Hospitals will treat 'em and street 'em as COAG dumps mentally ill

23 April 2010

Going into Monday's Council of Australian Governments meeting, the signs for genuine mental health reform were good.

Kevin Rudd had indicated his support for those young Australians who face tough times. Health Minister Nicola Roxon was a fierce critic of Tony Abbott's failure to reform commonwealth mental health programs. The Bennett commission highlighted mental health, indigenous health and dental care as the areas of greatest health inequality and service neglect. The new premiers of NSW and Western Australia had articulated the need for radical new approaches to mental health service delivery. Australian of the Year Pat McGorry was recognised for developing world-leading early intervention programs.

To cap off the excitement, Roxon revealed the federal government's key strategy: to push for 100 per cent commonwealth funding of community mental health programs. This would have been a landmark reform. It would also have provided a template for genuine reform in other areas of chronic and complex disease.

How is it possible we are now faced with a mental health system that is more fragmented, less resourced and more invisible than ever? Despite the Prime Minister's trumpeting of mental health reform, it's time to face the facts. Mental health services received only two per cent of the new funding initiatives announced ($116 million of $5.4 billion in the next four years). This is despite the fact that mental ill-health and related alcohol and substance misuse account for 24 per cent of all health-related disability, rising to 60 per cent in those aged 15-34 years.

The community mental health sector, which is funded by the states (costing $1.5bn a year), now lies outside the new 60-40 split of activity-based funding for public hospitals and the commonwealth's 100 per cent support for GP-based services. It has been left with promises of future negotiations. In the interim, existing commonwealth programs have been narrowed to focus on those with less disabling anxiety and depressive disorders.

Facing increased fragmentation of financing under the new deal, smart state bureaucrats will move community-based services back to emergency departments. That way the commonwealth will be forced to pick up at least 60 per cent of the bill. The pressure on overstretched public services will increase. As indicated by the tragic death of a young indigenous man in Townsville last week, the most likely response is that people with mental ill-health will be handled by security guards, not clinicians or humane care systems.

We are now headed for the US model, where the emergency room is the centre of the service system. The cold-hearted response to those with even the most severe disorders will be to "treat 'em and street 'em". Those who have travelled in the US will be aware of how this philosophy contributes to prolonged hopelessness, recurrent acute hospitalisations and disconnection from family and other social supports.

In Australia, we are well down this track. Most states are moving their acute assessment services to units within emergency departments. We have increasing rates of acute hospitalisation of those with mental ill-health and high rates of youth homelessness attributable to psychiatric disorders and associated alcohol and substance misuse. As community mental health services implode under the COAG agreement, we can expect all these phenomena to accelerate.

These issues are not new. In 2005, the Not For Service report of the Human Rights Commission and the Mental Health Council of Australia, documented extensive experiences of injustice and despair among the mentally ill. Coincidentally, that year Cornelia Rau's experiences with mental health services and mandatory detention were also documented by the Palmer inquiry.

In 2006, recognising these catastrophic service failures, the Senate established a national inquiry and John Howard and then NSW premier Morris Iemma led COAG to commit $4bn to the mental health sector. However, those leaders did not remove divisions between state and federal responsibilities and left related issues, such as youth homelessness, in the too hard basket. Repeated Senate inquiries have highlighted the lack of implementation of those 2006 reforms and the unwillingness of nine health departments to deliver a national service plan.

In the past 12 months, less than 13 per cent of young men and 31 per cent of young women with mental health problems received any care. As 75 per cent of mental illness begins before age 25, the early years are critical. We have no national network of early intervention services for young people developing life-threatening or chronically disabling psychotic illnesses. The most recent data suggest that after a decade of decline, suicide rates may again be on the rise.

To those outside the corridors of power, the way in which COAG has turned its back on these major health, social and economic issues is staggering. The lack of empathy for those affected, the lack of time spent with families who have lost relatives to suicide, the lack of smart health planning and the meagre investment in youth strategies (particularly for psychotic disorders) is inexplicable.

For any prime minister or first minister who does understand the issues, the next steps are clear. The commonwealth must fund 100 per cent of community-based mental health care immediately. This would drive the development of alternatives to acute hospitalisation and other forms of coercive care. As signalled by the Bennett commission, the sector urgently needs at least $300m a year of new money (not the $30m on offer) divided between three key programs: youth-specific primary care services based on the Headspace model, a national network of early psychosis treatment centres and community-based programs that link health and housing for those with persistent illness.

Mental health reform is not that complex. It's not that costly. This year, the missing ingredient appears to be political leadership. We need first ministers who can invest in the future and plan longer-term community-based services. We are not served well by those who spend our taxes on their short-term political needs.

Professor Ian Hickie is executive director of the Brain & Mind Research Institute, University of Sydney, and a director of Headspace, the National Youth Mental Health Foundation.

Media inquiries: Sarah Stock, 0419 278 715,