SSWAHS = SWSLHN and mental health in the Southern Highlands - 8

What will it cost to move beyond “60 years of band-aids” for mental health?

April 6, 2011 – 1:41 am, by Melissa Sweet

Continuing the theme of recent Croakey posts on mental heath and the federal budget, John Mendoza argues that it’s well past time we moved past band-aid solutions. Instead, Australia needs to spend about $9-10 billion per annum on mental health services, or around 12% of current health care spending, he says.

John Mendoza writes:

In the past week there has been another round of calls from a variety of groups for major investments in mental health. These have in part being timed to influence the framing of the May Federal Budget. These have included calls for an extra $5 billion over five years from the Australian Medical Association and others.

A Blueprint to Transform Mental Health Services was also released and called for an investment of $3.5 billion over the same period. This came from an “independent mental health reform group” lead by Professors Pat McGorry and Ian Hickie and Monsignor David Cappo.

The latter are all members of the expert advisory group announced by Minister for Mental Health and Ageing, Mark Butler and the Prime Minister late in 2010 after a year of mounting calls for action on mental health. Minister Butler chairs both this group and the National Advisory Council on Mental Health.

Federal Labor knows that it must deliver a substantial boost to mental health funding come the May Budget after the chorus of criticism in 2010 and its oft stated pledges to make “mental health a second term priority”.

The “Blueprint” document released by McGorry and co has been largely positively received. Some criticisms – including the Croakey piece from Alan Rosen – from within the mental health sector have focused on the government’s piecemeal and confused approach to consultation (not the fault of the Blueprint authors I would have thought).

Rosen’s criticisms point to the omission of some evidence-based services including assertive community treatment teams, better forensic mental health care for the vast numbers of people with mental illness in corrections systems and the inadequate size of the investment.

Criticisms were also voiced by consumers at the ACOSS conference last week on the failure to advocate for the re-establishment of a national consumer representative body following defunding of the body by the Department of Health and Ageing in 2008.

In their defense, McGorry and colleagues say the 30 initiatives in the Blueprint are areas where the Commonwealth can act with or without state government cooperation and with a large dose of realism given the “tight Budget” rhetoric of the Government. They also believe that if the Commonwealth can get its act together, as it did under the leadership of Howard in 2006, then a commensurate investment could be forthcoming from the states and territories.

This would be a massive $7 billion over five years building on the $5 billion flowing from the 2006 COAG action plan.

The Australian public are entitled I would have thought for someone to tell them what amount of new funding is required to fix the seemingly contiguous crisis in mental health services.

Firstly, it’s important to understand no presently serving politician in either Federal or state governments created the shambles we now see in mental health in Australia. But all those First Ministers (i.e. PM, Premiers and Chief Ministers) and the respective state and territory Ministers have an opportunity to join a very small group of politicians who have taken bold and effective action in this area. To succeed, they will need to respect history in mental health reform efforts.

Australia has had a long history of responding to crises within mental health services. Indeed Prime Minister Menzies was forced to act following widespread and continuous public concern about the state of services in 1954. Somewhat reluctantly, Menzies and his Health Minister, Earle Page, appointed a Melbourne psychiatrist Allan Stoller, to review mental health care. Stoller was “shocked” by what he found – inhuman conditions, overcrowding, little or no therapeutic care, abuse and neglect. Menzies responded with a capital grants program to modernize the facilities. While some work was done, within six years, again public concerns forced the NSW Government to set up a Royal Commission into mental health services.

This cycle of crisis, review, government action and then within a decade another full cycle, has now characterized mental health reform in this country for close to 60 years.

There are a number of reasons for this, but a consistent one has been a failure by both state and Federal governments to ever undertake a systematic assessment of service requirements. No one has even taken up the challenge to fully scope requirements: the range of services based on available evidence, the scale of services to meet demands and then commit the funds to the development.

The consequence is that we have had 60 years of bandaids applied to mental health. We see dozens of excellent programs or small scale programs all round the country that have never been scaled up or linked with a spectrum of care to support recovery in the community.

The implementation of the policy of deinstitutionalisation from the 1960s to the so-called community based services of today, represents arguably the greatest failure of public policy in the post-war period.

The calls in the last week for major new investments in mental health, while they will improve the access to services and quality of some services, they will fall far short of providing people with mental illness with equality of care when compared with those experiencing physical health problems.

Both Pat McGorry and colleagues and the AMA have presented pragmatic proposals – proposals that take account of the political context. That’s fair enough, but it runs the risk that again we have another band aid – albeit maybe a full size plaster!

The question remains how much do we need to invest in mental health to end this terrible history of neglect? The Senate in 2006 argued that between 9-12% of health expenditure was required. The Mental Health Council of Australia has long argued for the 12% figure. Rosen is his Croakey article refers to 13% of health spending up from the current 7%. All of these are simply sound estimates.

Two health economists, Darrell Doessel and Ruth Williams have attempted to take a more analytical approach and they find that current resources and structures meet about 35% of the mental health needs of the community. They also find that significant resources go to those without a mental health need – in essence a wasteful use of scarce resources. Using their analysis and assuming one could significantly reduce the resources going to ‘non-needs’ as they define them, the funding required to provide for the mental health needs of the Australian community is in the order of $9-10 billion per annum. Maybe coincidentally, this is close to the 12% of current health care spending that many have called for and is almost double the current combined spending of all Australian governments.

This is an enormous challenge and one which will only be solved through a more strategic and sustained 10-15 year reform agenda. We also need to put in place as a first step, an appropriately empowered Commonwealth statutory authority to drive the restructuring of services and report to the Australian community on the progress and the outcomes from this investment.

• John Mendoza is Director, ConNetica , and Adjunct Professor, Health Science, University of the Sunshine Coast, and Adjunct Associate Professor, Medicine, University of Sydney

Comments

1. Shooba
   Posted April 6, 2011 at 9:24 am

   I don’t want to hijack the conversation here, because I think “what portion of the budget should go to health” is a conversation worth having… but… surely bowel cancer screening is priority one? Croakey’s fixation on mental health and physician assistants recently has kind of duopolised discussion at the expense of topics like the FOB test and its glaring need for a full national program

2. Shooba
   Posted April 6, 2011 at 10:08 am

   Awww shucks Croakey… you DO listen!

3. Melissa Sweet
   Posted April 6, 2011 at 10:10 am

   Shooba, I was just about to comment and say: your wish is my command (well, at least sometimes).
   But you got in first…

SSWAHS = SWSLHN and mental health in the Southern Highlands - 7

Explaining the new blueprint to transform mental health services

April 4, 2011 – 12:09 pm, by Melissa Sweet

This post is responding to a recent Croakey article, “So you’re wondering what’s happening with mental health at a federal level?”, by Professor Alan Rosen.

Sebastian Rosenberg and Professor Ian Hickie write:

Alan Rosen’s recent article raises some important points and the need to clarify a couple of issues.

He is certainly right that the recently released Blueprint to Transform Mental Health Services in Australia is not the whole solution to fixing mental health. There are evidence-based services apart from those specified that would indeed merit ongoing investment, including assertive community treatment, mobile acute teams etc. However, as services largely provided by states and territories currently, they were simply out of scope in terms of providing a budget submission to the Commonwealth.

The crazed determination to deliver a budget surplus is now forcing Prime Minister Gillard and her Ministers to seriously lower expectations about the budget, wet the ground for the traditional horror-budget which typifies the first year of most administrations. As reported in countless parliamentary and other inquiries, mental health is so far behind the game that it cannot afford to be caught up in this.

The Independent Mental Health Reform Group which prepared the Blueprint was an informal group which got together for a few weeks specifically to keep some blowtorch of pressure on the Federal Government to make good its promise to make mental health a second term agenda priority.

The Group was comprised of the usual suspects in some ways, people with a long track record of cajoling governments into greater action and investment in mental health. The Blueprint merely reflects the views of the Group, which never intended and was never resourced to undertake broad public consultation.

Unlike the impression given by Professor Rosen, the Group was not constructed, mandated or authorised by Minister Butler or anybody else and had no relationship to any existing committee or body. Minister Butler did not commission the Blueprint. The presence of Monsignor David Cappo meant that the group did have an excellent insight into how best to shape and present its advice to government however there were others on the group with an excellent understanding of the federal budget process.

The Blueprint is one of no doubt myriad budget submissions made by different professional and community groups, attempting to influence the direction and scale of Federal Budget decisions. It is certainly true that key health professional groups have already made formal budget submissions, such as the Australian Medical Association and the Australian Psychological Society. It is less clear the extent to which community sector organisations have made submissions.

Professor Rosen is correct in that the Blueprint really focuses on clearly listing actions the Federal Government is able to take autonomously, without reference to state or territory jurisdictions. This inherently limits the scope of the Blueprint but fits with the imperative to provide urgent advice about intelligent Federal spending options in the upcoming Budget.

As far as we know, there has been no commitment to establish a second National CoAG Action Plan on Mental Health, to replace the first plan which lapses this year. If a second plan is proposed, then the Blueprint lists a series of vital areas of state responsibility where their contribution to a new CoAG plan should be directed. These areas do not include continued mindless investment in new acute hospital beds.

The Blueprint also clearly states the need to ensure that mental health’s share of the promised new 1300 sub-acute beds is not allowed to create new hospital-based warehouses to catch the overflow from psychiatric wards.

Professor Rosen is correct in asserting that CoAG-type intergovernmental agreements seem to fail more often than succeed. However, should a second CoAG Action Plan be agreed, we would strongly suggest the establishment of a clear set of Commonwealth incentives and sanctions to persuade the states and territories to purposively fund the areas identified as priorities in the Blueprint, particular the type of evidence-based community services described by Professor Rosen, or other community-based innovative services. This type of approach to incentives was actually successful in the First National Mental Health Plan and really not attempted since.

While this type of coordinated action is important for holistic reform investment in mental health in the future, the Blueprint represents the vital contribution the Commonwealth can make right now. So let’s get on with it.

• Sebastian Rosenberg and Professor Hickie are from the Brain and Mind Research Institute at the University of Sydney

Comments

1. skipjack
   Posted April 4, 2011 at 4:39 pm

   The closing of institutions has let to people being thrown onto the street and at the mercy of for profit providers of accommodation where there are no nurses or mental care at all. They call them hostels but they are really flea pits. And this was meant to be an improvement on institutional care.
   I have a mother in a mental health ward, and I just want to say that we need to bring back the word ‘insane’ to differentiate the truly sick, who need full time care, from those with temporary mental illnesses and illnesses not requiring full time care.
   Bring back care for the insane, and stop throwing them onto the street – or into the hands of private sector jocks who rip them off in flea infested hostels.

2. Tully Rosen
   Posted April 5, 2011 at 11:26 am

   Yes let’s!

   Those pushing for mental health reform may not always agree point-to-point, but we’re harmonising like never before on the basic problem – we need billions invested in the mental health system – and it must be community-integrated and ongoing!

3. Tully Rosen
   Posted April 5, 2011 at 11:27 am

   And congratulations by the way for taking the initiative.

SSWAHS = SWSLHN + SLHN and mental health services in the Southern Highlands - 1

So you’re wondering what’s happening with mental health at a federal level?

April 1, 2011 – 6:08 pm, by Melissa Sweet

Note to readers: Please see author’s correction at bottom of the post.

At this time of year, there is always a lot of pre-budget jockeying. This year there is great expectation and also great apprehension about what the Federal Budget might hold for mental health.

Mental health advocate Professor Alan Rosen has been watching recent developments closely, and his analysis follows below (at the bottom of the post you will find an invitation to provide feedback to the Federal Government’s mental health advisors).

Professor Alan Rosen writes:

"The bookies seem to know what every election result will be. So why did we bother having Saturday’s NSW election? Couldn’t we just extrapolate from where the odds stand at midnight on election day?

"Then we could spend the Electoral Commission’s budget on our run-down mental health services. Maybe, on past disappointing form, we should not even wager our lunch on having much of a boost for mental health on budget night, despite Julia Gillard’s insistence that it is a 2^nd term priority. (Perhaps it should be called budget-smugglers’ night, to celebrate that dark art of sleight of the contents of taxpayers’ pockets?).

"But the longer the Government keeps postponing the crying need to reform Mental Health Services, the more that the growing affected community will keep raising the stakes. It is a dead-cert that it won’t just go away as an issue if ignored. In an international survey last year, foremost among all countries, the Australian public placed mental health services as one of its top 3 concerns, alongside the global financial crisis and climate change.

"Sensing the disquiet and impatience of the burgeoning Australian mental health constituency, Mark Butler, the federal Minister for Mental Health, recently put out an update letter about his deliberations with his expert committee, which said next to nothing about what they might be proposing in their advice to him, about which they were all sworn to secrecy.

"It may be that he is engaged in a delicate negotiating process to squeeze something substantial out of the tightening federal budget, but for what purpose?

"It is a bad move not to take this seasoned network into your confidence on your way. It is laudable that early in his tenure, Mr Butler did a whistle-stop tour around Australia, running brief group consultations in urban and regional centres.

"But that was before he installed his expert panel to develop these proposals. The fact is that he does not seem to have foreshadowed any wider consultation process, on any actual proposals. He has commissioned a separate kitchen committee, derived partially from his expert group, to develop a “blueprint”, published not as a draft out there for consultation, but as time is of the essence in the budget build up process, as a finished submission to be taken urgently to Treasury, hopefully for funding*.

"There is a lot to commend in its striving for a transformative approach, and its shopping list of “evidence based best buys” for different age groups. So far so good.

"However, many of its proposed structures for adults though possibly promising, are substantially untested. We need time to produce some evidence that they work, because we don’t want to repeat the blatant wastage caused under Howard’s CoAG initiatives like Better Access, perpetuated by Nicola Roxon.

"Even more concerning is that the real firmly “evidence-based best buys” for adults with severe and persistent mental illnesses, especially with forensic, drug and alcohol comorbidities, have been left out. These include (acute) 7 day and night mobile crisis and continuity of care teams, assertive community treatment (rehabilitation) teams, and 24 hour residential respite households as an alternative to many admissions.

"The Blueprint group can’t back this trifecta, we are told, because their riding instructions stated that these are viewed federally to be state responsibilities, particularly since the states wouldn’t relinquish that 30% share of GST. This could almost be construed as a washing of hands in retaliation.

"At whose expense? These proven service delivery systems will become orphans, and many severely disabled clientele will continue to be clinically abandoned.

"Most states squandered the resources allocated for them long ago, by diverting them to medical and surgical procedures, and by failing to complete the disgorging of stand-alone institutions, preventing the shift of some of their resources to community care. With few exceptions, this has resulted in stunted development or dismemberment of such evidence-based mobile community-based mental health services, and often the retraction of their rumps back onto hospital sites.

"A little under $2 billion over 5 years is required to provide firmly tied funding to the states to restore these key teams, including rural adaptations of them Australia-wide, and to monitor, this time around, their outcomes and fidelity to evidence via a national mental health commission.

"Either that or they will need a contractual arrangement with the states to meet them half way if they want the money, not just via another CoAG agreement, which is bound to be broken.

"The AMA is completely right that we need at least a commitment of $5 billion over 4 years, partly to make up for lost time and lost people. Most in the mental health community would differ with some of the AMA priorities for this funding, however. By my rough reckoning we need at least $5.5 billion over 5 years to kick-start a national mental health program with reasonable expectations of success.

"Professors McGorry and Hickie are overly modest in their estimates of what is required to deliver an effective transformation of the mental health service system, saying they will settle for around $3.5 billion over 5 years.

"This government also needs to commit resources to:

• a widely consultative process, arriving at a rough consensus inside a few months, about priorities and a framework for a national mental health reform program for the next 10 years, integrating public, non-government and private, including fee-for-service sectors. By now, this national mental health taskforce should be out there seeking a broad consensus for this national mental health program. It must overarch the superficial revamps of the national mental health policy, plan and standards, all devoid of practical goals and timelines, which have been diluted and downgraded in political compromises between state and federal bureaucracies. Gillard & Butler & co, need to hunt the money, but they also should not waste this build-up of expectation, momentum and opportunity for really consultation leading to transformative reform. If we are really into social inclusion, we need to practice what we preach.

• a National Mental Health Commission, as also proposed in “the Blueprint” like New Zealand, Canada, and now Western Australia, and soon NSW too, which promotes the resourcing and monitors the implementation of the reform agenda at arm’s length from government, while constantly consulting with all stakeholder groups, and reporting on an all-of-government scorecard basis to the Prime Minister, Health ministers and parliament.(Link to Rosen et al 2010, International Mental Health Commission review).

• Regional integrative budget-holding commissioning authorities ( as established in New Zealand, the UK and now on a statewide basis in WA, and soon to be formed in NSW ) ensuring integration of all mental health and support services, by being able to purchase flexibly from all funding streams, public, non-government communally managed, and private health organizations if need be (Link to AHHA paper on Funding Methodologies 2008).

• We need government to find new resources to bring the mental health proportion of health budget, currently sinking from 8% to 6%, up to 13%, closer to the proportion of health burden due to mental ill-health, as most other developed countries have done.

"As clinicians, we need to follow the form and play the system squarely in the interests of our clientele and their families, in every age group and phase of care.

"And we don’t need yet another policy shoot-out between the parties to entertain the political punters.

"We need a consistent tripartisan commitment to integrated collaborative mental health care for the whole Australian community.

"So while we can’t yet bet safely on the fate of mental health in the federal budget, either way, let’s hope it romps home.

"*However, the authors have placed it in the public domain, and Professor Ian Hickie of the Brain & Mind Research Institute, Sydney, has now undertaken to invite and collate comments by email. Contact: Ian Hickie

TAMHSS (Transforming Australia’s Mental Health Service System, tamhssATyahoo.com.au) will take and list comments publically on its blog from Monday 4^th April 2011.

• Professor Alan Rosen holds positions with the Brain & Mind Research Institute, University of Sydney, and School of Public Health, University of Wollongong.

2 Comments

1. achimova1
   Posted April 1, 2011 at 7:35 pm

   Interesting that the RANZCP was not asked to field a delegate.

2. Melissa Sweet
   Posted April 1, 2011 at 9:59 pm

   Correction from Alan Rosen:

   Note: It has been drawn to my attention that there is an error of fact
   in the 2nd part of the 7th paragraph. It should read:

   “The fact is that he does not seem to have foreshadowed any wider consultation process, on any actual proposals. Meanwhile, a separate little committee, derived partially from the minister’s expert group, and including his designated deputy, Monsignor David Cappo, convened to develop a “blueprint”.