approaches and the use of technology. “A more intelligent response to mental illness,” they conclude, “means taking a broader view about how best to arrange quality care and then properly assessing the impact of that care on a person’s life.”

If Greg Hunt is to prioritise results over access then he will need to reassess his commitment to Better Access. But, as Graham Meadows warns, programs like that can be hard to draw back from, even if they are not delivering good value to the community. Meadows believes that Better Access has created a sense of entitlement to a certain type of mental healthcare and a workforce expectation that the funding stream will continue. Removing these funds would significantly disrupt consumers and providers. Other options, such as a gradual reduction in the rebate, may also be problematic, as they could lead to higher co-payments and increase the inequities that already exist in the program.

Part of the problem is the fact that, unlike most other mental health programs, Better Access operates within Medicare, which means its budget is uncapped and its funding grows to meet demand. Not surprisingly, spending on the program has risen every year since its inception in 2006, and it now costs around $16 million every week. No simple mechanism is available for Hunt to restrict spending under this program, and Better Access’s steadily increasing budget over the past decade will also make it difficult for him to convince his colleagues to allocate any more funding for mental health programs.

A recent proposal from the Australian Psychological Society highlights the challenge. It attempts to deal with some of the program’s shortcomings by creating new Medicare item numbers for online and phone services and doubling (to forty) the number of services consumers can receive under the program. While this might increase access for some consumers not currently well served by the program, it would do so at significant cost to a budget already growing well in excess of health inflation. Nor would it tackle the needs of consumers with more serious conditions for support across a range of domains, including housing, income and physical health. Only a long-term, team-based commitment will do that.

Adding to the challenges facing the health minister is the array of high-profile personalities and organisations that dominates the mental health sector. Many of them have been successful in attracting funds for their areas of interest and influence, but some critics question whether these funding decisions have been influenced more by their status and profile than by evidence of health outcomes.

John Mendoza, director of ConNetica, a mental health and suicide prevention enterprise, and an adjunct professor at Sydney University, describes this approach as “funding mental health brands rather than mental health care.” John Feneley agrees: “There are high-profile individuals and brands in the mental health sector and some of these carry significant weight and influence. This can make it difficult for ministers and those responsible for allocating mental health funding to focus on the needs of the community.”

For Feneley, governments will always be tempted to give prominent people enough money to keep them quiet, rather than the harder task of investing resources where they are most needed. To overcome this effect, he believes it is important for policymakers to have a conversation about mental health without any “brands” in the room, which he concedes to be, politically, “virtually impossible.”

One of these brands is the youth mental health service, Headspace. Headspace has been supported by both sides of government and has a number of vocal advocates, but it has also been criticised for failing to deliver on its promises.

No one disagrees with Headspace’s goal of providing “tailored and holistic mental health support to twelve- to twenty-five-year-olds.” As Sydney University’s Sebastian Rosenberg comments, “75 per cent of mental illness manifests before age twenty-five, so the key to the future mental health of the community is determined by how well we can prevent, treat and manage mental illness in young people and support them to finish their education, enter the workforce and participate in the community.”

But Rosenberg and other mental health experts are questioning whether Headspace is achieving the outcomes claimed for it. “Very few Headspace services can deliver on their original vision: that any young person with mental health symptoms could turn up and receive high-quality care,” he says. “Many Headspace centres don’t even have a GP and often turn people away if they have associated drug and alcohol problems or any suicidality. This means that those young people then have to run the gauntlet of the public system, where we know they are unlikely to get the care they need.”

This view is backed up by an independent evaluation by the University of New South Wales, which found that Headspace delivered only a “small program effect.” Less than a quarter of young people treated showed significant improvements and about one-in-ten experienced a decline in their condition. Headspace’s “one-size-fits-all, shopfront approach” was failing to meet the needs of young people from diverse backgrounds, the report found, including those with complex mental health problems. A lack of data on the effectiveness of the program was also concerning, as was the potential for centres to duplicate or compete with existing services.

Like Better Access, Headspace appears to have delivered increased access without significantly improving outcomes. Hunt clearly still has faith in the program, though, and has allocated it an additional $208 million since October. But if Headspace remains inaccessible to the most disadvantaged and critically ill young people, it is unlikely to assist him to meet his goal of eliminating youth suicide. Hunt’s challenge in this area will be to balance support for standalone programs, such as Headspace, with a more decentralised approach that better integrates existing health and social services to respond to diverse mental health needs in local communities.

Another challenging area for Greg Hunt, and a highly visible element of the health sector over the past two decades, is mental health promotion. In fact, some organisations, such as Beyond Blue, are dedicated almost exclusively to raising awareness of mental health issues in the community through high-profile campaigns, sponsorship and even merchandise. Yet some experts, including John Mendoza, doubt that mental health promotion has achieved any significant health outcomes.

“Australia has probably spent more than the top ten OECD countries combined on mental health promotion and yet we have arguably the highest levels of mental health problems among the top OECD countries,” he says. “Awareness, stigma reduction and help-seeking campaigns and activities have been the focus of this work and yet we see almost no measurable outcomes in terms of higher employment rates for people with mental illnesses, fewer human rights abuses, or lower prevalence rates of psychological distress, anxiety or depression.”

It’s easy to see why health-promotion campaigns might appeal to governments and bureaucrats in an area as complex as mental health. When faced with a problem that has no easy solution, a health-promotion campaign can give the appearance of decisive action without actually changing the delivery of healthcare. Health-promotion campaigns also have the advantage of rarely annoying powerful stakeholders in the way that changes in policy, funding and legislation can.

What is clear from Australia’s investment in mental health promotion over the past two decades is that high-profile organisations, well-known “ambassadors” and well-funded campaigns don’t necessarily result in improvements in health. Tackling this and other problems means questioning not just the specifics of previous policy and strategy failures but also leadership and governance structures in this complex sector.

There, the national peak body Mental Health Australia, or MHA, is responsible for advising the government. MHA heads a network of state- and territory-based organisations that oversee mental health policies and programs in their jurisdictions. In theory, these organisations should provide frank and fearless advice on mental health policies and programs, but some stakeholders allege a lack of independence and credibility.

“MHA has been colonised by people close to the government and won’t speak out on anything controversial,” says Mendoza, the organisation’s former chief executive. “It is no longer a source of independent advice and policy critique and has only released one report in the past eight years.”

Feneley credits the current system with steering some major policy shifts in the sector, including a commitment to the deinstitutionalisation of people with mental illness and/or other disabilities. But it has not achieved the coordinated and integrated system of community-based mental healthcare that is essential for a deinstitutionalised model to be sustainable.

The Australian College of Emergency Medicine also questions MHA’s effectiveness, pointing in particular to the fact that it cannot enforce policy implementation and so has limited influence over funders and service providers. The college cites the failure to implement many of the recommendations of the Fifth National Mental Health and Suicide Prevention Plan and its predecessors.

Others say the problem is poor coordination between jurisdictions, rather than governance failures. Programs with mental health implications, including the National Disability Insurance Scheme and the Primary Health Networks, are implemented on top of each other, they say, without coordination or consideration of how they will interact.

John Mendoza is concerned by the bureaucracy’s broad inability to provide robust advice to governments on mental health issues. “The Department of Health lacks the necessary content knowledge to provide quality advice to governments,” he says, “which then rely on the views of a small number of ‘experts’ who often push their own interests at the expense of good public policy.”

One recent example was the injection of $1.45 billion for mental health services, over three years, into the Primary Health Networks, or PHNs. While this funding, announced by Hunt in January, has been welcomed overall by stakeholders, the general feeling is that it will do little to alleviate the significant unmet demand.

“There are some good aspects to new PHN funding — in particular, it rewards well-performing PHNs with continuity of funding [for three years],” says Rosenberg. “But while the quantum looks good, when broken down over thirty-one PHNs it is not very much, and most of the funding is just rubber-stamping programs the government has already committed to, such as Headspace, with very little capacity to do robust regional planning and fill service gaps.” Greg Hunt continues to fund national programs, such as Better Access, at a high level yet virtually ignores PHNs, he says. “It’s also important to realise that PHNs have no leverage of legal authority to influence service providers. They just rely on their networking and relationships to drive change.”

Meadows agrees. “When it’s distributed, the additional funding works out to an extra $1.5 million per PHN per year over three years. This might sound like a lot, but much of it will be taken up with wage increases, so basically they are just standing still.” And PHNs are so small a component of the mental health sector that they can’t be expected to achieve much.

Despite their current lack of influence, though, PHNs do appear to be Hunt’s best option for tackling unmet demand for mental health services. PHNs are the only organisations across the country capable of linking GPs, psychologists and other health providers with state-based health and social care organisations, such as Local Hospital Networks, to create the “joined up” care needed by people with more serious mental health conditions. But they can only do that effectively with a significant increase in funding, which is unlikely in the current environment.

That’s not because Australia is overspending on mental health. In fact, despite the increase over the past twenty years, most experts argue that Australia should be spending more. They cite evidence demonstrating that while mental illness contributes around 12 per cent of the total burden of disease, expenditure on mental health services comprises less than 8 per cent of the health budget.

And, again despite recent increases, the growth in funding for mental health over the past decade has not been enough to meet the rising demand for care. In fact, the annual $9 billion spent on psychiatry is a smaller percentage of health expenditure now than it was in 2010–11. But the health minister will find it difficult to argue for more mental health funding unless he has a better plan for coordination and for reining in the spending growth of uncapped programs such as Better Access.

As minister, Greg Hunt has avoided radical moves in favour of incremental change, which won’t deliver the necessary improvements in Australia’s mental health. But experts are united on the need to do things differently. Meadows proposes that the first step should be a comprehensive audit of current service provision and gaps. He also believes that it is crucial to get indicators of equity into performance agreements, so that providers have the incentive to focus on areas of need and look at alternative methods of service delivery, such as computer-aided consultations. “A single mum may not have a car or childcare, so traditional care is difficult to access, but she probably has an internet connection.”

Rosenberg broadly agrees, but believes that the reforms required need to start with greater clarity about what we are aiming for. “Are we trying to avoid an unnecessary hospital admission? Cure the illness? Get them employed? Address homelessness? Unless the broad goals of government policies and programs are defined, we don’t know whether we are measuring the right thing and have no idea what success looks like.”

He and Professor Ian Hickie have posed five questions they believe need to be answered in order to establish the basic infrastructure of effective mental healthcare. These focus on developing pathways for care, determining the optimum workforce mix and implementing payment systems that drive improvements in results.

Feneley supports greater collaboration between the PHNs and LHDs to ensure that regional planning is relevant to local needs, and identifies a lack of funding for team-based work as a key barrier to integrating services at a local level. “A team approach is crucial for many people with for severe and persistent mental illnesses,” he says. “There is little or no funding for GPs, psychologists and psychiatrists to work in a team-based environment with other health and social care professionals.”

Meadows also suggests looking at fundamental changes to Medicare, such as the Medicare Select option proposed by the National Health and Hospitals Reform Commission in 2009. “If we had multiple insurers — for example via a model like Medicare Select — there could be more care options available to people with low co-payments,” he says. “Our current system effectively enrols everyone in a single insurance system which does not guarantee the availability of services and has no restrictions on co-payments.”

Other options he believes to be worth considering include increasing the Medicare rebate for mental health consultations to 100 per cent of the schedule fee and making it illegal to charge co-payments for mental health services. He also suggests that restricting new provider numbers to areas of need would help tackle the maldistribution of providers, although he concedes that this might violate section 51 of our Constitution (the section that prevents Australia from introducing UK-style remuneration of doctors).

Among mental health consumers are advocates arguing for even more radical changes. Some consumers describe the current approach to mental illness as an overly medicalised reflection of the experience of providers rather than that of consumers. They believe that current treatments are often ineffective or even harmful.

Consumer advocate and peer worker Tim Heffernan describes the use of coercion within the mental health sector (when people are forced to accept specific treatments, for example) as a “huge issue,” leading to mistrust of the system, a reluctance to seek help and an overall worsening of problems, sometimes resulting in seclusion and restraint. “Trust between healthcare professionals and consumers is crucial to successful recovery. Coercion undermines this trust,” he says. “Of course, under the Mental health Act people can be detained involuntarily,” he clarifies, “But their ability to make informed decisions about their treatment should always be respected.”

Heffernan gives international examples of successful consumer-focused, non-coercive approaches that don’t centre on “medicines and psychiatry.” These include Open Dialogue and the “Trieste” model, which have a proven track record but are not widely used in Australia. He is also a strong advocate for the use of peer workers in the mental health sector and has seen programs based on this model achieve impressive successes. “Peer work is about supporting each other in a compassionate way, listening to people and sharing their journey,” he says. “Support like this from a peer worker can be just as effective as clinical treatment.”

Given these very different views about the nature of mental illness and approaches to treatment, it is understandable that governments might be tempted to back the most promising (or prominent) policy options at the expense of the alternatives. But it is clear that this strategy has led Australia down an expensive and ultimately ineffective path.

Reversing the mistakes made in the past will not be easy. But John Mendoza believes there is an upside to be found among the myriad policy and program failures: “Mental health stakeholders are very motivated to get together to do something about it.” If he’s right, this might be just the backing Greg Hunt needs to take on some of the vested interests and make the necessary changes. •