Position Statement

Mental Health - 2018

Published 14 January 2018

Executive Summary

Currently Australia lacks an overarching mental health ‘architecture’. There is no agreed national design or structure that facilitates prevention or proper care for people with mental illness.

Mental health and psychiatric care is grossly underfunded when compared to physical health. The extent of mental health conditions in the community is extensive, with almost a majority of adult Australians experiencing a mental health condition in their lifetime. Some of these have significantly worse levels of morbidity, or premature mortality, than the general population. Yet this sector receives less than half the funding of the comparable burden of disease funding.

The balance between funding acute care in public hospitals, primary care, and community-managed mental health needs to be correctly weighted and should be on the basis of need, demand and disease burden, not a competition between sectors and specific conditions.

There is marked lack of capacity at all levels of mental health care causing unacceptable delays to care.

The medical profession plays a key role in prevention, or amelioration of issues causing mental illnesses.

The AMA believes that a multipronged strategy is required to improve access and care to this very vulnerable group of Australians. This strategy should encompass:

improved service delivery;
significantly increased funding;
improved coordination;
robust workforce and infrastructure solutions;
prevention, education and research; and
e-health/ telemedicine solutions.

Preamble

Many Australians experience a mental illness at some time in their lives, and almost every Australian will experience the effects of mental illness in a family member, friend or work colleague. For mental health consumers and their families, navigating the mental health system and finding the right care at the right time can be difficult and frustrating.

Currently Australia lacks an overarching mental health ‘architecture’. There isn’t a ‘vision’ of what the mental health system will look like in the future. There is no agreed national design or structure that will facilitate prevention and proper care for people with mental illness.

The AMA believes in strategic leadership which integrates all the relevant components including the National Disability Insurance Scheme (NDIS), Primary Health Networks (PHNs), General Practice, National Strategic Framework for Chronic Conditions, Aboriginal and Torres Strait Islander Health Performance Framework, and the mental health workforce.

Mental health and psychiatric care is also grossly underfunded when compared to physical health, for the burden of disease and years of life lost. Mental health cannot be seen in isolation from wider societal influences, such as experiences in utero and early childhood, social disadvantage, marginalisation, and unemployment. The under-resourcing of mental health programs often prevents the least able and most vulnerable people from overcoming adverse health determinants and early childhood experiences.

The AMA wants the balance between funding acute care in public hospitals, primary care, and community-managed mental health to be correctly weighted. Funding mental health care and services should be on the basis of need and demand, not a competition between sectors and specific conditions.

There is marked lack of capacity at all levels of mental health care. Policies that try to strip resources from any area of mental health to pay for others are disastrous. Poor access to acute beds for major illness is manifested by extended delays in EDs, poor access to community care delays discharge or leads to failed discharges, and poor funding and community services mean prevention, support services and early interventions are not easily accessed or co-ordinated.

Commonwealth, State, and Territory Governments should work cooperatively to change the current patchwork of fragmented, competing and overlapping services to one based on evidence, research, investment, and sustainable funding.

The National Health and Hospitals Reform Commission, the National Advisory Council on Mental Health, the National Mental Health Commission, and a range of mental health groups have all pointed to the need for reform of mental health service delivery and funding arrangements. To date, government responses have fallen well short of meeting the need for change and additional resources.

It is vital that the key role of psychiatry, general practice and other medical professionals in this area is recognised and valued. The medical profession plays a key role in prevention, or amelioration of issues causing mental illnesses, responding to initial presentations, making clinical assessments, and following through with patients, other health professionals and support services.

Medical professionals are often the key decision makers in complex team-based care, and an effective system relies on and should value that expertise. This is why doctors, and in particular general practitioners, psychiatrists, emergency physicians and paediatricians, are well placed to identify the gaps in our current health system in the prevention, treatment and management of mental illness. In conjunction with the views from mental health consumers, they are well placed to articulate the solutions that need to be put in place to improve the system for consumers, carers and providers of psychiatric services.

Overview of Mental Health in Australia

7.3 million (45 per cent) of Australians aged 16 to 85 will experience a common mental health disorder (such as depression, anxiety or a substance use disorder) in their lifetime.[1]
Almost 64,000 people have a psychotic illness and are in contact with public specialised mental health services each year.[2]
560,000 child and adolescents aged 4 to 17 (about 14 per cent) experienced mental health disorders in 2012–13.[3]
Australians living with schizophrenia die 25 years earlier than the general population, mainly due to poor heart health.[4]

Almost one-third (30 per cent) of Indigenous adults have high or very high levels of psychological distress in 2012-13 and are 2.7 times as likely as non-Indigenous adults to have these levels of psychological distress. General practitioners manage mental health problems for Indigenous Australians at 1.3 times the rate for other Australians, and mental health-related conditions accounted for 4.4 per cent of hospitalisations of Indigenous people.[5]

The Australian Institute of Health and Welfare (AIHW) estimates that around $8.5 billion per annum is spent on mental health-related services in Australia. Services include residential and community services, hospital-based services (both inpatient and outpatient), and consultation with specialists and general practitioners.
It is generally acknowledged that there are significant deficits in mental health funding. In 2014-15, mental health received around 5.25 per cent of the overall health budget while representing 12 per cent of the total burden of disease.[6]
Non-government organisations that struggle to support people with mental illness and their carers also face chronic under-resourcing and lack of sustainable funding.
There is also a serious and continuing problem in the inability to link and integrate the mental health care provided to patients in primary care with the crisis or acute care they receive as hospital in-patients.
Reforms such as the National Disability Insurance Scheme (NDIS) and Primary Health Networks (PHN) are massive major policy initiatives that should be independently researched and made accountable to provide an evidence base that they are delivering their intended outcomes.
PHNs and the NDIS were designed to reduce the deficits and fragmentation in mental health care and reduce pressure on hospitals. Some PHNs are working effectively, but for others lack of transparency, opaque funding and less than robust governance processes must be addressed if every PHN is to achieve the promised reforms in mental health.

AMA Position

Service Delivery and Funding

All Australians with a mental illness deserve to have ready access to quality mental health care based on their particular needs. This requires a significant expansion of services, intervention and supports for people with mental illness across the whole continuum of care, and better coordination of clinical care for patients with severe, chronic and complex needs.
To address the gap in per capita spending on mental health, significant investment is needed to reduce the deficits in care, fragmentation, poor coordination and access to effective care.
Well-coordinated and properly funded community–managed mental health services for people with psychosocial disability will reduce the need for hospital admissions and re–admissions, and has the potential capacity to diminish the severity of illness and its consequences over time.
There continue to be problems with community–managed mental health services. These have not been appropriately structured or funded since the movement towards deinstitutionalisation in the 1970s and 1980s that shifted much of the care and treatment of people with a mental illness out of institutions and into the community.
Community–managed mental health care must be enhanced, supported, properly funded and better coordinated to ensure improved access to essential services, which include psycho-geriatricians, mental health nurses, psychologists, paediatricians, counsellors, and drug, alcohol and gambling support staff.
Physical and mental health care should not be viewed as separate or mutually exclusive.
Governments must address specific areas of underfunding and lack of sustainable investment, in particular adolescent mental health, refugee and migrant mental health, Aboriginal and Torres Strait Islander mental health, and mental health services in regional and remote areas.
Many people with serious mental illness are often readmitted to hospital, placing increasing pressure on the acute public hospital system.
Additional and timelier access to acute care in public hospitals is required. It is never appropriate for patients presenting with mental health conditions to spend prolonged (>4-6 hours) in hospital Emergency Departments. Specialised mental health and dual diagnosis spaces or departments should be established as part of public hospitals admitting psychiatric patients.
Access to MBS rebates for clinical care and treatment provided by GPs and psychiatrists must continue to be available on a universal basis for clinical need. This access should not be capped, bundled or rationed.
Private psychiatric services provide an effective alternative pathway for most psychiatric care. Psychiatrists and GPs working in the private sector deal with a large proportion of mental health delivery, and they add immense value in flexibility and overall planning for mental health care.

MBS items/funding need to be reformed to provide increased rebates for longer GP consultations for patients with mental illness who often have complex and multiple physical and mental health issues; for psychiatric care and treatment provided to patients with complex conditions by psychiatrists in community–managed settings; and for GPs and psychiatrists to coordinate care to ensure patients are able to continue treatment that keeps them out of hospital and living in the community.
More access to mental health assessment facilities for public patients is required, including through more and better resourced mobile outreach teams operating extended hours for high risk patients.

Step–up and step–down high acuity residential care, and resourced coordinated services under appropriate medical oversight, are an essential part of transition care and are an alternative to inpatient admission or for earlier hospital discharges.
Specific services are required for elderly people with mental health problems who are living in residential aged care or in the community. Additional acute care beds specifically for the elderly with mental illness, separate from general adult mental health facilities, integrated with the general hospital and geriatric medicine/rehabilitation services, are needed.
Expanded specific services are also required for perinatal psychiatry and adolescent mental health issues.
Early intervention should be available for people of all ages, recognising that early treatments often lead to better outcomes and reduced morbidity.
Access to respite care is necessary for many people with mental illness and their families, who bear the largest burden of caring for those with mental illness.
Increased investment in crisis intervention services is required, particularly for those with severe mental illness and/or those at risk of suicide.

Coordination

People with mental illness require clearly defined and properly coordinated care of both their physical and mental health.
Linking and integrating the mental health care provided to patients in primary care with the crisis or acute care they receive as hospital inpatients must be a priority in mental health reform.
The current system, characterised by gaps in services and fragmented safety nets, means people with mental illness can inappropriately end up in the non-therapeutic Emergency Department environment, with significant numbers under sedation and/or restraint. Referral to appropriate care (admitted or community) needs to be expedited and streamlined, and no patient should be discharged into homelessness.
While funding for a number of mental health programs is transitioning to PHNs, the goal of a healthier community, reduced pressure on hospitals, and reduced cost and blame-shifting is unlikely to be achieved unless the Commonwealth and States overcome jurisdictional and funding barriers.
Carers of people with mental illness should receive recognition and support from Government, including financial support and additional services. Caring for people with a mental illness is often the result of necessity, not choice, and can involve very intense demands on carers over unpredictable episodes of need.

Workforce & Infrastructure

Australia must have an appropriately sized, skilled and resourced workforce able to deliver high quality, recovery-focused mental health services in a safe and secure environment.
The aspiration of mental health reform should be a mental health workforce able to provide access to care that meets all reasonable needs.
Increased numbers of funded psychiatrist trainee places are required, along with an increased investment in workforce training and support for other mental health workers, especially mental health nurses, to ensure the mental health services continuum is achieved.
Increased use of mental health nurses with general practice is critical and can be achieved by reviewing and streamlining existing program arrangements to make access easier.
The mal-distribution of psychiatrists, psychologists and other mental health service providers has led to critical workforce shortages in regional areas which must be addressed.
The work of providers in mental health care – frontline Emergency Department staff, GPs, paediatricians, psychiatrists as well as psychologists and mental health nurses – must be recognised, championed and supported.
Health support services and appropriate security must be available for all mental health practitioners.

Prevention, Education and Research

Prevention is better than treatment. Prevention is also just as important in mental health as it is in physical health, and evidence-based prevention can be socially and economically superior to treatment. Significant funding should be provided to research and assess programmes that may deliver long term benefits.
Governments should recognise the importance of the first five years of life by providing the right supports for healthy pregnancies, and ensure all children have free and equitable access to education, nutrition, health care and meaningful activities that can build resilience. Vulnerable children/families in particular will benefit from measures that help overcome disadvantage, inequities, social problems and dysfunctions that can promote mental health problems.
Sustained national community evidence-based awareness campaigns are needed to increase mental health literacy and reduce stigma, misunderstanding and prejudice, including recognition of needs and options for treatment.
Early identification and intervention, particularly for people aged under 25 years, is required to not only prevent or delay the development of future mental health problems, but also to promote the best conditions for healthy mental development. Current programmes need to be rigorously evaluated with significant research funding so that they provide the most effective care in the most efficient way.
Online and telephone counselling/support services, with comprehensive information about local referral pathways, must be available to ensure patients get linked to the right service at the right time and provide alternative appropriate access to care for different generations.
Increased funding is needed for specific child and adolescent health services of proven efficacy, along with evaluation of specific prevention and early intervention programs to target key disorders such as eating and conduct disorders, anxiety, substance abuse, depression, self-harm, and support for children of parents with a mental illness.
Research (both basic and translational) is an essential part of providing effective mental health care and innovative delivery. Research into mental health should be a high priority area for public funding given the huge loss of productivity and rates of disability associated with mental health and substance abuse in our society. All new programmes should have research and evaluation funding (preferably performed by independent groups) as an essential part of the set up costs.

E-health & Telemedicine

Access to online support needs to be provided for medical practitioners, particularly primary care providers, and consultations should be facilitated via increased access to telemedicine and e–health technology.

References

[1] Mental Health Services in Australia, Australian Institute of Health and Welfare, https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/summary

[2] National Survey of Psychotic Illness (2010) in https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/summary

[3] Australian Child and Adolescent Survey of Mental Health and Wellbeing (Young Minds Matter) (2015) in https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/summary

[4] “Cardiovascular disease in patients with schizophrenia” by Leonard Kritharides, Vincent Chow and Tim JR Lambert. Med J Aust 2017; 206 (2): 91-95. || doi: 10.5694/mja16.00650.

[5] See: https://www.aihw.gov.au/reports/indigenous-health-welfare/indigenous-health-welfare-2015/contents/health-disability-key-points

[6] “Mental health funding in the 2017 budget is too little, unfair and lacks a coherent strategy” By Dr Sebastian Rosenberg, The Conversation, May 11 2017. https://theconversation.com/mental-health-funding-in-the-2017-budget-is-too-little-unfair-and-lacks-a-coherent-strategy-77470