Getting mental health reform back on track: a leadership challenge for the new Australian Government

History of mental health reform

From the late 1950s, specialist mental health services started rapidly moving out of asylums. In the 1970s, this was accelerated by the human and civil rights movements. In 1983, the Richmond Report of mental health services in New South Wales provided the first coherent policy framework in Australia to underpin the process. In 1993, as Australia finalised its first National Mental Health Strategy, the Burdekin Report on the human rights of people with mental illness highlighted systemic failures in both community and institutional care.

Since 1993, national reform has largely focused on shifting specialist services for people with persistent or psychotic disorders from an institutional to a community base.2 However, from 1998, the agenda widened to also include a commitment to reducing the broader social and economic impacts of anxiety, depression and substance misuse.

In 2005, the Mental Health Council of Australia and the then Human Rights and Equal Opportunity Commission (now the Australian Human Rights Commission) again detailed the failings of the full range of mental health services.3

Also in 2005, we reported on the lack of implementation of community priorities identified through extensive community consultations in 2002,4 and proposed the adoption of national goals and targets to help reinvigorate the reform movement.5

Responding to the level of community disquiet, in 2006, Prime Minister John Howard and NSW Premier Morris Iemma initiated a new 5-year national reform plan to be led by the Council of Australian Governments.6 A series of new investments focused on youth mental health7 and much broader provision of psychological services8 than had been provided since 2002.9 However, during the subsequent national health reform period, Prime Minister Kevin Rudd abandoned an active push towards direct federal funding of community mental health care.

After mental health re-emerged as a policy issue in the 2010 federal election, Prime Minister Julia Gillard committed $2.2 billion over 5 years to mental health care reform, including $571 million to enhance care for 24 000 Australians with severe and debilitating mental illness, and $492 million to expand youth services, designed to eventually reach 72 000 young people per year. This allocation of new resources to early intervention for young people with psychotic disorders was based on a strong evidence base,10 in contrast with the additional investments in coordinated care for those with persistent illness.

The Gillard government also established the National Mental Health Commission (NMHC), complementing the development of state-based commissions in Western Australia, NSW and Queensland. These new bodies reflect the community's willingness to invest in new structures to drive accountability and reporting of key health and social outcomes.

Are we making progress?

In 2013, as part of the process of re-evaluating community perceptions of health services and developing community-based priorities for reform, we repeated the surveys (using the same methods) we had conducted in 2004.3,5 With regards to enhanced local delivery of services in each key priority area, not one area was reported as improving, and some were perceived as going backwards (Box 1). From a user's perspective, however, some other elements of care did improve (Box 2). Importantly, users reported a significant increase in access to adequate services (from 43% to 60%) — largely consistent with the substantive investment in Medicare-funded psychological services during this period.8

However, we have also seen a return to unacceptably high levels of seclusion and restraint in our acute care services and ongoing use of compulsory treatments in those returning to community-based care.1

Meanwhile, recent community surveys focusing on the needs of young people have emphasised the large degree of unmet need for care, as well as the desire to develop new ways of providing services — particularly those that are linked to new technologies.12 Importantly, people living with mental illness die at least 15 years earlier than others (largely due to premature cardiovascular disease), and this gap appears to be widening.13

Challenges ahead

In 2014, the new federal government faces major challenges in accelerating the transition to a person-centric, accessible, equitable and high-quality mental health and social services system. Some still argue for a return to the 1993–1997 focus on public services for those 100 000–200 000 Australians who experience the most severe, persistent or psychotic disorders. However, most international health and economic planners now accept that mental disorders affect a great many more people throughout their lives and that there is an overwhelming need for a more coordinated and responsive primary and secondary health care and social services system.14 We argue that our health and social systems need to engage people of all ages in a philosophy of recovery, respond to clinical and social need, and act to reduce life-threatening risks, irrespective of formal psychiatric diagnosis. This is certainly the perspective promoted by the NMHC.11

The challenge now is to identify those factors that are likely to be transformative and overcome many of the organisational, financial and professional barriers that have interfered with previous attempts to deliver better outcomes.

Key priorities

There needs to be a clear focus on prioritising key strategies (Box 3) and delivering specific health and economic outcomes that respond to the previously identified community priorities,3-5 new community expectations11 and the overarching governmental emphasis on enhanced social and economic participation.11,15 We have described eight key priorities, as follows:

1. Rapid implementation of early intervention services for young people. While these services have the capacity to be transformative,16 it is not inevitable that they will lead to improved economic, social or health outcomes. To achieve these goals, the headspace network needs to be enhanced by skilled service development, regular reporting of outcomes and clear linkage to new specialist health, employment and education services.

2. Long-term development of community-based care and real alternatives to acute hospitalisation. As the states are focused on optimising hospital-centric services, new federal funding mechanisms and genuine innovations in health (step-up and step-down beds) and secure housing, backed by clinical supports, need to lead the way.

3. Developing national models of mental health and social care that would help all governments plan and arrange high-quality services and help reshape community and provider expectations.

4. Intensifying supported employment systems for people with a mental illness. Existing employment services are not properly resourced to find work for many people with a persistent mental illness.

5. Financing enhanced primary care systems to support people with persistent mental illness and physical health comorbidity. Promotion of targeted smoking cessation and active reduction of other metabolic and lifestyle risks related to premature cardiovascular disease are high priorities.

6. Developing serious e-health infrastructure to enhance access and drive broader system reform. Virtual care systems include assessment and monitoring of care. They can also deliver more flexible working conditions for health professionals, as well as better access, cost and equity outcomes for the public.

7. Recognising primary and secondary prevention strategies as core services. The capacity to deliver online primary prevention programs for anxiety and depression during the school years may be most effective. Key life skills and specific psychological learning can be incorporated into the core health and social goals of school curricula and be supervised by schools, parents and other community providers. Secondary prevention of self-harm and suicidal behaviour, alcohol or other substance misuse, other psychological disorders and physical ill health (notably premature cardiovascular disease) are major objectives for all who present for care, irrespective of formal diagnosis.

8. Developing suicide prevention at scale. The international evidence base for effective actions in this area has increased considerably. Taken together, research findings accumulated over the past 20 years from systematic reviews suggest that there are multiple interventions that are supported. The evidence is accumulating that these interventions may operate synergistically to lower suicide risk at the population level, and that a systems approach to suicide prevention may maximise outcomes.17 However, if we are to achieve a 25% reduction in suicide rates in 5 years and a 50% reduction in 10 years, a major planning exercise is needed to determine the size of the financial investment required and which combination of community (eg, workplace-based programs) or individual (eg, treatment of depression, access to suicide prevention online) strategies should be supported.