(This material is provided for information only. Neither SWSAHS nor Midas Dual Disorders Service seek to endorse the contents or the recommendations of this report).

A review of the experiences of those who use mental health services in Australia has documented that current community-based systems are failing to provide adequate services, support recovery from illness or protect against human rights abuses. In the view of the two major groups – consumers and carers and those health professionals who provide services – this represents a failure over the last decade to implement our far-sighted national mental health policy. This failure is due to a basic lack of resources, lack of on-going commitment by governments, and a lack of support for the community development required to deliver high quality mental health care outside institutional settings.

 

In response to this damning review the Mental Health Council of Australia and its partner organisations call on the Prime Minister and all Premiers to respond to the following key actions.

 

ACTIONS REQUIRED

 

Where there is agreement that we must never return to institutional and other more abusive forms of care, before embarking on a third 5-year National Mental Health Plan, this national review has identified the need for:

 

1.      Real Monetary Investment

 

Action: Lift mental health expenditure to at least 12% of total health expenditure (i.e. increase by 5%) within five years

 

2.      Real Intent, Accountability & National Leadership

 

Action: Development of an agreement between heads of Australian governments to support and review mental health reform, and prioritising an annual reporting system on progress against agreed services improvements.

 

3.      Real & Ongoing Review

 

Action: Establishment of a permanent independent commission to report on progress of mental health reform in Australia and investigate evidence of ongoing abuse or neglect.

 

4.      Real & Sustained Innovation

 

Action: Establishment of a national innovation and service development system with a $100 million initial investment and then supported at a level of 5% of recurrent mental health expenditure annually.

 

 SUMMARY

 

A nation-wide review of the experiences of those who both use and provide mental health services has documented that current community-based systems are failing to provide adequate services. Specifically, these services are failing in terms of restricted access, variable quality, poor continuity, lack of support for recovery from illness or protection against human rights abuses. In the view of both consumers and carers and the health professionals who provide services, this does not represent a failure of policy but rather a failure of implementation through poor administration, lack of accountability, lack of ongoing government commitment to genuine reform and failure to support the degree of community development required to achieve high quality mental health care outside of institutional settings.

 

ACTIONS REQUIRED

 

Where there is agreement that we must never return to institutional and other more abusive forms of care, before embarking on a third 5-year National Mental Health Plan, this national review has identified the need for:

 

5.      Real Monetary Investment

 

Action: Lift mental health expenditure to at least 12% of total health expenditure (i.e. increase by 5%) within five years

 

6.      Real Intent, Accountability & National Leadership

 

Action: Development of an agreement between heads of Australian governments to support and review mental health reform, and prioritising an annual reporting system on progress against agreed services improvements.

 

7.      Real & Ongoing Review

 

Action: Establishment of a permanent independent commission to report on progress of mental health reform in Australia and investigate evidence of ongoing abuse or neglect.

 

8.      Real & Sustained Innovation

 

Action: Establishment of a national innovation and service development system with a $100 million initial investment and then supported at a level of 5% of recurrent mental health expenditure annually.

 

Although we do not currently devote sufficient resources to meet current demand levels, the future costs of providing mental health care will increase substantially. This will be due to increased demand for services by, first, those who do not currently use services and, second, those who now receive grossly inadequate services. Changing population patterns of illness will also place great pressure on demand as the rates of illness continue to increase in younger persons. If those young people are not treated adequately both direct treatment and associated disability and unemployment costs will increase. The costs of purchasing new pharmaceuticals, which will need to be imported, and the need to establish broad population-based disease prevention strategies, will both add new costs to the mental health budget.

 

New pressures on the mental health system will emerge. These are already evident as a consequence of the direct negative impact on Australian families, and particularly young children, of the ongoing threats of domestic and international terrorism, the stresses of war and continued drought conditions. We are not well placed to meet new demands due to our prior lack of investment in effective community-based care, service innovation, biomedical research or population-based psychological and social prevention strategies.

 

Sadly, there has been a lack of national uptake of more effective service systems, particularly world-leading and Australian-developed prevention, early intervention and specialized treatment forms. For over a decade we have failed to support initiatives designed to increase workforce professionalism or redistribute workforces to meet population needs. We have only just commenced investments aimed at changing community attitudes about the importance of mental health problems.

 

While Australian mental health policy is often depicted as world leading, those using or providing the services continue to report widespread gaps in services and dissatisfaction with the quality of services provided. Our national policy has championed the appropriate move to non-institutional forms of ongoing care. Consumers, carers and local health service providers, reported that the Commonwealth and the States are unwilling to back widespread and systemic reforms and are ill-prepared to report on progress within any of the key service areas. Overwhelmingly, the perception of those who use current services is that we have now arrived at a position of ‘Out of hospital, Out of mind!’

 

The community calls on the Prime Minister and Premiers to support:

 

• Investment of financial and infrastructure resources,

• Greater transparency and accountability,

• Clear deadlines for key outcomes,

• A focus on quality service provision,

• Reduction of human rights abuses and neglect,

• Genuine investment in service innovation, evaluation; and

• Associated aetiological and treatment research.

 

THE HISTORY OF MENTAL HEALTH REFORM

 

In 1992 the Australian Health Ministers committed their governments to correct decades of neglect in mental health. A national mental health policy was developed and mechanisms were described to lift Commonwealth and State expenditures, reduce human rights abuses, move the locus of care from hospitals to the community and deliver quality mental health within the mainstream of Australian health and welfare services (Commonwealth Dept of Health & Ageing 2002).

 

In 1993, the Human Rights Commissioner’s Report (‘Burdekin Report’) brought the human rights issues of overt abuse within institutions and covert neglect in the wider community to the attention of the general public. For the next ten years Australian governments implemented two five-year plans aimed at facilitating genuine participation for consumers and carers, developing high quality community-based mental health care and outlining a broader population-based health promotion and disease prevention approach.

 

This new national focus on a long-neglected health area assumed that all governments would invest additional dollars in the exercise. Those persons in need of mental health services, and their families, greeted these national commitments with great enthusiasm and expectation. Everyone assumed that real change required not only large increases in resources but also promotion of genuine national leadership and widespread professional and community support.

 

 

THE 2002 MENTAL HEALTH COUNCIL REVIEW

 

After ten years of this national approach, the Mental Health Council of Australia conducted a nation-wide review to ask those who used or provided mental health care whether substantial change had been achieved. This national consultation involved over 400 organisations and individuals and was conducted between August and December 2002. The consultation focused on a wide range of national bodies representing consumers and carers, professional groups, non-government organisations and local service providers.

 

The major conclusion of the review is stark. Despite the efforts of many committed politicians, government officials, service providers and community advocates, we do not have a system of effective or accessible mental health care. At all levels of government, within some of the professions and out in the wider community, there is a perception of general apathy, lack of accountability and a lack of commitment to real change. While public understanding of mental health has begun to improve, the wider community remains relatively ignorant of the service crisis. Only when a family member needs care are they made aware of the gross deficits in care.

 

People with mental disorders, and their families, feel frustrated and let down by the system. Their goodwill, patience and support for the protracted nature of genuine health care reform have been dissipated. People whose lives have been affected are willing to back another five years of government national planning only if it is supported by genuine national leadership and commitment.

 

While mental health reform is difficult, and does need to be seen as occurring over years rather than weeks or months, those in need of services today require an urgent and substantial improvement in our mental health care system. To simply continue with the current inadequate pace of reform, perpetuate the same inadequate resource base, utilise the same governance structures and fail to invest in innovation and disease prevention is to condemn many of the most disadvantaged and ill members of our Australian community to many more years of abuse, neglect and very poor mental and physical health. It also puts at great risk the well-being of many other Australian families who are likely to require such services for the first time in future years.

Community-based voices now favour a more proactive, more critical and more political approach. National and state governments have substantially underestimated this groundswell of disenchantment.

 

Enquiries within several states over recent years have only scratched the surface of experiences of poor quality care. Further agreements between governments are now in danger of being perceived as hollow and without integrity.

 

The current oversight of mental health care reform needs to be extended beyond the National Mental Health Working Group of the Australian Health Ministers Advisory Council to include heads of government.

 

 

THE KEY ISSUES

 

A.    Grossly Unmet Need for Basic Mental Health Services:

·        Currently 62% of persons with mental disorders do not utilise mental health services (National Survey of Mental Health and Wellbeing, 1997). Reported reasons include the stigma associated with mental disorders, fearfulness of medical treatments, the poor distribution and costs associated with specialist services and the inappropriate mix of medical and psychosocial services provided by government-financed systems;

·        Although 38% of persons with mental disorders access care, that care is largely provided by general practitioners (National Survey of Mental Health and Wellbeing, 1997). The decline in bulk-billing is placing further pressure on even this very limited access to of persons with mental disorders to basic primary care services;

·        GPs report that they are poorly supported by specialist care services and evidence from practice reviews indicates major deficits in the quality of care they provide (SPHERE supplement, Medical Journal of Australia; July, 2001).

·         As a direct consequence of our lack of community understanding of current treatments available for mental disorders and our poorly resourced and poorly distributed service systems, the majority of people with mental disorders receive either no treatment or treatment that fails to meet current international standards for optimal care. For example, less than one in six persons with depression or anxiety are currently receiving evidence-based treatments (SPHERE supplement, Medical Journal of Australia; July, 2001).

  

B.    Grossly Inadequate Growth in Expenditure Basic Services

·        Australia spends approximately 7% ($2.56 billion) of its health budget on mental health. While comparisons with other health areas are problematic, mental health accounts for at least 20% of total health costs due to death and disability.

·        Although international comparisons can only be approximate, other first-world countries report spending 10-14% of total health expenditure on mental health;

·        The costs of all health areas continue to increase due to increased population size (17.6 to 19.0 million Australians) & increased demand for new treatments, new technologies & more comprehensive services.

·        Despite the increased expenditure in mental health over the last decade ($778 million), there is no evidence that the proportion of total health expenditure devoted to mental health has increased. Increases in expenditure on mental health (46%) have simply mirrored increases in the costs of providing other forms of health care (42%).

·        The National Mental Health Strategy assumed that the proportion of health expenditure devoted to mental health would increase. While the Commonwealth did increase its contribution significantly (by 73% from $26.80 to $46.38 per capita), growth in state and territory expenditure was only 19.8% per capita (from $68.22 to $81.76 per capita; National Mental Health Report, 2002). The larger states of NSW and Victoria recorded very low increases of only 18% and 4.4% per capita respectively;

·        While growth in Commonwealth expenditure was significant, over two thirds of this was accounted for by the increase in pharmaceutical costs (402%) rather than planned or appropriate expansion of service systems;

·        The expansion in pharmaceutical costs is a result of the rapid growth in new products to treat brain-related disease as well as the decline in the external purchasing power of the Australian dollar. There is no substantial investment in development of these products in Australia.

·        The National Mental Health Strategy required all governments to broaden the mix of services they provided and to promote actively notions of disease prevention, early intervention and prevention of relapse. Additionally, partnerships with other services (particularly primary and general health care) were supported. Essentially, such expanded roles had to be financed from within the same overall budget and local clinicians and service providers reported actual declines in the total number of direct clinical services provided.

 

Each year for the next 5 years, each Head of Government should be asked to respond to four simple questions:

 

Is there evidence in your State or Territory that:

 

1.       The proportion of total health expenditure on mental health has increased by 1%?

2.       Access for people in need of primary care, emergency care, specialist care or ongoing community support has improved?

3.       Quality of mental health care has improved – as determined by reduction in adverse incidents as well as increases in the rate of provision of effective forms of treatment and the consumers’ experiences of care? And

4.       Reports of human rights abuses and neglect have diminished?

 

 

C.    Restricted Access to Existing Services

·        The experience of current consumers of mental health care is that they have severely limited access to primary care (exacerbated by current declines in bulk-billing rates), emergency care, specialist care or rehabilitation services;

·        Current care systems are perceived to be chaotic, under-resourced and overly focused on providing brief periods of medicalised care within acute care settings;

·        Private psychiatric services are grossly maldistributed and involve large out-of-pocket costs, while access to specialist psychologist and other allied health services has been restricted largely by lack of government or private insurance support; and

·        The demands on the carers and families of people with mental illness are increasing.

 

 

D.    Ongoing Human Rights Abuses and Neglect

·        While the locus of care under the National Mental Health Strategy has moved from institutional to community-based care no effective management system has evolved to provide either high quality care or the necessary supports for living productively within the wider community;

·        Persons with mental illness report ongoing abuse within hospital forms of care (particularly within emergency departments and other acute care settings of general hospitals), and ongoing abuse and neglect in the wider community;

·        Persons with mental illness report ongoing discrimination in key areas of employment and insurance and restricted access to basic welfare services and support.

 

 

E.     Increasing Demand for Mental Health Care

·        The future of mental health care will be one of increasing demand and increasing costs to health and welfare services;

·        Increasing demand will be driven by the significant stresses placed on Australian families from war, threat of terrorism, ongoing drought, more young people developing mental disorders, increasing numbers of persons with current disorders presenting for care (as public awareness of these conditions increases), and increasing expectations that services will provide optimal & evidence-based care for whole episodes of illness;

·        Persons with disorders will expect treatments to be provided earlier in the course of their illness, in more specialised forms and for longer periods.

·        Increased costs of care will arise as a result of demands for increased quality, better mix and duration of care as well as the costs associated with importing new pharmacological agents affecting the central nervous system;

·        Increased public, business & professional awareness of the total societal burden & economic costs of untreated mental disorders (as described within the Global Burden of Disease framework) will create increased expectations of a broad population-based approach; and

·        Governments will be expected to fund not just basic services but also support mental health promotion and disease prevention campaigns for the whole population.

 

CONCLUDING REMARKS

 

The findings of this review resonate strongly with and build on the extensive research undertaken by SANE Australia in 2002-03. SANE’s “Mental Health Report 2002-03” clearly showed that ‘mental health services are in disarray around the country, (and) operating in crisis mode’. SANE also reported that ‘effective treatments are not routinely available’, and ‘untreated mental illness is a leading contributor to Australia’s suicide rate’. We can no longer ignore the broad range of compelling evidence before us and must act now for the improvement of mental health care in Australia.

 

 

References:

 

Australian Bureau of Statistics (1997) Mental Health & Wellbeing: Profile of Adults, Australia 1997, ABS Cat. No. 4326.0 Commonwealth of Australia, Canberra.

Burgess et al. (2002) Mental Health Needs and Expenditure in Australia, Mental Health and Special Programs Branch, Commonwealth Department of Health and Ageing, Canberra.

Commonwealth Department of Health & Ageing (2002) National Mental Health Report 2002: Seventh Report. Changes in Australia’s Mental Health Services under the First Two Years of the Second National Mental Health Plan 1998-2000. Commonwealth of Australia, Canberra.

Human Rights and Equal Opportunity Commission (1993) Human rights and mental illness: report of the national inquiry into the human rights of people with mental illness, AGPS, Canberra.

Mathers, C, Vos, T & Stevenson, C (1999) The Burden of Disease and Injury in Australia, Australian Institute of Health and Welfare, AIHW Cat. No. PHE 17, Canberra.

Murray, C & Lopez, A. (1996) The Global Burden of Disease, Harvard University Press, Harvard.

Thornicroft, G & Betts, V (2002) International Mid-term Review of the Second National Mental Health Plan for Australia, Mental Health and Special Programs Branch, Department of Health and Ageing, Canberra.

SANE Australia (2002) SANE Mental Health Report 2002-03, Melbourne.

SPHERE supplement, Medical Journal of Australia; July, 2001