Have We Got Mental Health Reform Right?

But after what appeared to be a significant injection of funds, and quite radical reform, in 2005 the adverse publicity is back, leading many academics to ask what's going wrong.

In the current issue of the Medical Journal of Australia, Harvey Whiteford, Professor of Psychiatry and Population Health at the University of Queensland, and Bill Buckingham of Buckingham and Associates, suggest the policy is right but the problems lie with the pace and the extent of change.

"There has been substantial service system change in the directions agreed by governments under the Strategy, supported by a 65 per cent growth in government spending on mental health," Professor Whiteford said.

"Despite this there is growing public and professional concern about deficiencies in the mental health service system. We review the current call for change in light of increased community expectations and growth in demand for services."

The authors say the 65 per cent increase in spending only parallelled growth in overall government health spending during the decade, and that there's a significant disparity in per capita spending between the states and territories.

The past decade of service restructuring was a response to 30 years of deinstitutionalisation that saw the number of psychiatric beds decrease from 30,000 to 8,000. Over this period there was limited development of community services and a doubling of the Australian population.

In 1993, the beginning of the national mental health strategy, only 29 per cent of state mental health resources were directed toward community-based care. By 2002 this had risen to 51 per cent.

Contrary to popular belief, the overall number of acute beds in Australia increased by 6 per cent over 1993-2002 but there's been a 52 per cent decrease in long-stay beds.

In 1997 an Australian Bureau of Statistics survey found 18 per cent of the population met the criteria for mental disorder or substance abuse in a 12-month period, but only 38 per cent of those people received treatment from a health professional.

"Initiatives in mental health promotion and illness prevention were introduced under the Second National Mental Health Plan.

"A recent report by the AIHW shows that GPs deliver over 10 million mental health related consultations annually, more than double the attendances in the specialist mental health public sector.

"Several evaluations of the Strategy, a recent review by the Canadian Senate and a prevailing view in the mental health sector support the directions of the Mental Health Strategy."

The authors say the service system is being reformed in the agreed direction.

"While the redevelopment has been uneven, with disparities in funding and services continuing between the states and territories, change in many areas has been substantial."

The key question is whether the pace and extent of change has been enough.

"There are indications that it has not. Consumers, carers and advocates point to persisting problems with access to acute care, continuity of care and the availability of rehabilitation services.

"The significant unmet need highlighted by the 1997 mental health population surveys is beginning to surface, with more individuals now seeking treatment.

"In a world where the health dollar is finite, it is essential to ask whether the 65 per cent increase in mental health spending since 1993 has given us a comparable return on investment, measured in terms of increased quantity and quality.

"Unlike other areas of health care, little attention has been given to ensuring efficiency in public sector mental health service delivery. Achieving value for money remains one of the key issue to be tackled in our national mental health reform," Professor Whiteford said.

In the same issue of the Journal, Gavin Andrews, Professor of Psychiatry at the University of New South Wales, says while more money might make things easier, lack of money is not the cause of the crisis. He says the mental health chariot needs a single horseman - and that better coordination costs no more and improves the lot of patients.

"There are six contributors to Australia's mental health service - general practitioners, private psychiatrists, private psychologists, private hospitals, state inpatient and community services, and non-government charitable organisations. The work of these contributors is poorly coordinated. It is like a six- horse chariot with six horsemen who seldom communicate," Professor Andrews said.

He says perhaps an Australian Health Commission that could take responsibility for all health services and provide a patient-focused health care system which would be to everyone's benefit, would be that one horseman.

CONTACT Professor Harvey WHITEFORD 0418 755 224

Professor Gavin ANDREWS 0419 904 803 / 02 8382 1720 (9 hours behind

Judith TOKLEY, AMA Public Affairs, 0408 824 306 / 02 6270 5471