Mental health in Australia – past performance is no guarantee of future results

Andrew Dempster, Associate Director, Health, Ageing and Human Services
Andrew Dempster, Associate Director, Health, Ageing and Human Services

Historically Australia is a leader in the treatment of mental health. One of the early adopters of deinstitutionalisation, on the forefront of the use of Lithium and the first to trial models that are now used across the globe, such as community based treatment teams, outreach teams, early psychosis services and perinatal mental health. Australia can be proud of its efforts to reform mental health service delivery in recent decades, but it now risks being left behind.

A little over a year ago I was in Luxembourg facilitating breakout sessions for the World Economic Forum (WEF) project examining ‘misalignments in health care’. The sessions with a number of international clinical, academic and research leaders, focused on mental health and the challenges confronting us globally

Both the sessions and the report made me question to what extent these global challenges apply to Australian mental health.

We’ve built a system that creates such robust misalignments which get greater year on year. In fact, there is a chance that if they are left for much longer, solving the challenge of mental health care will make solving the ‘wicked problems’ of the world seem simple.

The challenges

The results of the past, should not blind us from the misalignments we are faced with today. Translating the WEF approach into the Australian context, it doesn’t take long to find similar challenges:

Divergent objectives

There is a disconnection between service need and availability. Specialist state based services often restrict access to only the most “unwell” or “at risk”. Yet we know intervening earlier can avoid the need for much more intensive support later.

Power asymmetry.

Mental health seems to be losing the battle for a greater share of the health budget against acute health care advocates. Mental and substance use disorders represent the third highest burden of disease category[1] (12 per cent of Australia’s burden of disease and 24 percent of Years Lived with a Disability (YLD)) and yet we continue to spend only 5.3 percent  of the health budget[2] on it.

Cooperation failures

Our care system layers and the degree of specialisation brings the risk of a ‘not my patient’ mentality, placing quality of care at risk. When we know “the life expectancy for someone living with a mental illness is 10 to 25 years lower than the general population[3]” it’s time we shift the focus. If we don’t the gap will likely continue.

The effects

We seem over focused on being able to provide coverage, meet response times and reduce restrictive interventions, ignoring the fundamental shift happening before us:

  • Private psychiatry has seen insurers reducing or removing mental health care from all bar premium policies
  • Ambulance services respond to mental health and substance abuse crises more than ever (approximately 20 percent [4])
  • High and increasing homelessness rates throughout Australia
  • High suicide rates relative to other developed countries
  • Emergency departments have become quasi mental health triage points – the only place people with mental health needs cannot be turned away or referred on
  • GPs commonly “fill their books” after the first week of setting up practice.

I believe we have the ability to make clear changes today that will reap benefits for decades to come and reposition our mental health system once again as a leading example we can all be proud of.

What changes can we make today?

  • Incremental proportional funding increases to mental health today will better align our services to meet the burden of disease in the future.
  • Reform our funding models to align with individual need rather than historical service activity.
  • Make structural changes to curriculum, compulsory subjects and placements to equip the workforce to deal with the increasing complexities of mental health in turn providing the skills, competence and confidence to advocate for strong evidence based care to become the norm.
  • Develop mental health metrics to drive change in the same way that general health care has used KPIs successfully.
  • Maximise the use of existing eHealth technologies we have to reduce the impacts of distance and disconnection.

While for Australian Governments, health departments and clinical and academic leaders the time to act on mental health was yesterday the opportunity for change is here now.

This is a discussion we need to have now.

 

The WEF roundtable report, Misaligned stakeholders and health system underperformance, is now released highlighting critical ‘macro’ level ‘misalignments in health care’.

[1] Australian Institute of Health and Welfare, Australian Burden of Disease Study, 2011.
[2] AIHW. 2014-15.  Health expenditure Australia 2014–15
[3] World Health Organisation, Information sheet – Premature death among people with severe mental disorders, 2016.
[4] Lloyd B., Gao C. X., Heilbronn, C., Lubman, D. I. (2015). Self harm and mental health-related ambulance attendances in Australia: 2013 Data. Fitzroy, Victoria: Turning Point

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