Mental health needs lost in sideshow debate

The decision by federal Health Minister Mark Butler to not continue with the extra 10 Better Access mental health therapy sessions under Medicare, introduced as a temporary pandemic measure, has produced a storm. At first glance, the minister’s decision seemed at odds with the unprecedented crisis that has developed in mental health care in Australia.

With the 25 per cent surge in anxiety and depression which followed the pandemic – and the even more alarming 50 per cent surge in mental illness in young people since 2007 – we are in the eye of a perfect storm. Mental health is now Australia’s most pressing public health problem.

There has been a surge in the number of people with mental illnesses since the start of the COVID-19 pandemic.Credit: iStock

But the Better Access debate is a sideshow and yet another symptom of more fundamental underfunding and structural weaknesses in mental health care. As Matt Berriman, chair of Mental Health Australia, has highlighted, this controversy risks taking the focus off the broader national crisis in mental health care, which the Albanese government has yet to address.

There are two storm fronts of crisis in mental health care. The first is initial access, and the second is quality care for persistent and complex conditions.

First, primary care innovations such as Better Access and headspace are world-leading initiatives which have improved access for Australians with mild to moderate, shorter-term conditions. They are effective – and cost-effective – for whom they were designed.

However, the rising tide of mental disorders has overwhelmed primary care and blocked access to psychologists and psychiatrists. Notwithstanding potential benefits for a select subgroup, as feared, the addition of an extra 10 psychology sessions during the pandemic – to make it up to 20 sessions a year covered by Medicare – increased the problem of blocked access. With a limited number of psychologists, more people staying longer means there is capacity for fewer new patients.

Second, most people with mental illness need more than a time-limited episode of care with a solo, office-based practitioner. These people have more persistent and complex conditions for which primary care functions, as with physical illness, more like an entry pathway to specialised care. We have termed these people “the missing middle” because they currently simply cannot get access to sustained quality care.

The current debate has certainly shone a light on this crucial area of unmet need and has implied that the extra 10 sessions are the solution. On the contrary, Better Access is not the main game, and certainly not the sole solution.

While 20 sessions were on offer, only 15 per cent of the cost of psychology sessions in Better Access sat within the extra 10 sessions, amounting to about $120 million a year.

And despite public statements to the contrary, the removal of the extra 10 sessions is not a cut, and will not save money. This is because Better Access clinicians will fill those places with new patients, thereby improving access for people on waiting lists. So practitioners’ incomes will also not suffer. In any event, the cost of these sessions is a very minor issue in the landscape of mental health funding.

We currently spend about $11 billion a year in Australia to cover 5 million Australians with mental ill-health. For perspective, we spend about $30 billion a year through the National Disability Insurance Scheme on 500,000 Australians with disability.

The 2020 Productivity Commission report on mental health called out this asymmetry and the self-defeating nature of the underspending. It found the mental ill-health and suicide are costing the economy about $200 billion to $220 billion a year. This is made up of welfare costs, loss of tax revenue and a raft of other expenditures – the cost of failure. Conversely, there is potential for major return on investment if we expand evidence-based mental health care.

Equity has been invoked on both sides of the debate, yet the major source of inequity is the growing failure of Medicare to sustain the viability of bulk-billing, whether the practitioners be GPs, medical specialists or psychologists. Co-payments are now the norm, meaning that psychologists, like doctors, can charge the patient a gap fee (rising to an average of about $90 per session) on top of what Medicare covers. While they are entitled and may need to do so, it means many people who need care – especially those in outer-metropolitan and rural and regional Australia – simply cannot afford it. The co-payment burden also increases with the number of sessions, hence so does the inequity.

Nevertheless, more sessions could be a partial solution if they could be better targeted. Some of the missing middle do benefit from more sessions, but it is unclear how to identify them.

What is clear, though, is there is another much larger group who need sustained multidisciplinary care for complex, persistent, potentially chronic conditions. Mental illness is now Australia’s No. 1 chronic disease. These patients cover multiple diagnostic areas with wider and deeper socioeconomic needs, for which office-based psychology alone is not fit for purpose.

The good news is that the assembly of specialised community-based services funded by the federal government is underway, originally commenced by the current health minister under the Gillard government, to integrate with headspace primary care. The Coalition government extended this concept, with its initial focus on youth mental health, to older adults.

These models need some redesign, better financing and standardisation for quality of care, but they are ready for scaling up to all regions of Australia. They are highly cost-effective. Rather than a cost to the budget, they produce savings in many other portfolios of government. In short, these services save lives, futures and money.

The positive effect of the intense Better Access debate is that it has lifted the rock once more on the hidden needs of hundreds of thousands of ordinary Australians who simply cannot gain access to quality care for serious and treatable health conditions.

Professor Patrick McGorry is executive director of Orygen, the centre for youth mental health at the University of Melbourne, and a former Australian of the year.

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