Essay

An inclusive blueprint for mental health

Lifting the iron curtain around care

In the shape of things to come
Too much poison come undone
’Cause there’s nothing else to do
Every me and every you

Placebo, ‘Every You and Every Me’

 

AS A MEDICAL student and young doctor in the 1970s, I was on the one hand fascinated by the mystery and hidden depths of mental illness and on the other appalled by the failure of society to safeguard the dignity and human rights of the mentally ill. Something about the mind and the spectre of mental ill-health seemed to me absolutely core to our humanity. In a forty-year career in psychiatry, I have sought to understand this mystery and to fight for a better deal for all those impacted by mental illness and its consequences. As an architect, with kindred spirits, of new cultures of care such as our early psychosis care systems and headspace centres, and in my role as guide to governments – most recently as Chair of the Expert Advisory Committee for the Royal Commission into Victoria’s Mental Health System – I have been uniquely privileged to contribute to the achievable dream of a fair go and quality care for people with mental illness.

People often talk about ‘the human condition’. What they usually mean is the fluid blend of suffering with contentment – the slings and arrows, the joys and defeats – that take place against a background of the routine of everyday life. We understand that our mood, our mental health and wellbeing is to a great extent hostage to these ebbs and flows of fortune, and the innate gifts or burdens we bear.

The COVID-19 pandemic has made this fragility clear to all. The human condition is inherently unfair. Some of us are dealt a much more favourable hand than others, a truth also highlighted by the pandemic. Some possess or acquire the skill to play that hand better than others. Some are spared or avoid heavy doses of trauma, separation and loss. Some are especially blessed with genes, life chances, mentors and role models, personal qualities and other advantages that insulate them from adversity and its effects. Others are not so lucky and may be overwhelmed, suffer and struggle to survive and flourish. Some are mysteriously undermined or struck down by unseen waves of mental ill-health that seem spontaneously to surge and spread from hidden inner depths.

Yet whatever the mix of forces, throughout history we have judged those who succumb – who go under, who turn out to not be ‘resilient’ – in the harshest terms. We overtly or covertly blame the victim, while typically respecting the survivor. Rubbing salt into wounds, we even ponder how we could teach the victims to learn from the survivor and be more resilient. In every society, we have inflicted additional suffering upon those afflicted by mental ill-health, even when our intentions have been to a greater or lesser extent good.

This pattern continues to the present day, in many of our families, in our emergency departments, our health systems, our schools and workplaces, and throughout the wider world. It may seem as though things have improved for those with the so-called ‘common mental disorders’ – anxiety and depression – since these are conditions that are now seen as affecting us rather than them. Yet even here one is expected to do the right thing and recover, not wallow. Certainly, conditions that are more difficult to understand and empathise with – such as psychosis, anorexia nervosa or borderline personality – often remain feared and judged.

Our response to the human condition and mental illness cannot be to passively accept the status quo with all its inequities. We should aim to mitigate the intrinsic unfairness of modern life through a whole range of responses through which we can build the mental wealth of our world, and that includes a fair go and full equity in healthcare for the mentally ill. Mental wealth is created not only by reducing the deep and enduring impacts of mental illness through more effective healthcare, but also through liberating hidden human potential and productivity. In this respect prevention and treatment of mental illness has much more to offer than any other focus in modern healthcare, where diminishing returns are the order of the day. This represents a universal challenge and unique opportunity for our society and our world. It really is a case of ‘every me and every you’.

And it feels like the momentum of human progress is on our side.

 

THE BORDER BETWEEN mental health and mental illness is a soft one. It is readily crossed yet difficult to map and fix. Many, perhaps most, people are unaware as to when, or even if, they have made the crossing. It is a border that has been shrouded in stigma and guarded by arbitrary diagnostic criteria and unyielding triage systems.

The latter are vital tools in the defence of the underfunding of mental healthcare everywhere. Some border guards assert that a soft or porous border poses dangers, citing the harm that flows from the stigma that taints recognition of mental ill-health, and from the risk of premature and over-treatment with narrowly focused and potentially harmful drug therapies. However, these harms can be overcome through healthy cultures and stepwise, staged care guided by risk-benefit principles.

There is far greater danger in a hard border that delays and denies the enormous unmet need for care and is unwelcoming and frequently traumatic for those who do penetrate it.

The current reality is that we have a hard border, an iron curtain, with harmful and perverse effects on us all. Mental illness is the non-communicable disease (NCD) with the most potent social and economic consequences and is a major source of disease burden alongside cancers and cardiovascular disease. Yet it attracts a mere 2 per cent of health spending worldwide. Countless lives and futures are swept away as a consequence.

A soft border has many advantages. At least half of us – and, arguably, all of us – will experience at least one period of mental ill-health during the course of our lives that will cause considerable distress and impact our day-to-day functioning. In three quarters of cases this will occur by the age of twenty-five. A recent landmark study from New Zealand shows that 86 per cent of people by forty-five will have experienced at least one substantial period of mental ill-health, and that this represents a major, yet ignored, risk factor for physical illness and premature death.

Sometimes, because mental ill-health can resolve with time alone, it might work to take a chance and negotiate a mental health crisis on our own, perhaps drawing upon self-help, social and peer support or online help, at least for a short period. But for most of us there is no more reason than with physical ill-health – such as chest pain, a headache or a respiratory infection – to discourage help seeking at least at a primary-care level within our health system. Early diagnosis, as well as safe and proportional stepwise intervention, depends on such a soft border.

Similarly, a soft border between mental illness and prevention – and ‘wellbeing’ – is in our best interests. In mental illness, as in physical illness, prevention is always better than cure, but until this ideal is fully realised, we must invest in both, as with cancer and heart disease.

This is one of the many false dichotomies we succumb to in mental health: the tendency for binary or black-and-white thinking. The social determinants of mental ill-health – the risk factors such as childhood trauma and neglect, attachment disruption, bullying, substance misuse, poverty and social isolation – are well defined and obvious. They have potent effects, especially when combined, upon the onset and course of mental illness. But they are somewhat less malleable than many of the risk factors for physical illness – such as poor diet, smoking and lack of exercise. The concept of early intervention softens the border between prevention and treatment by allowing early clinical features to augment the use of risk factors to modify the early course of illness, to soften the impact and damage that would have otherwise occurred. For example, recognising and responding to early warning signs of psychotic illness is transforming the treatment of schizophrenia and psychosis. This preventively oriented treatment has been the missing element in mental healthcare until recently. It saves money, lives and futures.

When it comes to mental ill-health on the one hand and mental wellbeing, resilience and positive mental health on the other, there is really no need for a border: these two states can coexist. The value of mental health promotion and positive mental health does not depend on its capacity to reduce the risk of mental ill-health. Mental health is a valid goal in itself: as the World Health Organization has always said, health is not merely the absence of disease. Mental wealth can be increased by improving wellbeing as well as by reducing mental ill-health and mental illness. However, it is unsafe to assume, as many do, that improving wellbeing will necessarily reduce risk for mental illness.

This means our use of language needs to be sharper, because much of the time in public discourse we use the term ‘mental health’ when we mean ‘mental illness’. This is confusing. During the pandemic we have witnessed a ubiquitous loss of wellbeing and a deterioration in mental health, overlapping with a rise of mental illness and suicidal behaviour. The two are related, but it is also possible to suffer a major loss of wellbeing without developing a mental illness. This has probably been the experience of many Australians during the pandemic. It has nevertheless made us more acutely aware of the fragility of our mental health and the clear and present danger of mental illness. Positive mental health strategies such as supportive relationships, exercise, a sense of purpose or meaning, and connection with nature can not only reduce the risk of mental illness but also promote wellbeing and fulfillment side by side with the symptoms of mental illness. Indeed, the adversity produced by mental illness can often be the stimulus for resilience and fulfillment. However, it is crucial that the allure of mental health awareness and promotion is not allowed to pose a threat to responding to mental ill-health with accessible, timely, holistic and high-quality care. The former strategies are much cheaper, can create the avoidable downside of assigning failure to those who become or remain ill, and let governments off the hook by deceiving the public into believing that a cheap, superior, more appealing alternative to the heavy lifting of high-quality mental healthcare exists rather than understanding that these strategies complement that high-quality care. Supporting anti-smoking measures and ‘slip, slop, slap’ doesn’t mean that first-class treatment and care of cancer can be neglected.

 

IN 2018, THE Lancet Commission on Global Mental Health revealed a continuing scenario of worldwide neglect in this area. Throughout history, the mentally ill have been subject to fear, loathing, neglect and a litany of human rights abuses, including torture and state-sponsored murder. Until the 1950s, treatments were largely ineffective and frequently harmful. The Lancet Commission confirmed that human rights abuses continue for the mentally ill in low- and middle-income countries, and that despite a decade-long global campaign to stimulate reform and investment, access to and quality of mental healthcare has lagged way behind those found in physical healthcare even in high-income countries.

What had appeared to be progress in dismantling, in many high-income countries, large and crumbling nineteenth-century asylums – well past their use-by date – had proven to be a failure, merely creating a further cycle of neglect. Vast numbers of severely mentally ill people were no longer able to access care within allegedly integrated health systems, where mental healthcare was ‘mainstreamed’ with physical healthcare. Bed numbers were dramatically reduced with the promise that even severely ill patients could largely be treated and cared for via community mental health programs and a much smaller hospital base. The funding never materialised to make this possible, and mental healthcare never reached parity with physical healthcare, nor was it respected, valued or embraced within the health system.

Design of the mainstreamed system was also crude, inhumane and ignored scientific evidence and lived experience. The clinical governance of the mental health system was extracted from a standalone model and entrusted to the boards and CEOs of acute hospital networks. This governance model essentially betrayed this trust, never affording mental health the same importance as physical illness. Even the inadequate funding that was allocated without ring-fencing by state governments to hospitals for mental healthcare was all too often repurposed to subsidise other hospital-based programs by CEOs, supported by their boards. The bottom line was the creation of a system that has been unable to implement compassionate evidence-based care. It was a case of ‘set and forget’, and the mainstreamed mental health system slowly eroded and imploded, leading to Victoria becoming the first state to acknowledge that the system was now officially ‘broken’ – and to Australia’s first Royal Commission into mental healthcare.

The morale and safety of dedicated mental health professionals have been sacrificed by placing them in dilapidated, highly stressful and often dangerous clinical settings with inadequate support and little respect for the complexity of and skill required for their work. Clinicians suffer moral injury daily from having to make ‘Sophie’s choices’ regarding whom to accept for treatment and whom to deny. Waves of enthusiastic new graduates have been placed in demoralised cultures of care and allowed to burn out; they either leave the scene or fail to flourish, unable to contribute their expertise and gifts. As soon as most locally trained psychiatrists are able, they leave the public health system for the calmer yet isolated and fragmentary world of private practice, leaving the frontline of public psychiatry to be reinforced by overseas trained psychiatrists who, to put it mildly, are not well supported and often follow the same path as soon as they can. There is very poor continuity of public mental healthcare in a field where a trusting, long-term personal relationship with a therapist is an essential contributor to recovery and should be at a premium.

The outcomes of these conditions have been predictable: substantial numbers of mentally ill people end up incarcerated in the criminal justice system, homeless or marooned, begrudged and in the end impoverished on social welfare – alongside rising and devastatingly high suicide rates. Private office-based mental healthcare continues in a fragmented fashion rather than in team-based multidisciplinary mode and exists for the most part behind substantial access and financial barriers. Multidisciplinary care is especially crucial in mental health because the needs of many patients are multiple and diverse, and several sets of expertise are required to ensure that all are positively addressed.

The ‘system’ has steadily crumbled and imploded to the extent that even political leaders, notably Victorian Premier Dan Andrews, have been prepared to describe it as ‘broken’; the Prime Minister is now personally and directly involved. That is why we have had the recent Royal Commission in Victoria to analyse the mess, and mandate and design a new system of care. Having had the privilege of chairing the Expert Advisory Committee for the Royal Commission, I regard its report, released in March 2021, as a watershed for mental health reform.

Federal governments have incrementally increased capacity from the primary care level but, as the recent Productivity Commission Inquiry Report into Mental Health has estimated, for at least one million Australians with more sustained and complex mental disorders, quality care remains inaccessible or highly elusive. These people constitute the ‘missing middle’. In fact, the missing middle could number closer to two million, if we combine those who are denied access with those who can only access poor-quality care.

While disadvantaged people suffer most here, the affluent and much of the middle classes also struggle to find quality multidisciplinary care. The Lancet Commission on Global Mental Health illustrated that this policy failure is almost universal across the globe. This continues to represent a human rights challenge yet also offers the most urgent and cost-effective healthcare opportunity for civil society.

 

IN TERMS OF what is possible – and what is needed – the reality is that most mental illnesses are as treatable as any other NCD. Effective psychosocial interventions, drug therapies and models of care have been developed, refined and tested. While a subset of patients is not dramatically helped by existing treatment approaches (though they should still receive compassionate and supportive care), a substantial reduction in death and disability due to mental illness could be achieved if we provide timely, sustained access to quality care within healthy and compassionate cultures of care for as long as is necessary.

Professor Gavin Andrews, an Australian pioneer of health services research, once termed this the ‘avertable burden of disease’: that is the proportion of death and disability that can be averted if existing knowledge and evidence were fully implemented. However, in my opinion he significantly underestimated our capacity to do this, calculating the avertable burden of disease in terms of mental illness at around 15 per cent or less. In fact, if we implemented the evidence and treatment capacity at our disposal now, we could reduce premature death and disability by a much higher percentage – certainly for some conditions such as psychotic disorders. This would produce health, social and economic benefits and would pay for itself many times over. It would also dramatically increase mental wealth.

The Productivity Commission certainly confirmed this opportunity, originally highlighted by the World Economic Forum in 2011. As the commission’s final report explained:

In total, mental illness, on a conservative basis, is costing Australia about $200–220 billion per year. To put that in context, this is just over one-tenth of the size of Australia’s entire economic production in 2019. The cost is between $550 million and $600 million per day. Not all of this cost is avoidable, but there is considerable scope for Australia to do better.

Although the Productivity Commission endorsed some positive directions – notably prevention and early intervention – there were surprising omissions of widely accepted evidence-based programs that deliver better outcomes through early intervention, and they ultimately failed to provide a coherent and integrated blueprint for reform. As economists they successfully analysed the underspend on mental healthcare and its serious economic consequences. However, they were not health economists; they were newcomers to the complex field of mental illness and lacked expertise in health-service design. So, despite the great expectations placed upon them, it was ultimately not reasonable to expect a coherent set of solutions from this source. The latter is quite achievable but can only emerge from a more robust process, with the right blend and level of expertise. The Victorian Royal Commission into mental healthcare has been the most genuine and sophisticated endeavour that has occurred so far, and will catalyse generational reform of governance, financing and culture in mental healthcare.

So how do we go about averting the burden of disease – that is, transforming the ‘avertable’ to the ‘averted’? First, prevention must be embraced wherever possible. While some risk factors for mental illness – such as social and economic inequality – are major geopolitical barriers, the reduction of premature death in people with mental illness through the prevention and treatment of medical illnesses such as cardiovascular disease and cancer is low-hanging fruit. If prevention were fully realised, perhaps up to one third of cases might be prevented – although the environmental risk factors involved are often ‘wicked problems’ such as inequality, child poverty, abuse and neglect. Beyond prevention, the next key focus is on early intervention, which is as crucial in this arena as it is everywhere else in healthcare. This means providing welcoming and proactive services from the onset of illness: this typically occurs in children, but more especially in adolescents and emerging adults, where new cases reach peak incidence. Quality multidisciplinary care must then be assured and sustained for as long as it is needed: there is little point in getting people well and into remission if no effort is made to keep them well. This requires attention to vocational and social aspects, substance use and physical health, not merely psychiatric symptoms. Survival rates and social recovery rates could be rapidly transformed. In Australia and in many high-income countries around the world, health-promoting and optimistic cultures of care have been created, and while they certainly show what is possible, they exist as oases in a desert.

We also need to increase the proportion of disease burden that is avertable, which means scientific breakthroughs are also urgently needed – especially in terms of safer and more effective drug and other biotherapies for more severe conditions such as schizophrenia, anorexia nervosa and complex mood disorders. An additional tranche of health gain and increase in the avertable disease burden could be achieved if new discoveries through research were more seriously sought, as they constantly are in cancer. However, medical research, like healthcare, has treated mental illness as a second-class citizen. Funding is at less than half the level demanded and justified by the public health importance of mental illness. The philanthropic sector was even further off the pace until recent years. There are indications that this is beginning to be understood with the National Institutes of Health in the US, the Wellcome Trust in the UK, the Australian Medical Research Future Fund and the philanthropic sector creating priority schemes focusing more on novel treatments.

 

THE HIERARCHY OF needs as defined by American psychologist Abraham Maslow in the mid-twentieth century highlights that some issues must be addressed ahead of others in terms of survival and progress. Water, food and shelter are the top priorities and prerequisites for moving up the hierarchy. Human progress is advancing. Many social evils – such as war, homicide and extreme poverty – are abating. Social cohesion is improving. With the retreat of many non-communicable and infectious diseases – Covid has obviously caused a rethink here – it may be assumed that reducing mental illness and improving mental health could ultimately become the last remaining quantum leap for healthcare and for humanity to make. This tantalising possibility has come sharply into focus in high-income countries and is emerging in many others as they transform their economies and societies. While it’s understandable that healthcare systems have focused on solving other challenges lower in the hierarchy so far, the reasons mental illness has not gained greater traction within the NCD pecking order are more complex and are explored below. Now, with life expectancy increasing to record levels, there is a sense that mental illness could be the awakening giant of healthcare; there is a sense, too, that addressing this particular NCD could realise the most potent social and economic benefits. This imperative has been injected with greater urgency as the worsening mental health status among young people over the past decade has become impossible to ignore – shown in rising rates of distress and suicidal behaviour. But are we ready for a ‘moonshot’ mindset here? And what has held it back? What would form the components of such a project?

 

ONE OF THE great benefits of breaking the silence on talking about mental illness and suicide – though we still have a way to go on the latter – is that the scale and impact of this major source of premature death and disability are now better understood. These days increasing numbers of people are asking how it is possible for this issue to continue to be neglected. 

There are many contributing factors.

First, in this and a number of other previously contentious domains – such as gender diversity, extreme poverty, frequency of war – our society, our world, is maturing. In the optimistic Factfulness, Hans Rosling – a Swedish doctor and statistician – reveals the extent of global progress over recent decades on major health and social issues, emphasising that this progress is largely concealed and not appreciated by most people for several key reasons, including the bias of the media in reporting bad news. Delayed by stigma and prejudice, such progressive forces have come late to mental illness. It was not until towards the end of the twentieth century that the nineteenth-century model of care, the asylum, was superseded. Until then, the mentally ill were ‘out of sight, out of mind’, and the silence that shrouded the topic has been the greatest obstacle to progress. Even now the taboo surrounding suicide is tenaciously persistent, even among some mental health experts, propped up by exaggerated fears of ‘contagion’ and a failure to appreciate the benefits of lifting the lid on this major cause of preventable death.

Second, but at the same time, a lack of consensus regarding the fundamental nature of mental illness – and the consequent factional and ideological discord within the field – confuses policy-makers, the media and the public. Through such disconnects, mental illness comes to be wrongly perceived as a ‘wicked problem’; confidence is reduced in solutions that should not be contentious, and scientific evidence is denied the respect it automatically commands in other areas of healthcare. An example here is the tedious ‘groundhog day’ media debate on the relative value of medication versus psychological treatment for depression. The evidence supports both.

False dichotomies and binary thinking abound in mental health, with the most fundamental deriving from Cartesian dualism and the mind–body (brain) split. The tension between psychological reductionism, represented by psychoanalysis that is focused on the human mind, and neurobiological reductionism, which regarded mental illness as a brain disease, reflects this paradigmatic struggle. The struggle appeared to be resolved in favour of neurobiology as psychoanalysis declined in the 1970s. However, this was not at all the case, and the faultline persists to this day. The debate ebbs and flows from mindlessness to brainlessness. Of course, a holistic integration of multiple paradigms – biological, psychological, social, cultural and spiritual – is the only way to approach the understanding and care of the mentally ill. Psychiatrists and most Australian mental health clinicians are trained within such an integrative bio-psychological paradigm and mindset.

However, the chronic neglect of mental healthcare in Australia has meant that clinicians typically are unable to practise what they have been trained to provide, and the experience of too many people with mental illness is that they receive a very narrow and limited version of mental healthcare, which typically neglects the psychological and wider sociocultural and contextual elements that are essential for recovery. This undermines respect for the essential and effective elements of medical and biological aspects of treatment, as well as trivialising expert psychotherapeutic skills. This adds to a sense of moral injury among many clinicians. And people who have experienced poor-quality care are often traumatised, and quite understandably go on to reject all the valuable evidence-based interventions that psychiatry and mental healthcare have to offer, and that should have been available to them under optimal conditions.

Involuntary treatment, essential for a small subset of people with certain conditions and risks, is used excessively throughout Australia because the underfunded system has failed to offer early intervention and effective treatment to avert crises and severe relapses. People are understandably often traumatised by this experience, especially when it is carried out with a lack of compassion and expertise. Anger from this source has helped to power consumer-driven activism for reform, which has been both necessary and positive. However, the extremes of a ‘destroy the joint’ mentality will prevent much needed consensus – and could actually subvert genuine reform. It is important to expand the reach of the constituency with lived experience into a fully representative voice for people with mental ill-health who can shape a modern mental health system.

Deliberative democracy is one possible process to broaden and harness influence, and one that depends on mutual respect. At another level, the underlying mechanisms that create and sustain some of the more serious forms of mental illness – such as psychosis, borderline personality and eating disorders – are not yet well enough understood to allow for the best design of reform. Advances here will pave the way for more effective treatments and cures; these are the ultimate weapon against stigma – as we have seen historically in diseases such as tuberculosis, epilepsy and leprosy.

Third, the failure of the public to connect, mobilise and demand a fair deal for a group of illnesses that threatens every family – and our whole society – has meant a lack of pressure on political leaders to address neglect in this area, and even those leaders sympathetic are not fully mandated to undertake reform. The road to change in recent decades has been paved with a series of scandals and adorned with more than fifty inquiries and reports; these have merely triggered limited and desultory reform, followed by complacency and neglect. The failure of the public to mobilise in their own self-interest has been mirrored by a passivity and weakness in leadership within psychiatry and other mental health disciplines. This can be partly explained once again by stigma, through which those who work with the mentally ill have also been disempowered.

 

THE FIRST STEP towards creating a moonshot mentality – and a blueprint for the most productive way forward – is to commit to finally ending the discrimination against people with mental illness across all aspects of society through a grassroots national campaign. By building on a much greater awareness of the personal risk we all face, such a campaign would aim to not only secure a guarantee in parity of funding to ensure equity of access and quality of care but also to end workplace stigma and discrimination in areas such as insurance and educational settings. By making mental health a top priority in healthcare – as the current Prime Minister and the Victorian premier have done by committing to serious reform this year – we could translate that into affirmative action to fund mental healthcare and research in proportion to its contribution to burden of disease and loss of economic productivity. Affirmative action in medical research is especially crucial so that discovery and implementation of new treatments are as aggressively pursued as they are in cancer and other disease areas. Mental health currently lacks even a fair go here, though some funders are giving it a higher priority. A new organisation, Australians for Mental Health, has been established to develop a standing campaign aimed at mobilising the voices of millions of Australians impacted by mental illness to end discrimination and the second-class status of mental health within healthcare.

The lack of a broader consensus about the way forward also allows mental illness to be wrongly perceived as a ‘wicked problem’. Five million Australians are directly affected by mental illness every year – including close relatives converts this to a number that translates to most Australians. If mobilised coherently, such a collective voice would ensure discrimination was swept away and real progress would rapidly occur. Lived experience has been given high priority in the co-design of youth mental healthcare, with huge benefits, and has been listened to carefully within the Victorian Royal Commission on mental health and the Productivity Commission.

However, to fully realise the potential value of the expertise and contribution of people with mental illness, such a voice needs to be more inclusive so that we can build the trust needed for a collaborative approach. Activism needs to mature into a future-oriented constructive mindset to influence the design of new mental healthcare. In augmenting the voice of lived experience to set priorities and shape the design of mental healthcare, a complementary process of deliberative democracy through citizens’ assemblies is also worth considering so that a more inclusive and representative contribution can be made.

We also need to diagnose past policy and governance mistakes and failures in order to correct them. The failure of public policy around mental healthcare is one of governance as well as financing. The past two decades have taught us that there is a genuine need to revisit and transcend the policy underpinning the naive mainstreaming of mental healthcare within acute hospitals, which left mental healthcare unprotected and disempowered. Equally importantly, the corporatisation and commissioning of community mental healthcare needs to be completely rethought. People with mental illness have diverse, complex and often enduring health and social needs. These cannot be met by a fragmented ‘system’ that lacks both horizontal integration (where services are provided under the auspices of one agency or point of governance) and vertical integration (which integrates different primary, secondary and tertiary tiers of care). Medicare Benefits Schedule funding fails to incentivise collaborative and integrated care, rewarding by default a siloed form of private practice that segments elements of treatment that belong together under one roof. Community mental health services have for some time been commissioned via a competitive tendering process that awards short-term contracts to non-government organisations, large and small; this embeds a culture of competition between agencies rather than one of co-operation and collaboration, which is vital for effective integrated, co-ordinated care. The corporate governance model of these organisations – although often not-for-profit – is modelled closely upon the company cultures and mindsets of the commercial world, where competition is seen as an essential force for efficiency and successful outcomes. This assumption simply does not apply to the provision of mental healthcare, where collaboration and integration of services is crucial. This is not a critique of the many altruistic people involved, but of the underlying corporate governance model and the effect that competitive tendering for scarce funding engenders. The latter drives fragmentation of care, and while aiming for efficiency produces suboptimal outcomes. This is not the best use of public funds, and the scenario is very different from the commercial world, where private investors, not the taxpayer, provide the funds, and profit and growth are legitimately key objectives.

Recently, the federal health department’s commissioning function – whereby services are ‘purchased’ with taxpayers’ dollars – was also outsourced to private companies called primary health networks, further reducing transparency and increasing the imperative to adhere to a national plan to safeguard assured access and quality to all parts of the country. The pendulum has swung too far to a devolved and diffused model with insufficient regard for standards and evidence. The Productivity Commission Inquiry Report missed an opportunity in failing to address this serious weakening of governance and financial controls on public expenditure. There are solutions to this policy flaw, which would nevertheless respect and sustain a balanced amount of devolution of commissioning to enable justifiable local adaptation of care and possible innovation, but with appropriate governance, appropriate controls, a much more transparent statutory model, national oversight and a requirement that services are commissioned as integrated platforms of multidisciplinary care. Such visible platforms should be jointly commissioned according to a nationally agreed model by new statutory entities, fuelled with both federal and state funding. This is a key solution to the missing middle, the people too unwell or complex for primary care and not desperately ill enough for acute hospital care.

Another policy failure insofar as it impacts mental healthcare – and inexplicably out of scope for the Productivity Commission – is the National Disability Insurance Scheme (NDIS). Mental illness is the largest single cause of disability in Australia by a country mile. Yet it was included as an afterthought within the new model of disability insurance designed for people with physical disability. The number of mentally ill people covered under the cap was set at less than 10 per cent of the most severely mentally ill and disabled people in Australia. This ignored the needs of the other 90 per cent and of the millions of other Australians with less severe forms of mental illness. The scheme is extremely generous but off-beam for people with mental illness. It tends to fund things that are nice to have – such as getting your lawn mown – but not essential. Access to a skilled mental health team or psychiatrist, to vocational recovery workers or to safe and secure accommodation is typically out of scope, yet out of reach for many people with mental illness. Those inside the tent receive packages of care averaging $47,000 per annum, which is roughly three times the funding allocated to the care of mentally ill people within the most specialised level of state public community mental healthcare.

NDIS funding packages are also allocated to the individual rather than the program, which sounds good in principle. In practice this means much of the allocated funds are not even used. And the application process is so complex and lengthy that third parties have been contracted to assist the person to apply. The NDIS for mental healthcare needs a major rethink and rechannelling into a bespoke model for the pattern and type of disability associated with mental illness, which is not the same as for cerebral palsy or paraplegia.

At the same time, new and reinvented workforces must be created and inspired to deliver quality care within a greatly expanded and flexible multistage system of care. The inevitable delay built into expanding workforces is a major barrier that must be urgently addressed. If the system needs to be around twice its current capacity, then this can only be achieved by defining the complexion of the workforce required and by setting targets to increase capacity in a rapid but stepwise manner. It is important that while task-shifting can play a role here – and has already occurred to a significant degree – we do not compromise on skills and expertise and again sell people with mental illness short.

We do not do this within pandemics nor with other NCDs, like cancer. There, we aim for – and generally succeed in delivering – world-class care. In the area of mental healthcare, tertiary institutions and existing professions must be encouraged by government to respond quickly and review the content and scale of their training programs. New workforces, notably peer workers – who offer unique support and shared experiences – and vocational recovery professionals – who preserve or restore work and/or study – and new platforms, notably digital health, are key innovations that need to be incentivised and fast-tracked. Covid has helped to accelerate some of the latter innovations.

A new staged mental health system must also be built to deliver pre-emptive care rather than anything superficially similar, such as stepped care. The latter, as characterised in the Productivity Commission report, is too dilute at each step and implies waiting for the person’s treatment needs to escalate before responding. Staged care aims to pre-empt and prevent worsening or progression of the illness.

 

THE SCALE OF this health and social problem must finally be acknowledged. Mental illness impacts five million Australians directly every year and cumulatively impacts the lifecycle of almost everyone. Unlike cancer and the other major NCDs, every Australian family will face this issue and without much support or expert care. We spend around $10 billion annually on mental healthcare; it sounds like a lot. However, the NDIS devotes $22 billion annually to just over 400,000 Australians with disability. The momentum for a moonshot mindset and program depends on recognising and turning around this massive underspend in the same way as the NDIS secured such a mindset a decade ago. Despite the scale being tenfold greater, this next moonshot is much more achievable: better outcomes will pay for themselves through greater productivity, and dramatic savings will be made from welfare and other spending on the consequences of neglect.

An expansion of public education programs is needed too, to ensure that everyone understands how to safeguard mental health and the risks and protective influences on the onset of mental ill-health. These programs should equally equip people to recognise emerging or warning signs of such mental ill-health and how to seek help from family, friends and health professionals.

Pathways to care must also be structured according to stage of life for epidemiological and cultural reasons. There should be a paediatric or child mental health system that covers younger children up to puberty, during which preventive approaches are crucial and care focuses on childhood mental disorders such as autism, ADHD and conduct disorder. The stage from puberty to the mid-twenties is a second critical period during which major developmental tasks are faced and also when the major mental disorders of adult life emerge and reach peak onset. This includes mood, anxiety, eating, personality, substance use and psychotic disorders, or combinations of these conditions. The transition to adulthood, especially across the late teens and early twenties, manifests the full fury of this storm of disturbance and risk. This is where the mental health system has been weakest when, paradoxically, it needs to be at its strongest.

Australia has anticipated this reform focus well ahead of other nations and is developing and scaling up headspace, an enhanced or bespoke primary care model for this age range that shifted the boundary of care from age eighteen to the mid-twenties. Older adulthood is the period during which the bulk of more persistent and recurrent illnesses need care, a period that extends up to old age where, once again, the service complexion must change for developmental reasons and the increased needs to ensure medical and psychiatric care are intimately blended. This is where my energies and those of many colleagues have been channelled over the past two decades, with the design and growth of headspace, our network of soon-to-be 150 one-stop shops for young people nationally, and Orygen, Australia’s translational youth mental health research centre and the global epicentre for the new field of youth mental health.

At each life stage, accessible primary care portals such as headspace are the first stage of care, complemented by health professionals in schools and other educational settings for children and young people, and featuring digital platforms of care integrated with face-to-face options. Mainstream general practice plays a key role here but, given the prevalence of mental ill-health in primary care, more support for GPs is also essential. Better training, financial incentives, and genuine back-up from psychiatrists and accessible local multidisciplinary platforms of care are overdue.

Adult community mental health hubs are in the pipeline, but the concept needs to be strengthened and rapidly scaled up to assure expert care for those adult missing-middle patients. Headspace centres, as a youth-friendly version of primary care, already play an invaluable yet still financially constrained role as a first step for young people, but these need to be strengthened with additional funding for the recruitment and retention of GPs and allied health staff, alcohol and drug expertise, and the expansion of funding for vocational Individual Placement and Support workers to cover all centres. Australia doesn’t only need more centres; it needs the existing ones to be more strongly supported. These centres also need to be backed up by a new secondary tier of more intensive team-based community mental healthcare for the youth cohort of the missing middle. Such a back-up system for headspace in youth mental health has deep roots and is an example of an option that is ‘shovel ready’: designed and tested – based on more than two decades of Australian research and development – and already partially constructed. Better access and quality, producing improved outcomes for the missing middle – especially young people – would be transformational and represents the best buy in mental healthcare, given the stakes and lifelong consequences of neglect for this demographic.

But beyond primary and secondary care, we need a suite of residential care options ranging from acute and forensic beds through to the innovative hospital-in-the-home model, subacute and longer term therapeutic residential options, and a rediscovery of the need for very long-term residential care for a proportion of patients, which must be acknowledged. The options of prisons or the streets are no longer acceptable.

 

AUSTRALIA IS NOW ideally positioned to take a major step forward in mental health reform. The combination of a moonshot mindset over the next five years with an inspiring, decisive and uncompromising manner, based on a consensus derived from a distillate of wisdom and the best available evidence, policy and governance reform, political and administrative skill, generous funding and efficient financial models, will transform healthcare and society. Through this, we can inspire not only ourselves but many other nations around the globe that sense this is the last major frontier of health reform, with the capacity to improve quality of life and life expectancy.

Australia is already viewed as an innovation hub due to some of the successful reforms we have delivered in mental healthcare – but so far these have remained incremental and piecemeal and have not achieved lift-off. In October 2020, following a landmark speech on mental health at Orygen in Melbourne, the Prime Minister conceded that people with mental illness and their families had been ‘very patient’. However, those five million Australians with mental illness – and their families – are now running out of patience; we simply cannot afford any more false dawns.

The final report of the Royal Commission into Victoria’s Mental Health System contains by far the best blueprint for reform and expansion of the state system of mental healthcare with radical yet sound changes to the governance, structure and commissioning of mental healthcare at the state level. The federal government appears poised to align its own reforms in mental health with those of the Victorian Government, forming the vanguard for a National Reform Agreement later in 2021. Every Australian – every me, every you – will benefit from a deep reform and investment program of this kind, and it will allow us to create a society with much greater mental wealth.

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