There is now increasing appreciation that despite the rhetoric of burden-sharing associated with the 2014 budget,the most disadvantaged in the community will bear most of the burden. People with a mental illness are among the most disadvantaged in Australian society, and they already confront many barriers to the services they need; this budget raises those barriers and imposes additional costs on them and those caring for them. People with a mental illness still struggle to find any mental health care (let alone quality care). This budget does nothing to increase the poor rates of access to care and indeed on all the available evidence, will contribute to a decline.
The government has chosen to seek savings totalling $53.8 million by deferring establishing 13 Partners in Recovery organisations for two years. This program helps people with severe and persistent mental illness and complex support needs. People in this group are over-represented among the ranks of the unemployed, the long-term unemployed and as recipients of the disability support pension. They will clearly be affected by the new $7 co-payment to see their general practitioner, though only up to the $70 cap if they hold a pension or concession card. Co-payments will not apply if GP visits are allocated as ”chronic disease management” items – although ”mental health management plans” have not been explicitly included in this exemption. It will be interesting to see if rates of these types of consultations spike now. It should also be remembered that the $7 is not a maximum co-payment amount. Doctors are free to charge whatever they please (as they are now), with patients left to deal with out-of-pocket costs directly. As Medicare rebates to GPs will be reduced by $5, poor people must rely on the altruism of their doctor or go without.
The financial costs of mental illness are further increased by the new $6 co-payment for prescription medicines. There is a new disincentive for people with mental illness to go and see the doctor and to comply with their medication regimes. Adherence to anti-depressant and anti-psychotic medication is already poor and requires regular monitoring by GPs or specialists. There is a clear risk that by neglecting medication for a mental illness the condition will worsen and result in more emergency department presentations or worse still, policeinterventions.
Those who work in the health sector see this as some kind of perverse cost-shifting: as federally funded primary healthcare services are withdrawn, emergency services and state-funded hospital services are left as the only option. That not only represents poor quality care but a poor use of scarce healthcare resources. It seems the only aim is to reduce the overall spending obligations of the federal government, regardless of the personal, social and economic consequences elsewhere.
The National Commission of Audit made no recommendations in relation to mental health, pending completion of the review of services being undertaken by the National Mental Health Commission, due in November. The review has the potential to deliver real reforms, but on the basis of this budget, many in the sector are now concerned that mental health policy will be driven by ideology and the push for a balanced budget rather than new investment in what works. The Commission of Audit did recommend that the National Mental Health Commission be rolled into a new Health Productivity and Performance Commission. Perhaps delivering its November report will be the National Mental Health Commission’s final act?
The hit to those with mental illness comes not just in the health portfolio, but in a number of other key areas.
The budget describes new arrangements in relation to younger people receiving the disability support pension (DSP). People under 35 years of age will be reviewed (with a few exceptions) and placed on a ”program of support” or risk losing their DSP benefit.
Reassessment alone is not the answer to the growth in the DSP. Two decades of evidence from around the world have shown that to get people with a mental illness back into sustained employment, post-placement support is the model of service. Unfortunately, Australian governments have never embraced this evidence and hence we have both a low rate of employment and a high rate of social security among people with a mental illness.
Changes made over recent years have favoured generalist employment support agencies over psychiatric specialist employment support services. There has been a genuine loss of skills and understanding. This has been driven by inappropriate government payment models, creating incentives for employment support agencies to deal with some cases over others. This, combined with minimal effort to raise awareness among employers, means finding employment for people with a mental illness is extremely challenging. Issues are compounded if the person has an undiagnosed mental illness. The budget fails to address these matters.
There are currently an estimated 105,000 Australians who are homeless on any given night, and perhaps as many as 75 per cent of these people have a mental illness. Prime Minister Tony Abbott agreed prior to the budget to continue a national partnership agreement with the states but only for one year.
Momentum for mental health reform has foundered in Australia since a high point in 2006. The key question remains: who will drive the development of a genuine community-based approach to mental health care, one in which the hospitals are a necessary, tertiary backup to the mental health care system not its front door. Alternatives to hospital care remain a tiny part of the funding and program landscape with the vast majority of mental health resources still going to public hospitals (and several extant asylums).
The 2014 budgetprovides no answers. Instead it throws further confusion on the roles of the state and federal governments in relation to mental health. What was clearly most important to the federal government was who pays, shifting responsibility from government directly to the service user. This was certainly deemed more important than keeping people out of hospital and functioning optimally in the community. That is bad news for people with mental illness.
This article first appeared on ‘WA Today’ on 29 Ma7 2014.