Keynote presentation by Dr Sebastian Rosenberg, from the Centre for Mental Health Research ANU College of Health and Medicine. presented at the WA Mental Health Conference 2019.

1. Dr Sebastian Rosenberg
Centre for Mental Health Research
ANU College of Health and Medicine

2. 2
• Provide a picture of mental health in WA
• Consider contemporary policy settings
• Highlight key recommendations and issues arising
from the Productivity Commission Inquiry
• Present some key questions which should
underpin the next phase of mental health reform
This Presentation

3. 3
Mental Health’s Share of the Health Budget
6.60
6.80
7.00
7.20
7.40
7.60
7.80
8.00

4. 4
0.00
50.00
100.00
150.00
200.00
250.00
300.00
350.00
400.00
NSW Vic Qld WA SA Tas ACT NT Nat Avg All $
$304
$206
$232
Per Capita State and Territory Spending on Mental Health
$356

5. 5
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
NSW Vic Qld WA SA Tas ACT NT
Public psychiatric hospitals Specialised psychiatric units or wards in public acute hospitals
Community mental health care services Residential mental health services
Grants to non-government organisations Other indirect expenditure
Components of Mental Health Spending 2016-17

6. 6
NGO Share of Total State and Territory MH Spending
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
National WA

7. 7
• Despite repeated inquiries generally associating
the mental health system with the word ‘crisis’,
there has been minimal effort to bridge the gap
between mental health’s share of the health
budget (7.4%) and its contribution to the burden of
disease (12%).
• This gap does not explain everything. But it
explains something.
What does this mean?

8. 8
So what are we getting for the spending?

9. 9
NSW Vic Qld WA SA Tas ACT NT Aust
1286 1007 1014 1515 1243 1063 1227 1992 1205
Average recurrent costs per inpatient bed day, public hospitals
2016-17

10. 10
NSW Vic Qld WA SA Tas ACT NT Aust
13.9 13.6 9.9 15.1 10.3 11.4 12.2 14.0 12.7
Average Length of Stay, Public Hospital Acute Units 2016-17

11. 11
NSW Vic Qld WA SA Tas ACT NT Aust
M 13.8 13.2 13.6 15.7 14.0 11.9 13.4 10.3 13.8
F 14.8 16.1 14.4 21.1 17.9 15.4 16.6 14.1 16.1
Readmissions to hospital within 28 days of discharge

12. 12
• The Australian Capital Territory (34.5%) had the highest
proportion of service contacts provided to people with
an involuntary mental health legal status, while
Western Australia (3.4%) had the lowest.

13. 13
NSW Vic Qld WA SA Tas ACT NT Aust
Average treatment days per episode of ambulatory care
8.1 6.2 7.0 5.1 5.4 5.4 8.3 4.6 6.7
Average cost per treatment day of ambulatory care $
237.19 458.54 340.73 430.20 325.31 338.34 224.33 447.02 325.04
Ambulatory Treatment and Costs 2016-17

14. 14
Reg Psych
Clin Psych
}GP Plans
GP Plan Review
GP Treatment
GP Plans
Access to Better Access
2018-19 Australia
5.4m psychology
services costing
$570m.
For WA this
means almost
11,000 sessions
of psychology
costing more than
$1.1m WEEKLY
(not including
OOPs).

15. 15
Access to Better Access
NSW Vic Qld WA SA Tas ACT NT Aust
Psychiatrist services
92.3 113.5 113.8 64.8 96.5 97.6 47.7 18.7 98.0
GP mental health specific
services 141.9 157.3 146.8 118.3 125.6 111.8 115.3 66.1 141.3
Clinical psychologist
services 80.3 96.4 81.6 90.4 113.1 122.9 101.2 19.3 88.7
Other psychologist
services 112.6 137.9 124.5 72.2 72.5 86.5 93.7 35.4 112.7
Other allied health
services 12.7 22.4 16.3 10.9 19.4 9.1 7.3 2.3 15.9
Mental health care specific MBS items processed
Rate per 1000 people 2016-17

16. 16
• Data for genuine accountability is poor
• Focus is on outputs rather than outcomes
• Data on issues that matter to many consumers and carers like
employment, education, housing, social inclusion generally
missing
• Across Australia quality and access to mental health care
varies enormously depending on where you live
• Hard to see any jurisdiction investing in community-based
alternatives to hospitalisation
• Risk of perpetuating hospital/bed/crisis-focused responses
Summary

17. 17
• High expectations – once in a generation but latest in LONG line
• Re-emphasise social determinants – more like 4th Plan than 5th
• Some significant recommendations, including:
– No discharge to homelessness
– New engagement with schools and universities
– New activities around early intervention and kids
– New structures to promote regional governance
– New structures for accountability
• Big numbers: cost to the Australian economy of mental ill-health and suicide: $43
to $51 billion per year PLUS $130 billion associated with diminished health and
reduced life expectancy for those living with mental ill-health
• Draft report only – submissions due in Jan, fin report May 2020
Productivity Commission

18. 18
• Strangely health and clinically focused
• Role of psychosocial support misunderstood or poorly described:
Even with the best clinical treatment, episodic or persisting mental
illness can result in the need for psychosocial and other supports (Vol
1. p25)
• Responsibility for psychosocial support split between Feds for NDIS
recipients (64,000) and states for everybody else (around 700,000)
• Issues around psychosocial workforce, markets, collaboration etc.
poorly described
• Support for systemic consumer and carer advocacy missing
Productivity Commission

19. 19
• There is no clear national vision for mental health
• [no] collaboration with non-health portfolios
• Disconnect between the national vision statement and those
developed by individual State and Territory Governments (Vol
2, p.898)
• New role for National MH Commission as interjurisdictional
monitor of progress – where does that leave state
commissions?
• Solutions are new agreements and target setting processes
with governments that have previously been unable or
unwilling to engage in better accountability
Productivity Commission – On Governance

20. 20
• How can stepped care survive without steps or monitoring?
• Who owns the ‘missing middle’?
• Where is hospital avoidance?
• Where is clear articulation of the role of psychosocial support?
• What will make new Regional Commissioning Authorities
comprised of PHNs and LHDs choose to invest in community
mental health services?
• If all the PC recommendations were implemented would they
make enough of a difference?
• PC is just one horse – are we backing the right one?
Productivity Commission – Key Questions

21. 21
• Is it clear where we want people needing mental health care to go (based
on evidence, their wishes etc.)?
• Is it clear who they should see (issues of role delineation, ehealth etc.)?
• Is it clear what they should do next, if their situation improves or worsens?
• Is it clear that as a community we wish to preference community care over
hospital care (see National MH Commission Review 2014)?
• Is it clear that we wish to organise mental health services to clearly respond
to the epidemiology of illness i.e. focusing on early intervention among
young people?
• Is the role to be played by psychosocial care as a partner to clinical care
clear – links to social determinants?
• Are we serious about consumers and carers driving the system – planning
and feedback?
Key Reform Questions

22. 22
No
Thank you.
sebastian.rosenberg@anu.edu.au