Mental health: why is progress so slow?

Nearly 30 per cent of non-fatal disease burden in Australia is due to mental disorders. Mental health spending constitutes only 6.4 per cent of total health spending. The extensive media coverage of mental health disasters and the many submissions to the recent Senate Mental Health Inquiry suggest that the health of our mental health system is poor.

Some seriously ill patients do not get seen at all or there are huge delays before they are seen. Once seen they may be treated well for their specific condition, stabilised, and then left to the mercy of the grossly inadequate community follow-up services. Those seriously ill with comorbidities, such as substance abuse, may not be treated well when presenting in crisis because of the totally artificial separation in most state health systems of the treatment of substance abuse and mental illness. Even with the less seriously ill major problems arise in managing those with comorbidities.

The mild to moderately ill continue to have poor access to the full and appropriate range of health services they require, particularly psychological support. Community-based support, including access to housing and social security benefits, are inadequate and or difficult to access. This contributes to their poor recovery and rehabilitation, but may also mean they progress unnecessarily to becoming seriously ill. The successfully treated seriously ill are also affected by these service inadequacies.

The reasons for the above are complex but at one level they include: inadequate community support following deinstitutionalisation; uncoordinated primary care; inadequate resourcing of public hospitals, including a lack of psychiatric beds; and a lack of appreciation of non-medical factors contributing to the problems.

But at a second level the causes are more related to a lack of accountability, political will and vision, and a reluctance by governments to accept responsibility and show the leadership necessary to address the issues. No one level of government is responsible for the problems. That in itself is part of the problem, as the solution requires a degree of cooperation between governments, which currently does not  exist.

Much has been done to improve the situation. The development of a National Mental Health Strategy ( NMHS), and its revisions, have given policy direction which, if implemented, would address most of the concerns raised. To date, excellent work has been done: for example, addressing the stigma of mental disorders, addressing the media's portrayal of mental disorders, and addressing factors which lead to suicide.

Since 1997, suicide rates across the population and in the 15-24 year age group have fallen, and part of this may be the result of initiatives guided by the NMHS. Unfortunately suicide rates in Indigenous communities are rising. Access to psychologists has been improved through at least three different federal government programs. GPs have been better educated about mental illness through NMHS initiatives. Government support for crisis assessment teams, and for scattered initiatives for regional mental health services have led to improved access to appropriate services in some areas. In some states, excellent initiatives to address the issue of a lack of housing have been enacted.

These initiatives however, are either addressing the crisis end of the problem, or are excellent piecemeal initiatives in an uncoordinated approach to a huge problem, which is crying out for more resources and much better allocation of the resources already committed.

What is needed now is a mechanism so NMHS policies can be fully implemented. That cannot happen without political will and vision and an accountability framework which clearly indicates why progress is not being made in the implementation of policies.

The Federal Government, along with the state governments, initiated the NMHS. It is time that these governments stopped talking about the problems and worked out ways to implement policies. To date such cooperation is present in a variety of initiatives but not in a co-ordinated way across the spectrum of problems. The questions that need to be asked are, “Is it possible under our federated system for sufficient cooperation to occur to ever implement these policies? Can a system of governance be constructed which incorporates accountability, transparency and an appropriate level of funding and delivery of services?”

The concepts of pooled funding or a unitary source of funding combined with a commitment to a national set of standards theoretically offers a solution to the problem. The governance of such a process remains the problem.

Possibilities range from increasing the status of health care to Cabinet level to setting up an independent mental health commission charged with delivering the funds in an accountable and transparent way - to whatever health care and other service structures exist or are created to provide services. This might be on a state basis, a regional basis or other forms. In addition, such a commission would need to have access to the highest levels of government to coordinate the health services to other non-medical services, such as housing and social security support.

There is a fundamental flaw, however, in any of the above suggestions in the current political situation. A major barrier exists in Australia to the implementation of the NMHS and it is the Federal Government. A health minister who says, "Health is a market. If the doctor charges you, you ought to expect to pay something." (Abbott reported in The Age April 22, 2004) is telling us something about the beliefs of the Coalition. In their view co-payments are an important price signal to control demand. Their real intention regarding Medicare must be seen. It is that Medicare and the public system will be the safety net, and private medicine must expand. Such a scenario is incompatible with the NMHS.

Those affected by mental illness are not a powerful lobby group. They will not change governments. The social stigma associated with mental illness remains (despite improvements) and further limits their capacity to advocate effectively. The most needy are the ones who will be left grasping for the safety net. In good economic times the quality of the safety net will be improved. When the razor gang cuts, it will always cut the safety net.

In this setting, where opportunity rather than equity is the driving force, the best that can be hoped for is a continuation of the piecemeal improvements in some of the services that those with mental illnesses so desperately need. Until those in power believe that equity, equal access to equal health care for equal need, is fundamental to a healthy health system, we will continue to hear the heart-rending stories of lives lost or wasted due to treatable and preventable disease and the associated disability.