2022 Public hospital report card - mental health edition

According to an Australian Bureau of Statistics (ABS) 2020-21 survey, mental and behavioural conditions were the most prevalent chronic conditions in Australia, with one in five people (20.1 per cent) experiencing some form of poor mental health.¹ The numbers are even higher for young people, particularly young females, where almost one in three girls aged 15 to 24 will be affected by mental and behavioural conditions, the most common ones being anxiety and depression.²

Furthermore, the ABS survey statistics from 2001 onwards show a constant growth in self-reported poor mental health. In 2001, 9.6 per cent of the population reported mental and behavioural disorders. That proportion grew to 17.4 per cent in 2014–15,³ only to almost double by 2020 21 (20.1 per cent).

Suicide is the leading cause of death among the 15 to 44 age cohorts in Australia.⁴ Australia ranks above the Organisation for Economic Co-operation and Development (OECD) average in the number of deaths by suicide (OECD average is 11, Australia stands at 12.3 suicides per 100.000 population).⁵ Although the causes of suicide are often complex, in a majority of cases they can be linked to mental illness, with depression, substance use disorders and psychosis being the most relevant risk factors.⁶

Yet the Australian health system seems to be ill equipped to provide support to patients presenting with poor mental health. This is evident by the growing numbers of patients presenting to public hospital emergency departments (EDs), often the last resort for patients in distress who have exhausted all other avenues of seeking help, even when both clinical staff and patients know that EDs are not suitable spaces for mental health patients.⁷

Mostproblems in the public hospital system happen at intersections of federal and state/territory funding areas. Obvious examples include aged care and disability, where over the past decade there has been a growing reliance on public hospitals to pick up patients and provide care for patients who are not able to receive the care they need under the aged care and National Disability Insurance Scheme (NDIS) systems.

The AMA argues that mental health care is one of those intersections. The Australian Government fully funds aged care and disability services and has had a growing role in funding and managing mental health care, particularly mental health care in the community, both through Medical Benefit Schedule (MBS) funding (by subsidising general practice, specialist psychiatry or psychology) and Pharmaceutical Benefits Scheme (PBS), but also through increasingly providing funding to non-governmental organisations (NGOs) and providers such as headspace to provide early intervention and prevention.

The Better Access Initiative was established by the Australian Government in 2006 with the aim of improving “access to, and better teamwork between, psychiatrists, clinical psychologists and other allied health professionals”⁸ and to “improve outcomes for people with a clinically-diagnosed mental disorder through evidence-based treatment”. ⁹

Under the initiative, Medicare rebates are available for general practitioners (GPs) to provide early intervention, assessment and referral of patients with mental disorders as part of a GP Mental Health Treatment Plan. GPs can refer patients for Medicare rebated psychological services to psychiatrists, psychologists (psychological therapies), appropriately trained mental health social workers and occupational therapists (Focussed Psychological Strategies [FPS]), as well as GPs who are registered providers of FPS). For example, patients can receive up to 20 Medicare-rebated sessions with a psychologist per year, once they have consulted and created a mental health plan with their GP.

The data shows that in 2016 (last Bettering the Evaluation and Care of Health [BEACH] survey) 12.4 per cent of all GP encounters with patients were for management of psychological problems.¹⁰ That means that 6 years ago one in eight patients seen by GPs needed to access mental health supports. According to the RACGP’s last Health of the Nation Report 2021, mental health was the most commonly reported reason for patient presentations in general practice, with 71 per cent of GPs selecting ‘psychological’ in their top three reasons for patient presentations.¹¹

Even with the growing uptake of the Better Access Initiative since its establishment,stakeholders have raised issues with the initiative, the most obvious one being the lowering of bulk billing rates and growing out-of-pocket costs due to inadequate indexation of MBS rebates over the years. But despite this, the Better Access Initiative remains the one initiative where continuity of care and care coordination in mental health care is provided through the patients’ existing relationships with GPs and the development of a mental health plan.

Furthermore, Medicare funded mental health services, even with their increased uptake, cost less than other government funded services. According to Australian Institute of Health and Welfare (AIHW), $1.4 billion, or $53 per Australian, was spent by the Australian Government on benefits for Medicare-subsidised mental health-specific services in 2019–20. By comparison, per capita cost (constant prices) of units and wards in specialist psychiatric units of public hospitals was $90.11, while $100.49 per capita was spent on community mental health services.¹²

Additionally, in 2019–20, the Australian Government spent $63.82 per capita (constant prices) on ‘National Programs and Initiatives’, that includes programs managed by the Australian Government Department of Health and Aged Care; Department of Social Services; Department of Veterans Affairs; Department of Defence; Indigenous social and emotional wellbeing programs and the National Suicide Prevention Program¹³

Headspace is one of the programs funded under National Programs and Initiatives.¹⁴ Headspace provides services to young people between 12-25 years, to improve their health and wellbeing, including mental health and wellbeing, physical and sexual health, work and study support, and alcohol and other drug services.¹⁵

Based on the review of Australian Budget papers, the AMA estimates that Headspace has received around $600 million in funding since 2019 from the Australian Government.¹⁶ In addition to the (grant) funding by the Australian Government, additional funding may be provided by PHNs, state governments to deliver core services and through MBS activity-based funding of services. Headspace also receives in-kind contributions, private donations, and can charge out-of-pocket payments from young people or their carers.¹⁷

An evaluation commissioned by the Department of Health and Aged Care published in October 2022 found that “no single source captures these ranges of costs of delivering headspace”.¹⁸ The evaluation concluded that the longer-term impacts of headspace are not measured and that improvement in data collection is required. It recommends that the linked data sets include:

• self-harm hospitalisations
• substance abuse hospitalisations
• suicide deaths
• MBS mental health services accessed
• PBS usage
• mental health related emergency department presentations
• education and employment outcomes
• income support use.¹⁹

The Productivity Commission’s report into Mental Health Services suggested that “funding to headspace should not be hypothecated. Rather, like any commissioned service, headspace should be required to show how its services are meeting local needs in order to receive ongoing funding”.²⁰

Where does this leave people who need mental health care?

Gaps remain in access to primary and community care (aged care, NDIS), which need to be filled by Modernising Medicare²¹ to facilitate joined-up care led by GPs. In addition, we have a limited understanding about how federally funded national programs and initiatives like headspace influence tertiary care and hospitalisations. Immediate progress on the above listed data linkages recommended by the headspace evaluation would hopefully help better inform health policy and better target funding to the areas of need.

The shortfalls in primary care, due to the lack of fit-for-purpose general practice Medicare-reimbursed models of care, means patients increasingly rely on EDs and hospitals. And while this reliance may provide an immediate, short-term reprieve, EDs are not appropriate environments for mental health patients.²² Furthermore, lack of in-patient bed capacity in public hospitals results in extended patient stays in EDs, exacerbating the problem.

Staff working in EDs are focused on managing mental health crises and associated medical needs. They are not trained nor resourced to manage patients with complex mental health issues, who can become agitated and aggressive (especially when facing long waits for care) and this can lead to assaults on staff.

Similarly, the physical design of public hospital EDs is often not conducive to quality mental health care. Because of all of this, ED clinical staff are under increasing pressure, leading to stress, burnout and emergence of their own mental health issues. More recently, we have seen calls for establishment of security services in EDs and employment of security guards to protect the staff from aggressive patients who become agitated by waiting long hours.²³

Finally, the long term impact of COVID-19 on the mental health of the population is yet to be seen. According to the data available to the AIHW, the COVID-19 pandemic did not impact the rise in suspected deaths by suicide in 2020 and 2021.²⁴ However, we know the pandemic placed an extraordinary strain on primary care and acute hospital and community care that was already faltering under pre-existing demand.

The prolonged nature of the pandemic has led to workforce impacts including burnout and mental illness that has created a further cycle of decline of staffing levels as doctors and other health professionals exiting the sector.²⁵

Australian patients need a better and longer-term solution. Based on AMA analysis, that solution must include the modernising Medicare to support GP-led collaborative Primary Care and an increase in public hospital and community service capacity — primarily the number of mental health beds in public hospitals to avoid the hospital logjam that particularly disadvantages patients with mental illness. Furthermore, future policy on improving mental health care must be guided by the mental health professional community.