This article is featured in The Saturday Paper and is republished with permission.
In this second week of an election campaign in which Labor has made healthcare a centrepiece, mental health has finally attracted some significant attention. Prime Minister Anthony Albanese unveiled a funding package of $1 billion focused on youth and the so-called “missing middle” – that is, those too unwell for primary care and private services but too well for public state-based services.
The new funding will be channelled into the creation of 31 Medicare Mental Health Centres (MMHCs) around the country, which will offer free drop-in care, an expansion of current headspace services for youth, an additional 20 centres for youth with complex needs, and training places for 1200 mental health professionals and peer workers to fill staffing shortages.
This will cover some of the gap between state and Commonwealth government funding and is welcome assistance for a service that’s barely equipped to deal with the sharp increase in demand over recent years. It’s also a sound investment. Even before that pandemic-driven spike in demand, a Productivity Commission report in 2020 estimated that mental ill health cost Australia about $200 billion a year, and an outlay of $4.2 billion on mental health would return about $20 billion in benefits.
Clinicians don’t speak in terms of dollars – we tend to value lives and clients over output and productivity – but these figures reinforce the benefit of adequate investment in mental healthcare. The trouble is that $1 billion only just starts to address the huge need. Albanese’s announcement has drawn mixed responses across the sector.
“The package contributes to critical issues, including workforce shortages, long wait times and growing pressure on overstretched mental health professionals,” says Dr Sara Quinn, the president of the Australian Psychological Society. However, she adds that “to be effective, these reforms must be paired with reforms that recognise the reality of providing psychology services.
“People with moderate to high needs require at least 20 sessions, not just 10,” she says, referring to Labor’s decision, at the end of 2022, to drop to 10 the annual cap on psychology sessions funded by Medicare, from the pandemic-era increase to 20 under the Morrison government. Peter Dutton has promised a Coalition government would raise the cap again.
Research demonstrates that complex mental health disorders such as PTSD require 15 to 20 sessions for a course of treatment, and that increased frequency of sessions results in quicker recovery. The caps on funding mean people most in need often aren’t attending sessions frequently enough to benefit from them. The Better Access program, which was launched almost two decades ago to bring psychological services under the Medicare scheme, was never funded to provide for moderate to severe conditions, but this is how it has been used in the absence of any other psychologically driven care models.
Longstanding problems in the sector remain unresolved. Unlike other areas of health policy, Australia does not have a unified and integrated mental health strategy that clearly identifies vulnerable cohorts, targets and measurable outcomes. The Department of Health and Aged Care website currently hosts seven different policies, plans, visions and strategies, some dating as far back as 2008. This reflects the piecemeal nature of funding for mental health – the opacity of policy mirrors the experience of carers, consumers and clinicians who attempt daily to navigate a byzantine maze of bureaucracy and promises.
Without a coherent long-term strategy, we will continue to see a recursive set of commissions and inquiries, with funds allocated according to political whims or the loudest and most powerful interest groups. Change requires long-term investment and commitment, rather than one-off injections. Many well-intentioned and useful services have started, only to fail or be hobbled by a lack of ongoing funding. Examples include headspace centres, and programs designed to tackle suicidality in Victorian prisons, which were recently defunded.
The latest evaluation of Better Access found gaps in service delivery to men, people aged 65 and over, those in regional areas and people living in major cities in lower socioeconomic areas.
The proposed MMHCs will help close these gaps only if they are properly targeted. Detailed studies are needed to ensure that intervention centres are located in communities where there is specific and significant need. This may bring additional challenges, such as hiring and retaining skilled staff in remote regions – though, as we’ve seen, this is a crucial challenge even in metropolitan New South Wales.
Simply training new staff will not necessarily mean that these staff choose to work in remote areas or the public system, and a cohesive human resources strategy will be required to attract and retain trained professionals in these roles.
Another concern related to the new MMHCs is that it is unclear whether they will be staffed by appropriately trained psychologists. Skilled staffing is essential. A 2022 evaluation of Victorian drop-in centres found that consumers going to these centres were severely unwell on presentation and had needs more complex than anticipated.
I have spoken with several staff who work in similar models and have received feedback that their colleagues are often beginner clinicians who are under-trained for this client complexity. They are expected to provide services beyond their scope of practice and have very limited access to funding for adequate professional development.
“Not all the Medicare centres provide a permanent psychologist on staff,” says Carly Dober, who is a psychologist and policy coordinator at the Australian Association of Psychologists. “MMHCs at this point do not have the capacity to treat clients in the long term.”
It’s important, too, that access not be conflated with outcomes. For instance, a recent evaluation of headspace demonstrated that up to 70 per cent of its clients did not demonstrate any measurable improvement in psychological distress, and some reported a further deterioration, after accessing services. Measuring impact in complex health scenarios is very difficult – in my forensic work our best outcomes are often simply the absence of another serious offence – so there needs to be more debate about appropriate service models and how to best track improvement.
Finally, the new Labor policy and funding announcement focuses primarily on providing interventions for mental ill health once it is established. We are no closer to the holistic policy response envisaged in the Productivity Commission’s report and recommended by the World Health Organization in 2022 – that is, a focus on the social determinants of mental health, such as housing, disability services and food security.
Moreover, key services such as assessments for neurodivergence remain unfunded, leaving vulnerable young people and adults unable to access services that require a confirmed diagnosis.
While funding for treatment is important, says lived experience consultant and advocate Simon Katterl, “treatment alone isn’t enough to stem our mental health crises – we must address root causes, tackling discrimination against marginalised groups, making housing a human right rather than speculative investment, raising income support and abolishing robodebt-style mutual-obligations policies.”
Decades of research demonstrates that mental illness is inextricably linked to our life circumstances, and identifying and remedying the social determinants of ill health is an essential measure. This is an unpalatable political task, as it involves broad and bold interventions across a wide range of areas, including housing, gender, family violence, disability, employment, education and social security.
To effect true change for generations, policy interventions must step away from focusing only on medicalised interventions and must take a broader and deeper view aimed at primary prevention approaches.
This latest promise of funding will offer a much-needed boost to Australia’s mental health system. However, many policy interventions have failed in the implementation stage and remain nothing more than a set of plans or another round robin of consultations, strategy papers and consortiums, with no discernible outputs or benefits to consumers. Many on the frontlines of the mental healthcare sector are reserving their judgement given the context of this promise, on the eve of an election, following several years of inaction and a longer history of underfunding across this critical healthcare sector.