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 and mental health in the Southern Highlands - 6

Better Access debate rages

21st Feb 2011

Catherine Hanrahan all articles by this author

2 comments

CONTROVERSY continues to dog the Better Access mental health program, with two new studies reporting conflicting results about equity of access for disadvantaged people.

University of Newcastle researchers found between 88% and 99% of a sample of 15,000 women reporting a mental health condition had not used MBS mental health items, including those from the Better Access program.

The study, linking data from the Australian Longitudinal Study on Women’s Health (ALSWH) with Medicare records, found those who did not use the MBS items, despite having mental health conditions, were more socioeconomically disadvantaged than those accessing the services.

The findings conflicted with data published in the British Journal of Psychiatry by researchers from the Universities of Queensland, NSW and Melbourne.

They used data from more than 8000 respondents from the 2007 National Survey of Mental Health and Wellbeing.

To assess Better Access use, they determined who had seen a mental health professional, paid partly or fully by Medicare, and whether or not they had a disorder.

Among the 1521 respondents who had a mental health disorder, they found there was no difference in socioeconomic disadvantage between those who used Better Access psychological services, other mental health services or no services.

However, in general agreement with the ALSWH study, the BJP study did show that 92% of respondents with a mental health disorder did not use Better Access mental health services.

Professor Ian Hickie, executive director of Sydney’s Brain and Mind Institute, said the women’s health study data showed the Better Access program had the same issues as specialist mental health systems.

“It’s really driven by those who already have the greatest access getting more access and many of those who need, missing out,” he said.

Dr Caroline Johnson, mental health spokesperson for the RACGP, said neither survey was designed specifically to assess the Better Access program.

“We need to know more about the population who report mental health concerns but are not accessing care,” she said. “[And] what we don’t know is whether being in the scheme makes more of a difference than usual care.”

Meredith Harris, lead author of the BJP study, said it controlled clinical factors in the socioeconomic analysis, whereas the women’s health study did not.

Sebastian Rosenberg, senior lecturer at Sydney’s Brain and Mind Research Institute, said that unlike the women’s health study, the BJP study didn’t use Medicare data.

“When it’s Medicare data and it’s public information, then it’s possible to recreate and confirm,” he said.

BJ Psych 2011; 198:99-08

MJA 2011; 194:175-79

Comments:

Bibiana

22nd Feb 2011
9:59am

Just wonder is there any study which examines the 'stigma' associated with accessing mental health services? Since the 'beyondblue' - the National initiative to combat depression first established in 2000, de-stigmatization of clinical depression in mainstream Australia has been very successful. However, I was recently told by an Australian-born Chinese wanting to see a psychologist through the Better Mental Health Access Program that her GP asked her to think carefully whether she really wanted to do so. The reason being it will be entered in her Medicare record that she is a person needing mental health service.
I then shared my personal experience with her about the benefit of seeing a psychologist. However, I also told her that if she was really concerned, she could self-refer and pay the fees out of her own pocket. As a mental health researcher for nearly 10 years, I am very aware of the stigma of mental illness perceived by people from Culturally and Linguistically Diverse communities. This is another aspect of access issues not picked up by the mainstream radar.

wenz
23rd Feb 2011
5:10pm

It is quite clear to myself that the better educated and probably, financially better off patient is able to access psychology care. For a lot of disadvantaged patients, a 20 to 40 dollar copayment per visit to a psychologist is beyond their means - and there are very few bulk billers available. I understand that a small co payment might weed out the client with less commitment - but it also weeds out the sort of patients that require our assistance.

SSWAHS = SWSLHN and mental health in the Southern Highlands - 3

It is important to note the comments of Professor Ian Hickie in regards to the inequitable access of people from the low socio-economic levels within the Australian society. Equally, one must consider the capacity of people from culturally and linguistically diverse backgrounds having an even more limited access to the Federal Government's "Better Access" program. Not only may there be a financial disincentive but the numbers of therapists with other language skills is also limited.

Socrates adds another caveat to the "Better Access" program additional to the concerns raised by Professor Hickie. That concern is whether the newly formed "Medicare Locals" will have the capacity to restrict the businesses of those private practitioners who operate within the jurisdiction of the Medicare Local.

It would seem that even the current Divisions of General Practice, through their control over member general practitioners, have the ability to determine who they will promote and who they will not, within their current jurisdictions. It is not unknown that some CEOs of current Divisions will promote their own staff to general practitioners over any other private practitioner so as to, as one CEO put it: "I will promote my staff member to provide the medicare funded services because if they didn't get the work I would not be able to pay them." Perhaps, the staff member should have been expected, like every other private practitioner to promote themselves, in a competitive market. Such competition, obviously, might lead to bulk-billing and therefore improved access for persons with a low socio-economic status.

Mental health access program failing the needy

15th Mar 2011

Andrew Bracey all articles by this author

1 comment

A SENIOR Government adviser and mental health expert has warned that the contentious Better Access to Mental Health Care program has failed to meet its aims despite its ballooning costs.

Professor Ian Hickie, a member of the Government's National Advisory Council on Mental Health and executive director of the University of Sydney's Brain & Mind Research Institute, has called on the Government to urgently overhaul the program.

His comments, made on the ABC's AM program this morning, come as Mental Health Minister Mark Butler was set to release a long-awaited review of the program today.

Professor Hickie told the ABC patients in greatest need were getting the least services through the program, labelling its results a "travesty".

"The probability is that those in higher-income areas who have a capacity to pay are also getting the most money back from the Government for common mental health services," he said of the program, which was initially allocated $500 million over four years.

"It's now cost over $1.5 billion and it costs over $500 million a year and over the next five years it's likely to grow to being almost $1 billion per year. We won't have any money left for other essential mental health programs unless we restructure this particular program."

Professor Hickie also suggested the Medicare fee-for-service-based system had "allowed the professionals to set up lots of small businesses in the well-off suburbs of our major cities and to charge higher rates for their services".

"So that they can get both the co-payment... plus the Medicare rebate. And that's what the Government's essentially encouraged them to do."

"Nicola Roxon said in opposition that she would change this. A different payment system would see those same professionals providing services in other suburbs - in the outer suburban areas and the regional areas where they're desperately needed."

In response, Minister Butler conceded that there were "some limits to this program in terms of its capacity to apply equitably across the population and to reach the harder-to-reach groups".

"There's no question that it demonstrates the need to balance the fee-for-service arrangement that you see in the better access program that we've just evaluated with targeted programs that deliberately go out to reach the harder-to-reach population [such as] younger people, people who live in rural and regional Australia and people living on our urban fringes in lower socio-economic areas," he told the ABC.

Read the Better Access evaluation

Comments:

Cheung

15th Mar 2011
5:30pm

Try finding a public mental health service without long waiting lists even for those clients considered to be in urgent need. Rarely can you find a Psychiatrist who accepts medicare only and many families can not afford gap payments even if they have health insurance. It is just as difficult to access psychology services and then those with vacancies have only a couple of years experience which is fine for run-of-the-mill problems but not for those clients who are seriously in crisis.
On a positive note, the program has raised interest, awareness and acceptance of mental health issues. It is something we do not want to lose however with some refining and tweaking such as means tested access and taking the services to the people this program could truly be sensational.

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”.

SSWAHS = SWSLHN and mental health in the Southern Highlands

Socrates says: "It's great that the National AMA is prepared to put forward the case for more funding, but not all mental health services are provided from general practices in this country."

If we are to have a more egalitarian mental health service we do need to engage the other parts of the private sector in the treatment and support of persons with a mental illness.

Likewise, we need to ensure that part of the funding goes to support the carers of the persons with the mental illness. Mainly because they provide the 24/7 care and support to the person and not the clinicians in the private or public health sectors.

Finally, let's ensure that the public health sector has the finances and the staffing levels to provide a better mental health service to the persons with the mental illness. The level of mental health beds available in the state of NSW is currently abysmal, with one of the highest populations and the lowest number of available beds per 100,000 in the country. With the changes in the state's parliament it's time for a new broom to sweep away the dinosaurs who have held back NSW from taking the lead in improving mental health outcomes for people with a mental illness.

As far as the Southern Highlands is concerned I hope that the new broom sweeps through the Concord Hospital Centre for Mental Health and removes some of the incompetents there.


Mental health needs more funding, services: AMA

29th Mar 2011

Andrew Bracey all articles by this author

1 comment

THE AMA has called on the Federal Government to provide $5 billion in funding to expand, better resource and coordinate mental health services.

The money would be used over four years to increase MBS rebates for GP consultations relating to mental health issues, to better reflect the complexities involved and meanwhile support public campaigns to reduce the stigma attached to mental illness.

The call came as the association today unveiled its latest position statement on mental health which included a range of priority areas for government action in mental health policy.

The AMA plan also backed previous calls by mental health campaigners including Professor Patrick McGorry to expand the number of community-based youth mental health Headspace centres and the number of Early Psychosis Prevention and Intervention Centres.

Phone counselling services would also be expanded under the AMA plan.

AMA President Dr Andrew Pesce said that Australians with a mental illness deserved to have ready access to quality individualised mental healthcare.

"This requires a significant expansion of services, intervention and support across the whole continuum of care for people with mental illness," Dr Pesce said in a statement.

"This also requires a significant funding boost to address the gaps in our current mental health services and enable the delivery of comprehensive, integrated and coordinated mental health services for all people who may develop an acute or chronic mental illness at any stage of their lives."

The AMA's position statement, which also discusses the need for greater government action across areas such as prevention, early identification and intervention, community-based care as well as acute and sub-acute care, can be accessed at: http://ama.com.au/node/6524

Comments:

Bibiana
29th Mar 2011
4:53pm

It is great to see AMA taking a strong stand in pushing the Federal Government for more injecting more funding into mental health services at Primary Care level. It was Oct 2008 at the WONCA Conference in Melbourne that WHO launched their report "Integrating Mental Health into Primary Care - A Global Perspective". In the report it provided 7 good reasons for such integration. On top of the list is 'the burden of mental disorders is great'. In my view as a consumer, the most important reason is 'Primary care for mental health promotes RESPECT OF HUMAN RIGHTS'. This is in-line with AMA's call for more funding to support campaigns to reduce the stigma attached to mental illness.
I recently attended a mental health forum 'What happened to mental health under Gillard?' in Sydney, one of the speakers was Prof Ian Hickie. He highlighted his 'Love and Hate' relationship with the Federal Government (and all the PMS and Health Ministers involved). The current government is exhausted in fixing too many unpopular policies (carbon tax, mining super tax etc), the Health Reform has to give way and let alone mental health. In his concluding remark, Prof Hickie pointed out the obvious - if the Government is smart enough to fix the long overdue mental health problems, many of the physical health issues will become more manageable and not vice-versa!

To download WHO's report, go to the following link:
http://www.who.int/mental_health/policy/Integratingmhintoprimarycare2008_lastversion.pdf