The long-withheld National Review of Mental Health Programmes and Services proposes a fundamental overhaul of the systems in place to address with the massive cost of mental illness in Australia, as the current framework is “not cost-effective”, “does the wrong things” and fails to deal with “the dire status of the mental health and wellbeing of Aboriginal and Torres Strait Islander people”.

The report, by the National Mental Health Commission, chaired by Allan Fels, was provided to the government in November but remains officially unavailable. A part of the report was been leaked to the ABC, and a full copy of the four-volume report has now been leaked to Crikey.

The commission’s core finding is that current mental health funding arrangements are too skewed to treatment within the hospital system rather than focusing on prevention and care within the community. It finds:

“The status quo provides a poor return on investment for taxpayers, creates high social and economic costs for the community, and inequitable and unacceptable results for people with lived experience, their families and support people.”

The review complains of being hampered in its assessment of existing programs by the lack of reporting information, or information focused on activities rather than outcomes. “There is nothing efficient about funding activity-based programmes when there is no way of measuring the impact of those programmes,” it says. The commission wants to shift Commonwealth resourcing — currently around $10 billion, spread around 16 agencies, in addition to $4.5 billion in state and territory spending — toward prevention and early intervention, to fix a system “driven by supply (what providers provide), rather than by demand (what people want and need)”.

The commission states:

“At present, our programmes and services across sectors are not set up to promote early intervention. For example, sometimes people need to inflict serious physical harm to gain access to support… in mental illness, late intervention is too often the norm … For example, for people with complex needs, such as a person with severe bipolar disorder, optimal care (based upon greater GP contact, increased support from community mental health teams and continued access to care coordination and psychosocial supports) can yield savings over nine years of $323 000, with about half of that saving being directly to the states through reduced acute care costs (admissions).”

Moreover, the commission finds, Aboriginal and Torres Strait Islanders bear the brunt of current inefficiencies given the far higher rates of mental health problems in those communities.

Programs are often poorly co-ordinated as well, the commission finds, with different agencies administering short-term, sometimes duplicative programs with poor evaluation mechanisms and no links to other programs or programs addressing non-mental health issues that can play a key role, such as housing. And “the Commonwealth’s major programmes reward volume of activity and funding of one-off patient interactions, with no accountability for effective achievement of outcomes”. Worse, states and territories had been withdrawing specialised community mental health services, creating a “missing middle” between GPs and hospital care, especially in regional areas which already face poorer access to health services.

The person-focused “architecture” proposed by the National Mental Health Commission is based on a “stepped care” framework designed to address different levels of intensity of need with greater choice and responsibility, with resources — it does not propose an increase in funding — shifted “upstream” to primary and community care and non-clinical services, overseen by renamed “Primary and Mental Health Networks” (which have replaced the Medicare Local network). This is the basis for the $1 billion shift in funding from hospitals that has been widely reported, which has already ruled out by Health Minister Sussan Ley. GP incentive payments would be structured to strengthen the role of GPs, and pharmacists would be included “as key members of the mental health care team.”

The commission also wants to expand full-time mental health and social and emotional well-being teams for Aboriginal and Torres Strait Islander people, reflecting the need to take a broader approach to mental health among indigenous communities.

The report leaves the Commonwealth in a difficult position, and to an extent it’s understandable that the government has sat on it for months trying to work out a way forward. The status quo is simply not an option in the wake of this report, given the inefficiencies, lack of performance information and patchwork nature of our current approach to mental health; apart from anything else, a greater focus on prevention and community care represents an opportunity for substantial savings that can in years to come be reallocated to other priorities in mental health or the health system more widely. But the alacrity with which the government ruled out shifting $1 billion from state and territory-run hospitals to Commonwealth-funded GP and community services reflects the political problems inherent in such a recommendation — especially as the government is already facing a huge fight with the states and territories tomorrow over its massive cut to hospitals funding in coming years.

In short, if a more efficient, effective mental health system is to be found, the government may have to be prepared to invest up front in order to obtain savings down the track — but any “savings” in the health portfolio will always come with a political price tag.

16 April 2015

The Abbott Government is working towards the revival of a national approach to improving mental health outcomes and access to support services long-term.

The National Mental Health Commission’s Review of Mental Health Programmes and Services paints a complex, fragmented, and in parts, disturbing picture of Australia’s mental health system.

I acknowledge there are clear failures within both the mental health sector and governments and we must all share the burden of responsibility and work together to rectify the situation.

We cannot continue to place band-aids on the mental health system and expect it to heal itself.

This is why the Government has been working closely through the Review’s 700-plus pages in recent months to develop a considered, and most importantly, unified strategy to ensure the next steps we take actually deliver a genuine national approach.

A consultative and collaborative approach is essential to achieving this and I intend to seek bipartisan agreement to revive a national approach to mental health at tomorrow’s COAG meeting of Health Ministers.

I am conscious of the damage Labor did in Government by walking away from the fourth National Mental Health Plan with the states and territories, as well as the discontent in the sector with their alternative National Road Map for Mental Health Reform 2012-2022 that has clearly led nowhere.

However, the Review shows that fragmentation in the system is seeing far too many people still slipping through the cracks.

I see the COAG process as essential to developing a co-ordinated, binding national approach long-term and therefore the Abbott Government will seek to establish a dedicated COAG Working Group on Mental Health Reform to coordinate the process.

The mental health sector must also play a direct part in the development of any policies and work hand-in-hand with Governments to develop a national approach.

Therefore, I can confirm the Abbott Government is currently finalising the establishment of an Expert Reference Group to inform the entire process, including the development of short, medium and long-term strategies in four key areas based on the findings and recommendations presented in the National Mental Health Commission’s Review in four overarching mental health areas:

• Suicide Prevention;
• Promotion, prevention and early intervention of mental health and illness;
• The role of primary care in treatment of mental health, including better targeting of services;
• National leadership, including regional service integration.

The ERG will also be supported by:

• Broad stakeholder workshops to ensure mental services and organisations at the frontline can have direct input into this process;
• An NDIS Mental Health working group;
• An Aboriginal and Torres Strait Islander Mental Health and Suicide Prevention Advisory Group;
• Setting better access to mental health services as a priority for the Government’s new Primary Health Networks;
• And an inter-governmental approach to ensure Commonwealth agencies respond to the report’s concerns about fragmentation of payments and services and better co-ordinate future systems and policies.

This further work is necessary because, ultimately, there is no easy fix to this problem.

It’s also important to acknowledge this is a report to government, not of government, and while many recommendations offer positive ideas, others are not conducive to a unified national approach or require further investigation by experts, which these COAG and ERG processes will be best to co-ordinate.

For example, the Government does not intend to pursue the proposed $1 billion shift of funding from state acute care to community organisations, as we want to work collaboratively in partnership with other levels of Government.

Exact timings for the delivery of work will be finalised in consultation with the states and territories.

The Abbott Government also recently announced a $300 million extension of funding for frontline mental health services while this work is undertaken.

I have been consulting continually with mental health stakeholders in recent months and they all acknowledge this a once-in-a-generation opportunity for serious reform mental health in Australia for the long-term and I am determined to secure national support.

The National Mental Health Review report can be downloaded at the National Mental Health Commission website.