Budget 2020 exposes urgent need for mental health reform

THE 2020 federal Budget signalled the Morrison government’s intention to once again postpone any substantive or major structural response to the adverse impacts of COVID-19 on mental health and suicide.

Health Minister Greg Hunt indicated such changes will now follow the release of the final report of the Productivity Commission on Mental Health (which was delivered to the Treasurer on 30 June) sometime later in 2020. There is doubt whether the final report (as distinct from the draft report) actually factors in the likely large impacts of the pandemic on demand for both emergency and ongoing care services.

In the interim, the Health Minister and the Treasurer have both highlighted the decision in the 2020 Budget to increase Medicare-subsidised services for psychological interventions from a maximum of ten to 20 sessions under the Better Access Program. Minister Hunt justified this decision as a direct response to the recommendations of the October 2019 draft report of the Commission. Naturally enough, the decision has been warmly welcomed by providers. With mental health consumers often desperate to seek care, this change may well be welcomed by them, despite evidence indicating the Program is preferentially provided in the wealthier parts of our large cities. This is due to the common Medicare phenomenon whereby specialist services tend to aggregate in or close to districts where the patients who can afford to pay for their services live, while outer metropolitan, regional and remote areas go underserviced.

The government’s Budget decision and the Minister’s justification is bewildering, in our opinion, given the extensive critique of the Program provided in the Commission’s draft report. The Better Access Program was initially designed not for people with severe or complex mental health problems, but for people experiencing mild to moderate problems due to high prevalence disorders, such as anxiety and depression. It is in these areas that the evidence to support the application of cognitive behavioural therapy is strongest.

First, for those with lower intensity needs, the Commission recommends a radical shift to digitally assisted online care, estimating that such services could reach up to 150 000 people compared with 20 000 currently. Of this low intensity group, the Commission estimates that probably two-thirds are likely to be using Better Access, while one-third are currently receiving no care. A shift to digital care, at scale, would immediately free up a large amount of face-to-face services for individuals with higher care needs.

The Commission then goes on to list five major problems with the use of the Better Access Program for patients in need of moderately intense treatments:

• a lack of evidence of overall effectiveness;
• poor targeting of care relative to actual need;
• inflexible delivery modes whereby all clients are subsidised for the same number of sessions regardless of their needs;
• unclear benefits from the current intersection with GP-written (but additionally expensive) mental health care plans; and
• ironically, access can be an issue with Better Access, particularly for those with moderate intensity needs living in rural or regional Australia.

Despite this extended critique, the part that the government has now actioned in the 2020 Budget is described by the Commission as “approximately 10%” of those using Better Access who may “benefit from an increase in the session cap” from ten to 20 sessions. The Commission draft report proposed this change should proceed only as a trial, for evaluation. Modelling by the Brain and Mind Centre of this specific option, delivered nationally, has indicated that it would not deliver any specific advantage in reducing suicidal behaviour or pressure on mental health services.

Perversely, the Budget measure making 20 sessions available may reduce access (and lengthen waiting lists). It provides a new capacity or incentive for psychologists to see some of their existing clients over a longer period, thereby reducing their available capacity to see other existing or new clients. In this scenario, we assume no real growth in the number or distribution of providers of these services.

In the 2020 Budget documents, the changes are proposed to cost an $100 million over the next 2 years (ie, $50 million annually). As the program now costs more than $750 million annually (and over $550 million in psychological services), this suggests the Commonwealth itself only expects a relatively small actual growth in the national capacity to deliver new services, despite the publicised doubling of the cap.

The trend towards a continued decrease in the total number of new persons entering Better Access each year (now less than one-third of all users) was already evident before COVID-19. As demand increases alongside the social and economic impacts of the pandemic, this may now worsen and waiting lists for care will lengthen quickly. As that happens, pressure on the only available alternatives, notably public hospital emergency departments, will continue to grow rapidly. This is precisely what has been reported in Victoria already, where this modification to Medicare-subsidised services was enacted in response to the second lockdown.

There were alternatives to this piecemeal tinkering with Better Access. One idea, sadly not supported nationally in the 2020 Budget, has in fact already been actioned. Following direct Prime Ministerial intervention and as part of the emergency COVID-19 response in Victoria, 15 new service hubs have been rapidly deployed at a cost of $30 million for 12 months. This work is occurring in partnership between state services and the relevant Primary Health Networks, with the hubs distributed equitably between urban and regional centres.

Why this alternative was not considered for the rest of the country is not clear.

Other alternatives that the Productivity Commission draft report also recommended, such as rapid expansion of digital services to free up more clinician time for face-to-face contacts, are still not being utilised. Telehealth consultations have become essential during COVID-19, using the same time-based item number structures as conventional practice. While the government touts this as a very significant increase in mental health services, in reality, it is largely a substitution for face-to-face care and does not increase the size or efficiency of mental health service delivery. Additionally, it may have some unintended consequences due to the uneven distribution (socio-economic and geographical) of telecommunications capacity across our communities.

Conclusion

The 2020 Budget postponed the task of mental health reform, citing the imminent resolution of various productivity and royal commissions, suicide prevention task force reports and national visions. Mental health is accustomed to waiting. But rather than do so passively, major mental health organisations and stakeholders had already established some consensus around agreed priorities and funding.

To be specific, they identified and agreed that at least an additional $3.7 billion in federal funding was required over the next 4 years to tackle the high priority challenges in mental health service delivery and suicide prevention. The key areas for reform and priority funding identified were:

• effective care following suicide attempts;
• extended team-based, multidisciplinary and more specialised services in ambulatory care settings — this kind of care is more likely to meet the more complex needs of the “missing middle”;
• greater use of digital coordination and delivery of care;
• extended psychosocial support services; and
• support for the regional infrastructure (coordinated by Primary Health Networks) to drive more effective and mor equitable health care delivery in all our communities.

This appraisal was shared with the Morrison government before the Budget. We remain hopeful that these views will inform future decision making in relation to long-overdue systemic mental health reform.

Professor Ian Hickie is Co-Director, Health ad Policy at the Brain and Mind Centre, University of Sydney.

Dr Sebastian Rosenberg is Senior Lecturer at the Brain and Mind Centre, University of Sydney and Fellow at the Centre for Mental Health Research, Australian National University.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless that is so stated.