Opinion article

Building our mental wealth: time for serious structural reform

Major opportunities for structural reform in mental health are on the agenda, but what will Australia choose; serious structural reform or more of the same? University of Sydney Brain and Mind Centre, Health and Policy Co-Director, Professor Ian Hickie AM explores. 

Malcolm Turnbull was the first Australian Prime Minister to make the connection between investing in Australia’s ‘mental wealth’, and the future economic and social prosperity of this nation.
The term ‘mental wealth’ was coined in the United Kingdom in 2008 and describes the collective cognitive and emotional resources of citizens. To build ‘mental wealth’, it was said that nations needed to invest in the health, education, social and community processes that promote the building and retention of each individual’s mental ‘capital’. That’s a long and complex process. In child and youth development, from ages minus nine months to 25 years and then, for retention, across the adult life span.
We also need to keep one eye firmly on the broader economic health of the nation. A well-established fact in public mental health is that when a country experiences a serious economic downturn, suicide rates increase. So in 2018, when The Economist magazine featured the Australian economy, “The wonder down under”, on its front cover, you might have assumed that we were enjoying a prolonged period of very good national mental health. Sadly, this has not been the case. Australia is only a middle-ranking country for suicide rates and other key parameters of mental health, including participation rates of those with mental ill-health in employment, and of young people in employment, education or training. 
While suicide rates were higher in the 1990s, we have seen a significant deterioration in the last five years. Trends for psychological distress, self-harm, and suicidal thoughts and behaviours, particularly among young women, are all headed in the wrong direction.
Against this background of worrying trends and unacceptable variation in outcomes, mental health reform is again in the news.
On the upside, Prime Minister Scott Morrison has put youth suicide prevention on his personal ‘to do’ list. Across the Tasman, New Zealand Prime Minister Jacinda Ardern has surprised many by framing a 21st Century national budget focused not simply on economic outcomes but rather national ‘wellbeing’, with a strong emphasis on major new investments in mental health services.
On the downside, we see daily stories of overwhelming numbers of young people with suicidal behaviour presenting to Emergency Departments, high suicide rates among vulnerable populations including Indigenous Australians and War Veterans, the inadequate reach and depth of early intervention services and the tragic deaths of those with severe mental illness, homelessness and comorbid substance misuse that continue to attract national headlines. These stories are compounded by reporting of the low morale of staff working in front-line services, major service gaps and large disparities between actual needs and the size and scope of government investment.
A classic Australian response to a perceived crisis is more enquiries. Although the National Mental Health Commission (NMHC) was established by Prime Minister Julia Gillard in 2012 to break this cycle, policy advice to government in 2019 remains highly contested. Implementation of broader and more serious mental health reform, particularly within our complex Federation structure, is not on the agenda.  Currently, we have a Royal Commission in Victoria into state-based mental health services, the national Royal Commission into Aged Care and the proposal of a Royal Commission into Veteran’s mental health.
More optimistically, we await the draft report from the Productivity Commission (PC) in October 2019 and the final report in May 2020. They have been charged with the task of recommending a fundamental reorganisation of mental health services. The PC enquiry was commissioned by the Turnbull-Morrison Government in recognition of the fact that the current service arrangements are poorly suited to the population's actual needs.
To its credit, the Turnbull Government did pick up several of the key recommendations of the 2014 NMHC Contributing Lives, Thriving Communities - Report of the National Review of Mental Health Programmes and Services, particularly with regards to movement of most national mental health programs to a regionally-based model. These services are now reliant on the capacity of Primary Health Networks (PHNs) to oversee the development of smarter and better integrated local healthcare networks. Minister for Health Greg Hunt clearly moved to support the long-term functioning of the PHNs prior to the election – at least for those who had the clear capacity to fulfil their role.
Just prior to the 2019 Election, the Government released the draft recommendations of the Medicare Benefits Schedule Review item numbers that support specialised mental health interventions by psychologists and other professionals. This is the most important, and potentially most expensive item that is back on the desk of Minister Hunt. Many health professional groups simply favour pumping in more money. Our own estimates however, suggest that expansion of the current and poorly targeted system would cost at least another $2 billion over the next four years. On top of the ongoing difficulties with implementation of the National Disability Insurance Scheme (NDIS), this would represent very poor value for money.
By contrast, there is the potential for the Morrison Government to back serious investment in multidisciplinary and integrated care models, focusing on those with more complex and persistent difficulties, the so-called “missing middle” in mental health care. Investments in smart care with this group could result in serious productivity gains as they are most dislocated from active participation in the workforce. Minister Hunt has indicated his in-principle support for these types of initiatives through his support for funding such service models for those with anorexia nervosa and other chronic or life-threatening eating disorders.
Just spending more on unrestricted single practitioner-delivered fee-for-service interventions for individuals with minor anxiety or depressive disorders, or no disorder at all, as suggested by the Review Committee, is unlikely to be of much economic benefit. This is because those simpler counselling-based services focus largely on relieving distress among individuals who are engaged with education or employment. More skilled psychological interventions are more valuable, particularly when they are targeted at those in greater need, and where skilled practitioners work closely with other professionals to ensure a return to work or school. 
So, in 2019 where are we really headed? The answer is that major opportunities for structural reform are on the agenda, for example PC report, Medicare reform, PHN-based regional care, NDIS, early intervention services like headspace, digital innovations and regionally-targeted suicide prevention, but it is unclear yet whether the respective Federal or State Governments, or professional organisations, are up to the challenge.
The 2014 Report of the NMHC did set out the hard decisions;
  1. invest in prevention and earlier in the illness cycle – move away from just building more hospital beds;
  2. invest in the PHNs (money, infrastructure, governance, partnerships) to oversee the continuous implementation of high quality and regionally relevant mental health programs;
  3. support digital innovations that empower users of care and bring real expertise and access to regional Australia; and
  4. support genuine regionally based trials of new service models in mental health or suicide prevention.
We can now add:
  1. work with the reform of the Medicare item numbers to back team-based multi-disciplinary care;
  2. implement those recommendations of the PC enquiry that shift services to meet the needs of those with more complex disorders and emphasise the delivery of functional outcomes;
  3. promote the tools (planning, evaluation, technology-enabled delivery and data collection and integration) that support serious system-level and structural reforms; and
  4. be willing to reduce or cease funding to those less effective service models that dominate the current landscape of service delivery.
As with economic reform, Australia now has real choices. Serious structural reform or more of the same? In mental health, the danger is that we see continued emphasis on increased awareness-raising, for example more press releases, more ‘postage stamp’ program funding to small NGOs and transferring of the ongoing responsibility for action to those affected and their families. As PM Morrison, Federal Treasurer Frydenberg and Health Minister Hunt are certainly actively engaged, we do hope that structural reform is the outcome this time around.
About the authors

Ian Hickie

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Professor Ian Hickie is Co-Director, Health and Policy at The University of Sydney’s Brain and Mind Centre. He is an NHMRC Senior Principal Research Fellow (2013-2017 and 2018-22), having previously been one of the inaugural NHMRC Australian Fellows (2008-12). He was an inaugural Commissioner on Australia’s National Mental Health Commission (2012-18) overseeing enhanced accountability for mental health reform and suicide prevention. He is an internationally renowned researcher in clinical psychiatry, with particular reference to medical aspects of common mood disorders, depression and bipolar disorder in young people, early intervention, use of new and emerging technologies and suicide prevention.