Mental health inquiry has its work cut out

There are far too many gaps in mental health care, forcing GPs to take up the slack, says the AMA

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The Productivity Commission faces an “enormous challenge” in its review of mental health, the Australian Medical Association says, given a system that is underfunded, full of gaps and suffering from “a marked lack of capacity at all levels”.

Mental health is the single most common reason to see a doctor, and GPs nominated it as their top policy priority after Medicare rebates in the RACGP’s 2018 Health of the Nation survey.

The commission was asked in November to examine how improving mental health could enhance social and economic participation and economic growth. Its terms of reference include “sectors beyond health, including education, employment, social services, housing and justice”.

The commission, which will report in about a year’s time, intends to focus on high-prevalence moderate conditions such as anxiety and depression.

It acknowledges results of past reviews that found resources concentrated in costly acute and crisis care instead of community settings; fragmentation and limited coordination across providers, rather than a “system”; services centred on the needs of providers rather than patients; and inequitable access in regional and remote areas.

In its submission to the inquiry, the AMA says government portfolios currently operate in silos.

“The PC faces an enormous challenge here,” it says. “There must be an understanding that even though mental illness is an individual condition, collaborations by different agencies and disciplines (housing, employment, relationships, domestic violence, disability, drug and alcohol, migrant/CALD and Aboriginal and Torres Strait Islander) are vital to reduce duplication in services and ‘fill the gaps’.”

It notes that mental illness makes up 12% of the burden of disease in Australia, but receives only 5.25% of health funding (2014-15 figures), and says a disproportionate amount is spent on raising awareness and addressing stigma rather than on effective services.

AMA president Dr Tony Bartone told The Medical Republic there were too many gaps, leaving much of the slack to be taken up by GPs.

“There’s not enough acute beds, there’s not enough programs and services in between the community and hospitals,” he said.

“GPs are a significant part of the frontline service provision and they are having to be all things in terms of managing the step-up and step-down care of their patients, who often become very complex or challenging, and there’s no one to support the doctor in that process.”

The AMA says the threshold for public psychiatric care was inhumanely high, requiring a patient to be acutely psychotic or to have attempted suicide.

“Unless you are absolutely diabolically unwell, you can’t get into ED,” Dr Bartone said. “[If you can,] you may be kept in ED for an inordinate amount of time because there are no beds, but they can’t discharge you into the community. So they keep you for 24 hours or more in a cubicle or a behaviour assessment room under supervision, which is highly inappropriate.

“If you’re requiring acute care, ED is not the place for you.

“Patients are being discharged back into the care of the GP prematurely because they’re no longer requiring inpatient care, but there isn’t the support or services to assist the GP with managing that care in the community. Too often it backfires and the patient does deteriorate.”

Unemployment and poverty frequently attend mental illness, and job-seeker requirements fail to acknowledge the episodic nature of some conditions, the submission says, adding: “It is frustrating to see governments talk about improving mental health on one hand, and then introduce harsh penalties for vulnerable people on welfare, without seeming to recognise the barriers to employment for many with mental health problems.”

More people are on the disability support pension for mental health reasons than purely physical reasons, and it is hard to obtain and easy to lose; two-thirds of applicants are rejected every year, leaving only Newstart, which pays a single person just $539 a fortnight.

“At all levels there are barriers, imposts, factors that deter or decrease access [to care],” Dr Bartone said. “People with mental health issues suffer in multiple ways.”

The submission also notes the “too often ignored” fact that the commonest cause of premature death for mentally ill patients was physical illness.

“There is an enormous crossover in patients experiencing mental and physical health issues simultaneously,” Dr Bartone said. “The burden of chronic disease is significantly increased in patients with mental health issues, and they’re significantly more likely to have premature morbidity and mortality from their underlying chronic disease, so we need to get really serious about how one impacts on the other and having the appropriate funding for both.”

Dr Bartone said workforce was an urgent issue, especially in rural and regional areas, and welcomed the re-funded Workforce Incentive Program that would encourage the hiring of more mental health nurses. He said telehealth was a clear way to improve care within a pre-existing doctor-patient relationship.