Mental health reform: where are we in 2024?

The 2024 Federal Budget investments in mental health are modest and focused largely on enhanced access to care for those with early phases of mild or moderate mental problems.¹ This is consistent with existing Federal Government accountabilities in mental health, which of course splits responsibilities, with the Federal government managing Medicare-funded primary care and out-of-hospital specialist services, while the states and territories manage hospital-based acute care and outpatient services. The Productivity Commission reported that mental health reform depends on close cooperation between federal and state levels of government.² The provision of community services, particularly specialist care in the community, is contentious, given the dismantling by most states of some key services such as assertive, multidisciplinary outreach teams³ and the continued failure by all governments to fund psychosocial services.⁴

A legacy of dis-integration

In 2005, in partnership with the Human Rights and Equal Opportunities Commission and the Mental Health Council of Australia, our Centre produced a damning report on Australia’s mental health system, ‘Not for Service: experiences of injustice and despair in mental health care’.⁵ It focused attention on the unmet needs and poor quality of care experienced by those lives were most impacted by persistent or recurrent mental illness.

To their credit, in 2006 under the Council of Australian Governments (CoAG), Prime Minister John Howard and NSW Premier Morris Iemma responded, establishing a 5-year National Mental Health Action Plan.⁶ This followed Howard’s earlier establishment of psychological services under Medicare in 2001 (initially termed ‘Better Outcomes', and from 2006 onwards ‘Better Access’).⁷ He also established headspace in 2007 to promote early intervention for young people.

A clear expectation was that the States would move progressively to increase the reach, and improve the quality, of their publicly-operated services.⁸ Rather than drive a platform of joined up governance, the CoAG Action Plan emphasised and delineated the separate roles to be played by federal and state governments.⁹

Other Prime Ministers subsequently demonstrated national leadership. Prime Minister Gillard established the National Mental Health Commission and invested A$2.2b in early intervention in the 2012 budget. This period also provided an interlude of Federal funding outside the usual scope of primary care, through community mental health programs such as Partners in Recovery¹⁰ and Personal Helpers and Mentors,¹¹ which had people with more complex needs in mind. Another short-lived program funded at this time was the Mental Health Nurse Incentive Program, funded to better equip general practice respond to the needs of people with more complex mental health needs in the community.¹²

Following his election in 2013, Prime Minister Abbott initiated the review of Commonwealth programs¹³ which then led Prime Minister Turnbull to respond by supporting the development of a new regionally-based approach via Primary Health Care Networks. The Turnbull Government also established an overarching review by the Productivity Commission,² leading to a A$2.3b Federal investment in the 2021 budget. This new funding again increased the Commonwealth’s support for enhancing primary mental health care services, as well as suicide aftercare and early intervention.

In the dying days of the Morrison Government, the Commonwealth and States signed off new 5-year bilateral agreements to support agreed priorities in mental health services and suicide prevention.¹⁴ It is difficult to discern evidence this has resulted in better integration in planning and service delivery between the levels of government.

Where are we now?

In 2024 we are confronted with the results of this two-track system. Huge service gaps are too often revealed by tragic events such as the Bondi Junction shopping mall tragedy. The Royal Commission in Victoria,¹⁵ just as we had done in 2005, highlighted the failure of our state governments to deliver high quality and equitable public hospital, acute and ongoing community and forensic care systems. Typically, the states have focused primarily on the supply of hospital beds, recognising this as the option best supported by the current Commonwealth-State funding arrangements.

We now live in a period where community demand for more specialised services, particularly focusing on early intervention for children and young people, continues to grow rapidly. This increasing demand reflects wider public acceptance of the need for earlier and more effective interventions for a wide range of conditions including anxiety, depression, post-traumatic stress disorder (PTSD), eating disorders, personality disorders and self-harming behaviours.

Funding stasis

Public concern about mental health has not been matched by a sustained increased funding. Mental health services garnered around 7% of the total health budget in 1992, a figure unchanged in 2021–22.¹⁶ The 2024 budget allocation makes very modest new investments (A$360 m over 4 years) in new psychological services, IT-based service enhancements and increased public access to specialist care. The new ‘Medicare Mental Health Centres’ are intended to provide public access to specialist services provided by psychiatry and psychology.¹⁷ The Federal Labor Government also argues that its huge and ongoing investment in the National Disability Insurance Scheme (NDIS), provides new forms of psychosocial support to those with the most severe and disabling forms of mental illness, previously unavailable.

Where to now?

So, how is it that despite public and bipartisan support for action, we really struggle to deliver first class mental health care, particularly to those with more persistent and recurrent mental illness? The true answers reflect the complexity of our federated health, housing and social services systems, which deliver meagre structural reforms and palpably inadequate new investments. There are very low levels of accountability across our complex levels of Government, and major related investments such as the NDIS.¹⁸

Before any Government rushes to yet another inquiry, it would be worthwhile reviewing the key recommendations published in myriad past inquiries. For example, in 2015, the National Mental Health Commission recommended that new funding target community-based, prevention and early intervention services to take the pressure off emergency and public hospital care.¹³ It also made it clear, we needed to engage with new digital technologies to expand service capacity and support timely and appropriate services coordination and increased accountability.

In 2020 the Productivity Commission strongly endorsed coordination of Federal and State investments, services and accountability at the regional level.² This means closing the gap between public hospitals, emergency and private psychologist or psychiatry care for the ‘missing middle’ – meaning those in need of specialist or multidisciplinary care, often with severe anxiety or mood disorders, eating disorders, PTSD or other complex conditions. It also means confronting the ever-increasing out-of-pocket costs faced by those seeking specialist care.¹⁹

There are two key opportunities for change now. The first relates to reform of the NDIS, and specifically the need for much better access to foundational psychosocial services for people outside the NDIS.²⁰ This is unsurprising, given these services have always been a peripheral element of Australia’s response to mental illness, accounting for less than 10% of total mental health spending.¹⁶

The second and more significant reform opportunity relates to the Federal Government’s decision to increase its share of overall hospital funding under the National Health Reform Agreement, including some reconsideration of the services which qualify under this funding as ‘out of hospital care’.²¹ There is an urgent need to prioritise mental health in the design of this type of care.

Beyond the health system, all Governments have failed to invest in sufficient public housing to meet the essential needs of those with enduring mental illness. A secure place to live is an essential first step to providing effective mental health care for many of those who have become disconnected from families, ongoing health care and their local communities.²² Additional rental support is not sufficient.

Currently, there is real leadership for change among local communities, often led by independent political candidates and often most notable in rural and regional areas.

Sadly, much larger national issues (e.g. ‘cost of living’) and other health priorities (e.g. surgical waiting lists, emergency department wait times) grab the headlines and the bigger political investments. Perhaps we will soon see that people are prepared to vote locally to support better mental health care.