Published in Croakey, March 13 2020
Australia’s mental health services are in a mess. The Royal Commission into Victoria’s mental health system and the Productivity Commission’s inquiry into mental health have exposed the extent of the problem – and the damage done to Australians needing help.
The fundamental problem is that Australia has two mental health systems: an uncapped, fee-for-service, Commonwealth-funded system with high out-of-pocket payments for patients; and a capped, hospital-focused, state-funded system that is stretched to meet demand. Coordination of the two is poor, resulting in yawning gaps and duplication, poorly targeted services, and massive inequity in who gets services (the poor get fewer services than the rich; and the city does much better than the country).
The missing middle
The biggest losers are people who need intensive community support to recover and go on with their lives. These people are the ‘missing middle’ – they fall between inpatient hospital services, and services for people with mild to moderate mental health problems.
These people need competent, integrated services that provide them with timely, comprehensive care at home and in the community. These services have to be available seven days a week for extended hours. They have to be able to provide individual and group therapy, medical management, safe and supportive environments, and support to families, schools, and workplaces. This requires well-organised, team-based care with a strong focus on recovery and rehabilitation.
The Productivity Commission’s draft report on mental health makes clear that community services for the missing middle are wholly inadequate. Currently, planning and coordination of mental health services between the Commonwealth and the states is poor. There are no agreed regional plans that establish service models, levels of service to meet needs, resource levels, workforce and service development strategies, data and reporting arrangements, or governance and management accountabilities.
Looking for solutions
The Commission’s preferred solution would hand responsibility for complex community care back to state governments. But it’s the wrong way to go, because it would risk increasing the focus on hospital care for people with complex needs. It would weaken the link between Commonwealth Medicare-funded services and state-funded services, and it would further separate mental health care from physical health care. Worse, the states already struggle to find the money for their mental health services.
Nationally, it has been agreed the Commonwealth should have the lead responsibility for primary and community health services. The Commonwealth has established 31 Primary Health Networks (PHNs) to plan, coordinate, and commission a range of health services for regional, community based health services. The Commonwealth funds some community mental health through PHNs. As well, the Commonwealth has progressively taken responsibility for other areas of long-term care, including aged care and disability services.
Redesigning the Primary Health Networks
The existing Commonwealth Primary Health Network should be redesigned to deliver comprehensive services for people with complex, longer-term mental health needs (the missing middle). While inpatient mental health services should remain a state responsibility, PHNs should be given a bigger role in commissioning community based mental health services for people with complex needs – including services currently provided by the states.
The Commonwealth and the states should negotiate regional mental health agreements for each of the 31 Primary Health Networks. These agreements should specify a common regional approach to determine mental health needs and service responses. Service models that set out access and referral pathways, coordination arrangements, and funding levels should be agreed for each PHN, so patients can move seamlessly through different services. Consistent data, reporting, and accountability arrangements should be introduced to check that agreed goals and priorities are being met.
Australians needing mental health care deserve better than the mess of services they are currently offered. Regional mental health agreements, along the lines we recommend, would provide a practical framework for the Commonwealth and the states to integrate planning, funding, service delivery, and accountability for mental health services.