High-quality mental health care is possible. But it will demand structural reform, effective accountability, and the will to make it a reality.
Although 2022 is the 30th anniversary of Australia’s national mental health strategy, and after five previous five-year federal-state agreements, we are faced with the reality that affordable access to high-quality care remains out of reach to many of those in greatest need. As with aged care, the COVID pandemic has now highlighted to the wider public those major structural flaws that had been neglected for decades. Contrary to much popular and political belief, these major service problems are tractable in wealthy countries like Australia.
While our nine governments have just agreed another “landmark” mental health agreement on the eve of the 2022 federal election, the majority of the key recommendations of the 2014 National Mental Health Commission and 2020 Productivity Commission reviews have not yet been enacted. These structural reforms are the necessary actions that now need to precede investments of significant new monies.
More likely, however, is the announcement of many more small program funds, distributed across a wide variety of well-known “brands” and service providers with little attention to the reality that this piece meal approach has perpetuated the very poor experiences of care that have been documented by various commissions over the last 20 years, for example the Mental Health Council and the Victorian Royal Commission.
So, three questions must be addressed if we are ever to make serious progress. First, what are the key structural reforms that have not been implemented? Second, who will be held accountable for the implementation of these reforms? To use the phrase of the age, we must know “who does hold the hose?”. Third, given the longstanding and bipartisan political commitment to progress, what are the major political or social forces that perpetuate this public policy failure?
The structural reforms required have been well-documented and include:
- Expanding services to provide effective care for up to 15 per cent of the population in any year. This includes about 3-5 per cent who require hospital-based or emergency services and another 5 per cent of people do receive primary-care based or specialist services for various less complex anxiety or depressive disorders, but with high reliance on capacity to meet out-of-pocket costs. However, at least another 5 per cent of people, typically described as the “missing middle”, do not receive affordable or effective care. In this group, there is an over-representation of children, young people, those disadvantaged by geography or socio-economic status and those with more complex mental health needs.
- Shifting the balance of service funding (and specialist service provision) from hospital-focused and activity-based to community-focused and outcomes-based reimbursement.
- Moving the clinical service system from predominantly a late-intervention and chronic disease focus to prevention and early intervention. As 75 per cent of disorders have their onset before 25 years of age, and 50 per cent before 15 years, this means services need to be directed increasingly at children and young people.
- The catch cry for such services should be “Right care, first time, where you live”. Responding effectively to the challenges of “place” (“where you live”) requires the recognition of the importance of socioeconomic and geographic regions, each with their own demographic and cultural challenges. In Australia, we have 52 recognised regions where mental health services need to operate in synchrony with other human services.
- Provision of quality care that is based on highly-personalised assessment, multidisciplinary delivery of care and active use of measurement-based outcome tools. As our current public (activity-based for restricted services) and private (largely government-insured with large out-of-pocket costs) funding models respond poorly to these challenges, alternative and more equitable funding arrangements are urgently required, including: competitive, innovative funding pools; incentives to provide new specialist and multidisciplinary services for more complex care; and, other novel population-based models.
- Active use of population-based and other planning tools at the regional level that not only recognise the social and economic context of mental ill-health, but also engage the relevant local authorities and community leaders in collaborative decision-making with a commitment to long-term implementation.
- Responding urgently to the opportunities created by new digital technologies, not just for the delivery of low-cost, high-quality services to disadvantaged people, but also for the effective coordination of service delivery to empower the primary users of those services. This is likely to support better clinical outcomes. Internationally, the “uberisation” of mental health services is rapidly developing and this will inevitably disrupt the current business models of “bricks-and-mortar” based clinics.
- Recognising the need for real innovation in the delivery of psychosocial services that promote social and functional recovery at all stages of illness. This now means serious reform of the National Disability Insurance Scheme (NDIS), and the acceptance that while at least 90,000 Australians will require the highest level of individual financial support, at least another 250,000 require significant psychosocial services.
- Insisting that while suicide prevention at the population level is strongly influenced by major economic (e.g., employment, financial security) and social (e.g., social connection and cohesion) factors, mental health services have a key role to play in ensuring safety and reducing risk in those who present for care.
- Acting to reduce the premature death, and high rates of physical ill-health, in those living with major mental illness. As modifiable risk factors (most notably cigarette smoking) and lack of access to physical health care largely account for these poor outcomes, provision of effective physical health care by multidisciplinary and skilled teams is required.
- Development of smart data systems, that provide real-time information on key user concerns (waiting times, out-of-pocket costs, experiences of care), service access and affordability, individual-level outcomes, resource distribution and population-level outcomes.
- Support for regionally-based accountability frameworks, so that it is clear who is responsible for the planning, funding and commissioning functions for the full spectrum of services within each region.
The second key question is: who will be held accountable for promoting, funding and implementing these key reforms? Our 30-year history is that each level of government simply retreats to being responsible only for that part under its direct control. So, the states retreat to public hospitals and acute services, while the Commonwealth funds the activity without direct responsibility for the resulting services. At best, we have been left “half-pregnant”.
Both the Productivity Commission and the previous National Review emphasised the need to move to a system of regionally-based accountability, but recognised that this is only possible if the funding and commissioning functions are devolved to the regional level. A solution is therefore at hand if the respective governments agreed to cooperate and implement change at the regional level.
Given the conceptual consensus to shift to regionally-based planning, funding and service delivery, and the recognition of the key structural reforms required, why is there the lack of substantive progress? Many would argue that the funding never moves to match the rhetoric. The proportion of health spending on mental health and suicide prevention has remained static at 7.5 per cent over the last three decades. Given the burden due to mental ill-health is at least 14 per cent of total illness burden, and that suicide remains the major cause of productive years of life lost in Australia, the level of financial investment is grossly inadequate.
The clear reservation of many in power, however, is that many more dollars into our highly dysfunctional system would not result in better outcomes. Despite the many plans, there has never been a move to dismantle the financial and structural underpinnings of this dysfunctional system. This compares poorly with the restructure of disability services under the NDIS. So, the end-result is an ongoing impasse.
A political breakthrough, therefore, is likely to depend on three factors. First, enhanced belief at the community level that these problems are actually tractable. We can fix them by focusing on resolving the issues with less top-down “one size fits all” and much more “bottom-up” one region at a time. Second, by empowering local leadership, capability and accountability at the regional level to drive this process. Third, by governments engaging with twenty-first century approaches to co-design, system modelling and use of smart technologies to empower service users to drive substantive improvement in their own care.
Professor Ian Hickie AM is a Professor of Psychiatry and the Co-Director of Health and Policy at the University of Sydney’s Brain and Mind Centre. He has led major public health and health services developments in Australia, particularly focusing on early intervention for young people with depression, suicidal thoughts and behaviours and complex mood disorders. He is active in the development through codesign, implementation and continuous evaluation of new health information and personal monitoring technologies to drive highly-personalised and measurement-based care.
