Address to the National Press Club, Canberra - ‘Delivering a better mental health system for all Australians’
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24 May 2011
Thank you, Laurie, and thank you for inviting me to address you today, at what is a challenging but exciting time to be involved in mental health.
Challenging because mental health – or, more particularly, mental illness – affects almost every Australian. One in six of us experiences a mental illness in any given year – one in three at some point in our lives. And very few of the rest of us aren’t called on at some point to provide support to a family member, friend or workmate who’s directly affected. Perhaps, unsurprisingly, given these numbers, mental illness is the largest single cause of disability, responsible for fully one-quarter of the total burden of non-fatal disease in Australia.
But exciting because of the momentum that has built up behind reforming our mental health system. For decades, mental health advocates have argued – with considerable justification, in my view – that mental health has for too long been the ‘Cinderella’ of Australian health policy and health politics. All that changed over the course of the past year or so, and the Glass Slipper was well and truly produced and fitted very neatly in this month’s Budget.
The past year has seen an unprecedented level of community debate and discussion about the future of mental health services in this country.
It has been a passionate, often fiery debate because people care deeply about mental health, whether they work in the area, are a consumer or carer, or just part of the broader community.
So it’s good to have this opportunity to talk about mental health and more particularly, mental health reform.
There are three areas I’d like to focus on today.
Firstly, the dynamics in mental health over the past year or so and our engagement with the sector leading into the budget.
Secondly, the details of the Budget package and the breadth of its scope.
And thirdly, the ongoing reform challenge in this area and elements of our package that aim to lock in a sustained and more transparent long term agenda for change.
But let me begin with a frank acknowledgement.
Community concern has been building about the adequacy of our mental health system for some years – the implicit compact in the process of deinstitutionalisation, namely that adequate services and supported accommodation would be provided in the community, was frankly not honoured - at least not in full. The evidence of gaps in services and supports at a community level has been there for all to see – on our streets, in our emergency departments and, all too often, in the suicide statistics. Australians have been awake to it for some time.
Late last year, a British University, Kings College, published research conducted for it by Ipsos MORI. That research asked more than 1000 Australians and similar numbers in seven other countries a series of questions including – what are the two or three greatest challenges facing your country? Australians, like most, nominated the economy and climate change as the top two challenges. Uniquely, though, Australians placed “mental health” at number three on their list. Fully 35% of Australians nominated “mental health” compared to an average in other nations of just 10%. Australians were also unusual in nominating “ageing” as fourth on their list – which started to make me as Minister for Mental Health and Ageing feel a little pressured – but that’s a topic for another day.
A great deal of credit for the creation of such community pressure for change lies with a long list of people who have spoken openly of their own experiences with mental illness. People like Geoff Gallop and Andrew Robb have talked openly about their experiences, as have many other public figures. John Brogden’s open way of talking about his own attempt at suicide has been incredibly powerful as has Jessica Rowe’s testimony about her experience with post-natal depression. All of those acts of courage built on a foundation of stubborn and relentless advocacy by countless consumers, carers and service providers – many of whom had struggled to achieve deinstitutionalisation and the mainstreaming of mental health, only to become so disappointed with the lack of follow-up.
But it seems to me that the role of Patrick McGorry as Australian of the Year last year gave all of that long advocacy and deep community unease a shape and a profile that the cause had lacked previously. While he had many allies – not least being the connections through GetUp – Professor McGorry was personally relentless in his use of his position last year to create a sense of urgency for change. And all of that, in my view, is how mental health came to be – for the first time ever – a first-order issue in the Federal election campaign.
Labor heard the community’s message loud and clear that as a nation we had to do better in mental health and the Prime Minister expressly committed a re-elected Gillard Government to doing just that.
The Prime Minister’s first down payment on that commitment was to create the first ever Commonwealth Ministry for Mental Health. My instructions were clear – take the time needed to engage properly with mental health stakeholders to understand precisely what their priorities were – and to present the Prime Minister and the Cabinet with some clear options for reform. The Prime Minister has been equally clear that mental health reform must build on the broader process of health reform being led by Nicola Roxon – rejecting the view that Tony Abbott litigated last year that the community had to choose between the two reform ambitions.
The Prime Minister has also stressed that mental health reform depends on much more than health policy – good mental health, particularly for the severely ill, depends as much upon things like housing, employment, education, personal and family support. To that end, the PM established a cross-portfolio working group co-ordinated by me, but reporting to her, that marshalled the resources of all relevant ministers and departments. The group included well known figures like Professor McGorry, Ian Hickie, Monsignor David Cappo and Christine Bennett as well as consumer and carer representatives, paediatric, GP and psychology experts, and the leaders of Mission Australia and Employment Services Australia.
While it might surprise some, this level of cross portfolio collaboration is not especially common. There is a natural tendency for agencies to stick to their own departmental silos. We know, though, that the challenge of dealing with serious disadvantage – or what is now described as social exclusion – is not so much about brand new ideas – because there aren’t many ideas that are brand new. Instead, it’s about the development of policy, the design of programs and the delivery of government services being seamless – getting to a position where the public get the range of services they need without having to work out for themselves what the ingredients are and how they get them.
This Budget delivers the largest package of new mental health measures in our history. It should be remembered that the Howard Government’s package of $1.9 billion over five years was delivered in the middle of a four-year period when the Commonwealth’s revenue was revised upwards by more than $300 billion over the forward estimates. The Gillard Government’s package of $2.2 billion - $2.5 billion if you include measures that Tony Abbott includes in his costings – has been delivered in a period when revenue has been cumulatively revised downwards by $130 billion from pre-GFC levels.
Other than for its size, though, this package is notable for the breadth of its scope, and for its truly reformist bent. Tony Abbott’s mental health policy last year was rightly criticised for its singular focus on one age group – teenagers and very young adults. The Government’s package addresses the whole of the lifespan.
There is a strong focus on the earliest years of life. One-quarter of all mental disorders emerge before age 12. Our advisory group presented evidence that, as young as three, infants can present signs of poor social and emotional development. If not caught in time, those challenges can develop into more serious learning and behavioural disorders in primary school and, potentially, quite serious mental illness in adolescence and beyond.
The Government has decided in principle to expand the existing Healthy Kids Check to incorporate elements that assess a child’s emotional and social wellbeing and development. We have also decided to shift the check from age four to age three, reflecting the advice of experts that the younger age presents the best opportunity for early identification. We will be appointing an expert group to flesh out the details of those changes and to advise us on the level of existing service to support families with identified needs. Experts like former Australian of the Year Professor Fiona Stanley have emphasised that good early identification systems need clear referral pathways to support services with sufficient capacity to meet demand. We recognise and accept the importance of that whole supply chain.
To increase supports to families in this age group, we have decided to double the number of Family Mental Health Support Services from 40 to 80. This well-regarded program delivers broad support to families and vulnerable children, covering wellbeing, family relationships and school attendance, among other things. We’ll also vastly increase targeted funding to Medicare Locals to provide counselling services through psychologists, social workers and occupational therapists to children and their families.
The models of treatment and support needed for youth aged 12–24 are clearer. This age is a critical point of intervention where a significant proportion of mental illness, including psychosis, begins to emerge. We know that, left untreated, this has enormous potential to interrupt schooling, prevent a smooth entry to the workforce, damage relationships and lead to substance abuse. I’ve met many Australians whose entry to adulthood followed this path and who’ve remained out of the workforce and socially excluded ever since.
Patrick McGorry made the case very clearly last year for new, transformative models of care for the young. Those models recognise that young people don’t use mainstream services – particularly not Mum or Dad’s GP. headspace is a proven model designed to create a youth-friendly environment where young people feel comfortable accessing a range of services covering mental, physical and sexual health. The Howard Government funded 30 services – last year, we committed to doubling that number and, this year, we have decided to triple it – to 90 services nationwide. The headspace organisation says this will deliver national coverage and we’ve agreed to headspace’s claim for significant increases in core funding for each of those services.
The Budget also includes funding to establish 16 EPPIC centres – modelled on the Early Psychosis Prevention and Intervention Centre run by Professor McGorry in Western Melbourne. That EPPIC has been operating for almost 20 years. It’s an acute care service, as the name suggests, for young Australians with emerging psychosis. The first-ever support for this model at a Commonwealth level was provided by this Government in last year’s budget. This year’s Budget vastly expands that commitment and will deliver broad coverage across the country. Being an acute service, we have said that we expect states to share the cost of the new EPPICs equally. I’m pleased to say I have received strong indications of interest from states to partner with us in this area and we’ll be talking further with them about this element of the package.
Australians with mental illness should be able to get access to basic primary care services – when they need them and no matter where they live. For that reason the Budget also doubles funding for the ATAPS program – Access to Allied Psychology Services.
The ATAPS program funds Divisions of General Practice (soon to be Medicare Locals) to provide counselling services to hard-to-reach groups in their area. The much larger Better Access program, by contrast, simply provides a fee for service rebate for those same services with no targeting.
A recent Evaluation of the Better Access program found that its distribution of services across the community was relatively poor. The further you live from a GPO, the fewer services you get. Out in rural Australia – and especially in remote Australia – service levels drop off dramatically.
The data also showed a stark difference in access according to socio-economic status. In 2009 – the latest year with full data – the richest quintile or 20% of Australians accessed 2½ times the number of services, attracting three times the Medicare dollars in rebates compared to the poorest quintile of our community.
The growth in ATAPS targeted funding will be directed at addressing those imbalances.
Most of it will be targeted at lower SES communities with some intended for Indigenous communities. In keeping with our fiscal circumstances, this element of the package is funded through a redirection from the Better Access program by reducing the annual cap on Better Access consults from twelve to ten. We have also redirected funding from Better Access by re-calibrating the GP rebates under the scheme. This will bring those rebates into line with standard time-based consults while retaining a premium of 27 per cent on top of the standard fee.
A glaring omission from Tony Abbott’s mental health policy last year was any focus on adults with severe and chronic mental illness. I’m particularly proud that providing more intensive and better integrated support services to this group is perhaps the central theme of our reform package.
The Budget provides dramatic increases to support programs like Personal Helpers and Mentors, or PHaMs. The Prime Minister, Minister Roxon, Minister Ellis and I visited a PHaMs service last week in Adelaide and saw first hand the impact this service has in bringing people out of often lengthy periods of isolation and exclusion, sometimes off the streets; restoring their confidence and ability to make and enjoy everyday social interaction. Clients also develop their broader life skills and $50 million of the $200 million plus going into expanding this program will focus on those clients who are ready to enter the workforce.
But, perhaps the most consistent message I’ve received over the past eight months from people living with mental illness is that they want the services they receive to be better integrated. This group and their families have to tell their story over and over again, and get frustrated that the different service providers often don’t know what the others are doing. At best, this is frustrating- at worst, it results in poor outcomes and, occasionally, profound tragedy.
The 2006 COAG Agreement on mental health included as its “flagship initiative” a commitment to co-ordinate services for this group. With no money attached to those good intentions, though, that initiative went nowhere.
In this Budget, we provide funding for services to take responsibility for ensuring that all of the needs of the most severely unwell are being met. Organisations will be chosen through a tender process conducted in each Medicare Local region. I expect the tender will attract some Medicare Locals and many of the NGOs with a strong history in this area. People will be able to be referred from a range of points to this service and, if eligible, a worker will be assigned to take responsibility for co-ordinating all of their support needs. They will arrange for service providers to sign onto a single care plan with the co-ordinator as the key point of contact. Where an identified need cannot be met by a local service, funds will be available to purchase a service that meets that need.
While fairly simple at first blush, this is a revolutionary approach to providing supports to those with the most severe and chronic mental illness. It will provide great comfort to families knowing there is a single point of contact to call on when a gap or a need emerges, and I’m sure will result in greater levels of recovery and social participation.
Obviously this group receives also support also from state, and state-funded, services. Along with the discussions about the rollout of EPPIC, we will be seeking the agreement of the states to participate in this model as well as their assistance in developing assessment frameworks and the like. Given the significant money the Commonwealth is committing to this proposal, I feel confident of a positive response.
The Government will also take an additional $200 million to the COAG meeting that is scheduled to discuss mental health reform later this year. We want that money to help drive improvements in areas for which states have responsibility. I have particularly mentioned the capacity of major emergency departments to deal appropriately with the presentation, admission and discharge of people with severe mental illness. We also want to discuss ways in which states can expand support services around accommodation. This will be a very important meeting of COAG. My sense is that all state governments, no matter which political colour, take this challenge seriously and I’m confident that, through this Budget, they’ll see that the Commonwealth will be approaching that meeting constructively.
This package is genuinely reformist. We’re not throwing money at old models. We’re scaling up new, proven models and we’re driving innovation in entirely new areas. As you know, though, mental health advocates have argued strongly for an institutional reform that would instil greater accountability and transparency into the system.
The Government has met those demands by creating the first National Mental Health Commission. This commission will be established as an executive agency within the Prime Minister’s portfolio, reporting to her and to the Parliament. It’s important that this commission be separate from the key line agencies such as Health and Families and Communities and that it focus on tackling outcomes more than inputs – instead of just asking how many beds there are in the system, asking how many people have got off the streets into stable housing, how many are no longer regularly re-presenting to emergency departments, and how many are re-connecting to the workforce, to their family and to society more broadly.
The creation of the commission – and its placement under the Prime Minister – is a clear indication that the Government in no way considers that we’ve ticked the box on mental health reform and can move on to something else. As proud as I am of this package, we know that getting mental health services to the level that consumers deserve and the community expects will require long term, sustained commitment.
I hope that the size of this package but more importantly the shape of this package demonstrate to the Australian community that Labor is in this for the long haul.
Thank you for having me today.
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