Audit Commission proposals on mental health, homelessness “without context, understanding”

The recommendations of the Federal Government’s National Commission of Audit on mental health are “without context or apparent understanding” and will only add to the inequity that people with a mental illness already experience, says Sebastian Rosenberg, Senior Lecturer at Sydney University’s Brain and Mind Research Institute. See his post below on the recommendations on mental health, disability support, employment support, the NDIS, and homelessness.

Sebastian Rosenberg writes:

The only thing worse than being talked about is not being talked about, said Oscar Wilde. With this strained mixture of fear and anticipation I began to search the five kilogram National Commission of Audit (NCOA) report for references to mental health. Australia’s deficit in relation to the provision of adequate, high quality mental health care is well known. The Commission had better have understood this.

I don’t think they did.

The report certainly plainly states (at Recommendation 40) that responsibility for mental health is characterised by “overlapping funding and service delivery responsibilities and a lack of coordination across jurisdictions”.

On this basis it supports the current review being undertaken by the National Mental Health Commission, asking that it pay particular attention to “removing the significant duplication between the Commonwealth and the States that currently exists in mental health services”.

It seems strange that the NCOA felt confident enough to assert this duplication when (at section 8.6) they also state how hard it is to actually establish an accurate picture of services and expenditure in mental health, whether the right amount of money is being spent in the right areas. The NCOA here is clearly wishing the National Mental Health Commission the best of luck in its review.

But what is worse is the apparent failure of the NCOA to acknowledge the paucity of services and the huge variability in the quality of mental health care across Australia, as acknowledged in many previous national and state reports in this matter. In fact, the real area of duplication across state and federal governments is in their shared neglect of mental health over many decades. This neglect is at its most acute in the area of most need – the need to establish a national system of accessible, high quality community mental health care.

While the NCOA support the National Mental Health Commission’s review, this does not stop them also calling for the abolition of that Commission, or rather, its absorption into a new Health Productivity and Performance Commission, along with natural bedfellows such as the Australian Commission on Safety and Quality in Health Care, the Australian Institute of Health and Welfare, the Australian National Health Performance Authority, components of the Australian National Preventative Health Agency, the Private Health Insurance Administration Council, the Independent Hospital Pricing Authority and the National Health Funding Body.

Across all government agencies, the NCOA makes recommendations for reviews in relation to mental health committees and groups, including the Aboriginal and Torres Strait Islander Mental Health and Suicide Prevention Advisory Group in the Prime Minister’s Department, the Australian Centre for Posttraumatic Mental Health in Defence, the National Mental Health Forum in Veteran’s Affairs and the Australian Suicide Prevention Advisory Council in Health.bigstock_Statistics_553868

It is at this point that I feel an urge to say that health policy and reform is really complicated while cutting budgets is not.

The task of mental health reform is particularly difficult. It was not assisted by moving the National Mental Health Commission from the Department of Prime Minister and Cabinet to the Health Department and the move suggested by the NCOA would seem a further retrograde step.

The NCOA report does make the point that funding to mental health is fragmented and poorly coordinated, with the Commonwealth responsible for 21 different grant programs totalling more than $500 million in 2012-13. This fragmentation is mirrored in the states. But the NCOA report fails to acknowledge that merely reducing the fragmentation will not address the gap generated by mental health receiving around 5 per cent of the health budget but accounting for 13 per cent of the burden of disease. This is simplistic but illustrative. Better coordination will help but it will not be enough to bridge the gap.

More broadly than mental health, the NCOA also seeks to assert responsibility for homelessness to the states. This is not about good policy or reform, just about reducing Commonwealth spending. There was general relief in the homelessness and mental health sectors when Tony Abbott agreed to extend the partnership agreements in this area. These had created new services. Removing these arrangements would be a backward step in addressing homelessness.

The NCOA is also keen to reform employment support services, including reducing the average cost per jobseeker. While Australia’s unemployment rate remains quite low, our success in finding employment for people with a mental illness is poor. It is likely that a significant proportion of Australia’s current pool of unemployed people have a mental illness, diagnosed or undiagnosed. Generalist employment support services often lack the expertise to assist people with a mental illness back to work. Funding incentives paid by the Federal Government to employment agencies often discourage providers from taking on hard to place cases. Cutting the employment support services for the unemployed will not help these people find and keep a job. They need specialist support services and a system of funding for employment service providers that pays incentives to take on the ‘difficult’ cases, not shove them in a too-hard basket.

On the back of inadequate support to get a job, it seems additionally cruel then for the NCOA to also recommend reducing the Disability Support Pension (DSP). Psychiatric disability is now the largest component of the DSP, accounting for almost one third of the 825,000 Australians receiving that pension. Nobody supports malingerers. But after enduring poor access to mental health care, problems with housing and frequent unemployment, it really does seem unfair to then reduce access to a pension for many people with a mental illness.

Just in case somebody with a mental illness does slip through the net and find government support through the newly minted National Disability Insurance Scheme (NDIS), in order to promote fiscal sustainability the NCOA also recommends slowing the roll out of the Scheme.

I find it passing strange too, for an audit so keen to pursue efficiency, that so little was made of the Better Access Scheme. Now costing taxpayers around $12 million each week, the NCOA reports that the Scheme has driven an average annual increase of 11.2 per cent in Medicare-subsidised mental health services over the five years to 2011. Yet the NCOA did not even see fit to recommend a review as to whether these precious funds are being properly targeted and yielding good outcomes. Another job for the National Mental Health Commission perhaps, while it still exists.

Overall, people with mental illness are already getting a grossly unfair deal. This is not acknowledged by the NCOA. Instead, the NCOA has reported as if strangers in a strange land, without context or apparent understanding.

On this basis, the NCOA report confidently makes several important suggestions which could make things even more unfair for people with a mental illness. I rather hope Australia is not that kind of country.

This article first appeared on ‘Crikey’ on 1 May 2014.

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