Why mental health is the legacy-defining fight Scott Morrison can’t afford to lose | Katharine Murphy | Australia news
It has been a week for consequential reports. The Brereton inquiry illuminated the darkest corners of elite military activity during Australia’s longest war in Afghanistan, raising credible allegations of war crimes.
Earlier in the week we had the Productivity Commission’s deep dive into Australia’s mental health system. That report didn’t generate quite as many headlines as Brereton, but it was a comprehensive body of work that will hopefully help make the case for systemic change.
The diagnostic undertaken by the Productivity Commission is a companion volume to the ongoing deliberations of Scott Morrison’s suicide prevention adviser, Christine Morgan, who will provide her final advice to the government next month.
Morrison has asked Morgan to examine how Australia could reduce the suicide rate to zero. She is looking closely at prevention strategies. Morgan is talking about pursuing distress interventions, which means using data to identify people likely at risk, and then working out ways of providing a sense of support and connection to people who might not even be aware they are on a path to self-harm, or worse.
If the data shows people are vulnerable when they leave prison, or when they lose primary custody of their children after a family separation, then distress interventions to head off self-harm can be targeted. These interventions may not even speak their name. They may not advertise themselves as suicide prevention, because that badging could alarm or repel some intended beneficiaries, or confuse them, because sometimes existential despair takes time to build. People might cope mid-trauma, or mid-life change, but six months later, they might find themselves so disconnected from others that hope and human sustenance is destroyed.
From a policy design standpoint, as well as a human one, Morgan’s deliberations are genuinely fascinating, but I want to focus predominantly this weekend on the Productivity Commission’s clear-eyed assessments of the deficiencies in Australia’s mental health system.
Given one in five people in Australia experience mental illness in any given year, it’s important the system works as well as it can.
Now I’m certain people have positive experiences with mental health services. I also want to acknowledge the army of dedicated people who perform life-saving and life-changing work in this field.
But I also know a lot of Australians find the mental health system impenetrable and seriously deficient. If you are trying to manage your own mental health condition, or trying to support a loved one with a mental illness, you can find yourself gripped by a sense of utter hopelessness as you orbit between different clinicians and services that often fail to respond to your needs in a focused way unless the crisis becomes medically acute, and then you enter another world of pain.
I’m not sure irony is the right word to invoke in this context, it seems glib given people are suffering, but it is ironic nonetheless that a system supposed to help people manage anxiety and mental distress generates bucketloads of both.
The Productivity Commission cuts to the chase. It notes that half a billion dollars each year is allocated to programs aimed at lessening the prevalence of mental ill-health and suicide prevention. A further $9.2bn funds treatment programs.
But there is no real evidence that the investment is working. “These costs have been rising over time, with no clear indication that the mental health of the population has improved,” the commission says.
The commission describes a system that is not comprehensive; a system that fails vulnerable people. The clinical care system has clear gaps. There is, as the commission puts it, “a missing middle” – which is a service gap encountered by several hundred thousand Australians who have symptomatic illness too complex to be adequately treated by their GP and the limited Medicare-rebated individual sessions with psychologists.
But their symptoms don’t meet the criteria for entry to specialised services offered through state and territory health programs. Then it becomes a question of means. People with the requisite financial resources can access private psychiatrists or private hospitals, but the commission notes those interventions may be “inaccessible” for many people due to long waiting lists or very high out-of-pocket costs.
The commission maps the foundations of a systemic fix. It wants the system to be people- rather than services-focused and it wants the investments balanced as much toward prevention and early intervention as management. These concepts might sound obvious, but if implemented, they amount to a revolution.
The next point to make is technocratic, but vitally important. One of the challenges in mental health and suicide prevention is that national approaches are optimal but services are delivered in a federated model.
The Productivity Commission has unfurled a long list of recommendations, but there’s no breakthrough unless the governments in Canberra, Sydney, Melbourne, Hobart, Adelaide, Perth, Darwin and Brisbane work together in a spirit of cooperation. Nothing consequential happens unless there’s a new, fine-grained, national agreement to make the system work for people.
The other thing that needs to happen – given the Productivity Commission has said in very clear language that billions are being shovelled out the door when there’s no clear evidence that Australia’s mental health crisis is turning any sort of corner – is a proper evaluation of the existing services and programs.
Not just monitoring of programs and services. Evaluation of programs and services. Do the interventions work? Are people with depression, anxiety or bipolar disorder, or other mental health conditions, living better as a consequence of the mental health services taxpayers are funding?
The Productivity Commission has gone there. It notes the current system includes suboptimal supports “due to a lack of measurement and evaluation of what works, and in part due to a culture of superiority that places clinicians and clinical interventions above other service providers, consumers and their families and carers”.
One of the recommendations of the inquiry is the National Mental Health Commission should be given statutory authority, and that body should lead the evaluation of government-funded mental health and suicide prevention programs, “and other government-funded programs that have strong links with mental health outcomes, including those in non-health sectors”.
Then there’s a recommendation about dialling up the human voices to penetrate the culture of superiority. The Productivity Commission says the tiers of government need to “establish a clear, ongoing role for consumers and carers in all aspects of mental health system planning, design, monitoring and evaluation”.
Whether the government will go there remains an open question, because going there involves political risk.
Going there will likely generate a very noisy debate from well-organised and highly respected stakeholders about whether the government has a secret plan to rip money out of mental health services.
Morrison made a speech on Monday that kind of crept there, at least by inference. As he outlined the various insights and reform options the government had been given, the prime minister noted “we must be driven by evidence, by the data, enhancing our understanding of what is happening in our communities – understanding what works and why it works, and using this information to arrive at further decision making”.
Morrison said the government would be “carefully considering all of these reports but with a view to action”.
But his definition of action sounded slightly less promising: action was “reinforcing the actions we’re already taking” and “better coordinating and linking together the actions we’ve already taken [and] those of state governments as well”.
The government has already begun the necessary conversation with the states and territories to try to craft a national response (as opposed to federated brinkmanship).
During the first wave of the coronavirus pandemic, we all saw with our own eyes Morrison, the premiers and the chief ministers, declining to be dickheads at our expense between the months of March and July.
Sadly, we feel quite a distance from those halcyon days now. Perhaps this group of leaders can rally again.
Morrison is pointing to a comprehensive response to the Productivity Commission in next May’s budget. The prime minister has time to consider what this overhaul will ultimately be, and this will be one of the bigger calls of his prime ministership.
The sliding door moment is clear.
Morrison can preside over a necessary revolution, rolling out in stages, that will save lives and improve national wellbeing, or he can bowl up a monumental fudge festooned with empty slogans.