What does the “shake up” mean for mental health care?

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triThis week the Australian Minister for Health announced a “shake up” of mental health care policy. At this early stage the details are sketchy, and so far things are not looking good for Medicare, our main system intended for universal access to primary health care. In this short blog post I will share what we know so far.

The official media release describes the current system as being rigid and impersonal. The new plan promises to “reshape the delivery of primary mental health services towards a more modern, flexible model of care, rather than the current “one-size-fits-all” approach”. The main offering is a new set of services called ‘integrated care packages’ which will be delivered by Primary Healthcare Networks (PHNs) for people living with a severe and complex mental illness. Integrated care packages will include assessment and care-co-ordination, psychological services, mental health nursing, drug and alcohol services, vocational assistance and peer support. A fact sheet accompanying the media release explains that the PHNs will also promote digital mental health strategies for those who are assessed as having a mild condition. New specialised education and employment services will be integrated with existing programmes like Headspace to assist people aged under 25. The proposal includes services for Aboriginal and Torres Strait Islanders and a new suicide prevention strategy.

That sounds pretty amazing to me, but where will all the funding come from? The Minister (Sussan Ley) states that these new services will “get substantial money…within the existing funding envelope”. In other words, no additional funding. Our Government is claiming they can deliver more services (costed at $350 million) without additional cost. The question is which of our existing mental health care programs will be cut to fund these new services? Apparently all of that funding will be deducted from Medicare.

In the media release, the Minister makes her case against Medicare-supported mental health services. She claims “Medicare spending on psychological services for people in major cities is more-than-double that per capita of people in outer regional and remote areas”. However, the Australian Bureau of Statistics (ABS) points out that over 90% of our population lives in urban areas and over two-thirds of our population live in capital cities alone! So if the number of Australians living in major cities easily doubles the rest of our population who live in outer regional and remote areas, then our current distribution of psychological services seems about right. That is, psychologists appear to be placed in proportion to where our people are.

The Minister goes on to say that “Between four and five million Australians suffer some form of mental health issue in any one given year, seeing it ranked the third largest chronic disease in the country, only behind cancer and cardiovascular disease.” That is true, however, when we compare the funding allocated to mental health versus other medical problems, it is clear that the allocated funding falls far below the true scale of disability and years of life lost due to mental health disorders. In short, Australia under-funds mental health by approximately $5 billion per annum. Medicare-supported psychological treatment represent a tiny fraction of the current spending.

The more detailed response provided by our Government shows that Australia is headed down a path similar to the UK using the same terminology about low-intensity and high-intensity services (page 14). Funding will be withdrawn from the Better Access to Mental Health Care program and streamed into the salaries of peer support workers, vocational placement staff, and range of other in-house service providers (page 18). My question is whether this new strategy can provide more mental health services for the same amount of funding? There are some very good reasons to doubt that possibility.

The newly named PHNs were previously known as ‘Medicare Locals’. An audit of mental health care programs (called ATAPS) run at those centres has shown that up to 25% of allocated funding goes directly to administrative costs (page 53). In human terms that means one in four people will go without mental health care simply due to the additional expense of admin. By comparison, the Medicare system only provides funding for direct patient care. If we are going to face the problem of limited funding then we must acknowledge that point, otherwise lives will be lost.

Patients have expressed concern over social media that the new stepped-care system may be aimed at identifying people as “less deserving” of care to weed them out of seeking face-to-face help. Another major concern coming from both patients and mental health professionals is that coordination of care through the PHN will restrict choice of therapist. That issue is particularly relevant, due to the justification that the new plan offers more flexibility, choice, and a better match to the needs of each individual person. I find myself wondering though, if personally-tailored patient care is even possible in system where the choice of therapist is restricted and people are weeded out of accessing a psychologist? Similarly, I find myself wondering by what criteria can we assess that a person only needs electronic self-help, or only deserves 10 visits? It baffles me how the proposed changes could possibly deliver on all of those wonderful promises.

Perhaps the most disappointing aspect of these planned changes is the silence about the woeful state our Medicare system has been left in. Our system remains broken, offering just 10 visits of therapy, with no exceptions. When the Government was in opposition, they promised to fix this issue. Now it seems that when Medicare support runs out people will be left with nothing. By comprison, we are told that services delivered through PHNs will be “uncapped”. If that is truly the case, then how will those expenditures be paid for through the existing funding envelope? It just doesn’t add up.

Yes, I can see that some people with relatively mild problems will soon be helped by electronic self-help – for some that will work. And yes, I can also see that others with severe or complex problems will be able to access teams of therapists through the PHN. But what will happen to the large majority in the middle?

What will happen to people experiencing significant levels of depression and anxiety, who do not need or want a team or people getting involved in their life? Why are we ignoring decades of research evidence showing that effective psychological treatment requires closer to 20 visits of psychological care?

Like so many others, including my colleagues in the field of medicine, I find myself asking where is the evidence backing up this new strategy?