Australia can’t afford to underfund mental health

When lives and futures are at stake, society normally assembles the best expertise and evidence to design and implement solutions that work. There is zero tolerance for error, fads and mere opinion. So when we build aeroplanes, tall buildings or treat life-threatening cancers, we insist on highly standardised techniques, based on the best possible evidence. We also constantly strive to innovate and improve through research.

Mental illness is the major cause of premature death in young people up to the age of 40, and across the lifespan the largest contributor to disability and productivity loss.

Yet, despite two decades of awareness campaigns, countless reviews and plans, our approach to mental healthcare has been mostly ad hoc and fragmented. The disconnect between unprecedented awareness and the poor access and quality of care actually provided must be overcome with reform and investment. For this to succeed, hard-won scientific evidence must form the bedrock of a modern mental health system, as it is in physical healthcare. And we must invest in mental health research and innovation.

Could all this be about to change? Although there have been several false dawns, the synergy of unprecedented personal commitments pre and post-election from the Prime Minister and federal Health Minister, the Productivity Commission inquiry and the royal commission in Victoria have combined to build expectations once more.

The Productivity Commission released its interim report on October 31 and is actively seeking responses. The commission can be congratulated on its forensic mapping of the landscape of mental illness and the devastating impact of the underspend on people’s lives and the quality and productivity of our society.

The commission conservatively estimated the direct annual cost to the economy to be $43bn to $51bn, with the total impact from all sources being $180bn, and recognised the two key reasons for this disproportionate impact.

First, mental illnesses emerge in young people and derail and disable across many decades. Second, there is a serious underspend on access to quality mental healthcare that few Australians can reliably access in a timely way.

The commission quantified the extent of what I have termed the “missing middle”; more than one million Australians with mental illness whose conditions are too complex or enduring for primary mental healthcare yet not sufficiently desperate to force their way into the beleaguered state public mental health system.

The Productivity Commission gets full marks for diagnosis; however, when it comes to solutions, the verdict is mixed due to a failure to clearly recommend major investment growth and to endorse the best available scientific evidence. An exception is the recommendation to include vocational interventions within clinical services, thus moving the focus beyond mere symptom remission to functional recovery and hence productivity.

The Individual Placement and Support vocational model results in superior work and study outcomes, especially for young people, even in severe mental illnesses.

However, other evidence-based programs, many pioneered in Australia and exported around the world, were not appropriately endorsed for expansion and strengthening, and could in fact be placed in jeopardy.

Early intervention for psychotic disorders, a model created more than 25 years ago in Australia and scaled to hundreds of centres across North America, Europe and Asia, provides a return on investment of up to 17:1.

The wider field of youth mental health is one in which Australia is regarded as the global epicentre of innovation and reform. Since 2006, integrated primary youth healthcare, through Headspace, has been scaled up nationally, with improvements in access and encouraging outcomes. It is an oasis of reform and a central pillar of government policy. The Productivity Commission’s interim recommendations not only fail to endorse and strengthen this hard-won progress, they place it at risk.

The commission recommends removing the protection that hypothecation — or ring-fencing of funding — provides from the all too common ad hoc local commissioning decisions by primary health networks.

If this were to occur, Headspace and early psychosis care would be swept away and replaced by fragmented, ineffective and evidence-free approaches. Fidelity to early intervention models is essential for better clinical and economic outcomes and productivity, and should be embedded in the service specifications for commissioning of all programs.

This leads to issues of governance, commissioning and, above all, financing. In 2016, federal commissioning was abruptly devolved to regional primary health networks in the hope that local health needs would be more efficiently met. From a mental health standpoint the opposite has happened: more bureaucracy, delay and fragmentation of effort.

The PHN model involves private companies making commissioning decisions involving hun­dreds of millions of taxpayers’ dollars. These non-transparent decisions are taken outside of the normal regulatory framework. They too often fail to respect scientific evidence and are fragmenting the already diffuse mental health system. Australians deserve a system they can rely on, that ensures evidence-based interventions and models of care are mandated nationally.

Regional adaptation of mental healthcare is crucial but cannot be decoupled from evidence and national and global knowledge, models and standards. Australia needs an efficient mental health system that is based on the best evidence, lived experience and local needs, so it actually works for people.

The two governance models proposed within the commission’s interim report, without substantial modification, would not enable this to occur. Co-commissioning by federal and state/regional statutory authorities with an equal say in decisions, operating according to a detailed national plan, would provide a solution. We look forward to a mature and definitive set of proposals from the commission that will improve outcomes and, yes, productivity.

Patrick McGorry is professor of youth mental health and executive director of Orygen, the National Centre of Excellence in Youth Mental Health.