Thursday, 20 September 2012
Community Affairs References Committee; Government Response to Report
I present the government's response to the report of the Community Affairs References Committee on its inquiry into funding and administration of mental health services and seek leave to have the document incorporated into Hansard.
The document read as follows—
Recommendation 1: The committee supports the increased funding to EPPIC and headspace in the 2011-12 Federal Budget on the proviso that this significant policy transformation be evaluated after two years. However, the committee urges the Government to identify or develop strategies that will address the need for early psychosis prevention and intervention in rural and remote areas.
Supported in principle.
The Australian Government acknowledges the importance of evaluating the headspace and EPPIC measures to ensure they are delivering cost-effective, good health outcomes. However, given that the expansion of both services is being done progressively, evaluation after two years may not capture the full benefits of the service models.
The Department of Health and Ageing (DoHA) is working collaboratively with headspace in developing a suitable approach for the next headspace evaluation, which will include the 2011-12 Budget expansion.
An evaluation framework for the EPPIC model expansion measure is to be developed in consultation with successful jurisdictions and Orygen Youth Health, founders of the model. An independent evaluator will be engaged in Year 2 of the measure to undertake an ongoing national evaluation.
The Australian Government acknowledges the need to improve access to mental health services, including early psychosis prevention and intervention, in rural and remote areas.
The EPPIC model relies on high-intensity services delivered through 16 core components, and can be difficult to deliver without a critical population mass. Currently the EPPIC model is aimed at delivering prevention and early intervention services in a region with a population of 1,000,000 people. As a first step to making the service more widely available, DoHA is working closely with Orygen Youth Health to adapt the model to suit smaller population sizes, noting that there are workforce challenges associated with such smaller populations.
The Delivering National Mental Health Reform package included important measures that will help to increase access in rural and remote areas, such as the expansion of the Access to Allied Psychological Services program and establishment of a single mental health online portal. This will complement existing rural-focused initiatives, such as the Mental Health Services in Rural and Remote Australia program.
Chair’s Additional Comments
Recommendation 1: The Chair of the committee recommends that the rationalisation of the number of rebatable allied health sessions under Better Access be delayed until it can be demonstrated that other programs (such as ATAPS) are adequately equipped to provide services to people with a severe or persistent mental illness
Supported in Principle
While Better Access was neither designed nor intended to provide intensive services or ongoing therapy for people with severe and persistent mental illness, the Australian Government acknowledges that there are some people with more complex needs who have come to rely on the program.
The Government recognises that some of the services in the 2011-12 Budget package will need time to build capacity before they are fully able to provide care and support to those with more complex needs.
The 6 additional services available under ‘exceptional circumstances’ have been reinstated until 31 December 2012. The standard number of rebatable sessions under Better Access will remain at 10, consistent with the program’s focus on people with mental disorders where short term interventions are most useful. However, for the 2012 calendar year, eligible individuals can receive up to a total of 16 services.
The reintroduction of ‘exceptional circumstances’ for a limited period, provides time for consumers and mental health professionals to adapt to the new arrangements and time for the new mental health services to be able to respond to people with more complex needs.
Recommendation 2: The Chair of the committee recommends that the Government consider putting in place an interim program through the MBS that would allow access to six additional sessions under Better Access for consumers who meet tightened criteria based on the severity of their conditions
Refer to response to Recommendation 1 of Chair’s Additional Comments.
Recommendation 3: The Chair of the committee recommends that the Government continue to evaluate Better Access and keep a watching brief on how the program is being accessed nation wide with a particular focus on the take up of Better Access services by hard to reach groups.
The Government will continue to monitor the uptake and use of Better Access as a national program, including access by hard to reach groups.
Recommendation 4: The Chair of the committee recommends that the Government develop guidance materials as quickly as possible to assist Medicare Locals and GP divisions in meeting the full potential of the expanded ATAPS program. This material should include examples of nation wide best practice in areas such as financial management and the development of innovative projects targeting hard to reach groups.
The Australian Government recognises the importance of appropriate resources and guidelines to support the expansion of the ATAPS program, particularly in the areas of growth targeted in the 2011-12 Budget such as child mental health, indigenous mental health and suicide prevention.
Operational guidelines for ATAPS were revised in consultation with key stakeholders and the ATAPS Expert Advisory Committee and distributed to Divisions of General Practice and Medicare Locals in December 2011. This includes operational guidelines to support provision of suicide prevention services.
Purchasing guidance for child mental health services, being developed by the Australian Psychology Society, is currently being finalised and will inform the finalisation of child mental health specific operational guidelines and the training supports needed to upskill the existing allied health workforce to provide appropriate mental health services to children and their families.
Indigenous specific operational guidelines are also being finalised in consultation with the ATAPS Expert Advisory Committee and other key stakeholders. Arrangements are being put in place to provide culturally appropriate training to allied health providers delivering ATAPS services to Indigenous people in consultation with the Australian Indigenous Psychologists Association.
Effective development of local clinical governance arrangements is being supported by a nationally consistent framework and resources being developed by the Australian General Practice Network (AGPN) in consultation with key stakeholders. These will be rolled out in early 2012 and the AGPN will work with Divisions of General Practice and Medicare Locals on implementation.
The Department is commissioning work to undertake an economic analysis of the current ATAPS program (including different funding models) to develop options for enhancing the program’s efficiency, including possible introduction of activity based funding for ATAPS and the identification of efficient business models. The project is expected to be completed by mid 2012.
Recommendation 5: The Chair of the committee recommends that a comprehensive performance assessment framework be established as part of the ATAPS expansion. The data gathered should be used to develop benchmarking tools to compare ATAPS service delivery across Medicare Locals and GP Divisions with similar geographic and demographic indicators.
The Australian Government acknowledges the role of performance monitoring in ensuring cost effective, targeted service delivery. The development of an activity based funding framework outlined in recommendation 4 will enable benchmarking of service delivery across Medicare Locals and support the development of relevant performance indicators.
The current monitoring and evaluation framework for ATAPS will be progressively reviewed to ensure effective capture of benchmarking and performance indicator data, as well as responding to the monitoring and evaluation needs arising from the expansion of ATAPS.
Recommendation 6: The Chair of the committee urges the Government to revise its scheduling for the 2011-12 Federal Budget changes to ensure continuity of care.
Refer to response to Recommendation 1 of Chair’s Additional Comments.
Recommendation 7: The Chair of the committee recommends that any tightening of eligibility for Better Access be delayed until the youth mental health initiatives funded in the 2011-12 Federal Budget are fully expanded and operational.
Refer to response to Recommendation 1 of Chair’s Additional Comments.
Recommendation 8: The Chair of the committee considers that consumers must have a central role in any mental health advisory body, and that Aboriginal and Torres Strait Islander people should be represented. The National Mental Health Commission, which will have nine Commissioners and a Chair, should include at least one Commissioner who is a consumer, one who is a carer and one who has Aboriginal and Torres Strait Islander heritage.
The Australian Government acknowledges the importance of a central role for consumers, carers and Aboriginal and Torres Strait Islanders peoples in the National Mental Health Commission (‘the Commission’). This will be fundamental to enabling the Commission to fulfill its role in providing cross-sectoral leadership and driving transparency and accountability in the system so that better outcomes for consumers and carers can be achieved.
Appointed Commissioners include a mental health consumer, a carer, and a person of Aboriginal and Torres Strait Islander heritage. This was announced by the Minister Assisting the Prime Minister for Mental Health Reform, the Hon Mark Butler MP, on 11 December 2011
Recommendation 9: The Chair of the committee recommends that the Government review the operation and structure of the National Mental Health Commission after two years with a view to placing it on a statutory basis.
Supported in principle.
The Australian Government intends to review the Commission after two years, to ensure it is performing well and meeting its objectives. As such, the results of the review will determine any future decisions by Government about the operation and structure of the Commission. The review will also help determine whether the executive agency model is supporting the Commission to operate effectively or whether a statutory model would be more appropriate.
Recommendation 10: The Chair of the committee believes that the new Mental Health Commission should undertake ongoing monitoring of the two-tier Medicare rebate for psychologists to ensure that patients have access to the most appropriate practitioners and that workforce balance across the mental health sector is maintained.
The Commission has been established by the Government to increase transparency and accountability in the mental health services system and provide advice to Government on achieving better outcomes for people with mental illness and their families and carers.
In doing so it will work with consumers, carers, experts, professional groups, other stakeholders and governments, to increase accountability and transparency in funding, delivery, evaluation, effectiveness and outcomes of a range of mental health programs and services.
The Australian Government is committed to ensuring that patients have access to the most appropriate practitioners, that those practitioners have relevant skills and qualifications and that workforce balance across the mental health sector is maintained. The issue of the two-tier Medicare rebate for psychologists under the Better Access program reflects the international benchmarks regarding qualifications, skills and experience in delivering psychological therapy services.
Consistent with its role in policy development and administration DoHA will continue to monitor the uptake of services provided by psychologists as part of the ongoing monitoring and evaluation of Better Access. The Government would also welcome any input the Mental Health Commission might provide as part of this process.
No recommendations made n/a
Dissenting Report by Coalition Senators
No recommendations made n/a
Mr Deputy President, I seek leave to take note of the report.
It is opportune that this response is given by the minister. Let me take the opportunity to acknowledge that tomorrow is World Alzheimer's Day which aims to unite the world and raise awareness of dementia. I also acknowledge the significance of Dementia Awareness Week which also starts tomorrow and goes to 28 September. Of course, dementia can happen to anybody but it is more common after the age of 65. However, we know that people in their 30s, 40s and 50s can also have dementia. There are almost 280,000 Australians currently living with dementia. This is expected to soar to 2050 and each week there are 1,600 new cases of dementia in Australia.
I remind the Senate that when last in government the coalition committed $320 million in the 2005 budget to help fund the Dementia Initiative, making dementia a national health priority. As Alzheimer's Australia have said, 'the 2005 Dementia Initiative was at the time a world first'. Despite this initiative providing invaluable help to dementia sufferers—and a government evaluation in October 2009 found that the initiative was very successful—those opposite in the Australian Labor Party deliberately dropped the funding for this program. I am pleased, however, to see that dementia has now been made a national health priority. I also remind the Senate that we had on 13 September RU OK? day and various senators, including myself, made speeches in support of that.
So today we have the tabling of the minister's response, and I find this a bit curious actually because the letter to Senator Siewert from Minister Butler was dated 17 April 2012 and it was supposedly received by the committee, I would assume, on 20 April 2012. I find it very curious—and perhaps Senator Siewert might be able to shed some light on this—why it took five months for the minister's response to be tabled in the Senate. I see Senator Siewert shaking her head, and if you did not get it, Senator Siewert, it makes it even worse. What sort of an incompetent government do we have that it takes five months for a letter from the minister for mental health to actually find its way to the committee? I think it would be appropriate for the minister to provide us with an explanation of that.
Having received the response, I must say the minister's response is not really worth the paper that it is written on because, certainly from the coalition's perspective, it absolutely does not address—and I will leave it to Senator Siewert to deal with the recommendations that were in her chair's report—and offers no comfort in relation to the issues, and in particular addresses the justification for the cuts to Better Access. I remind the Senate that the Better Access initiative was one of the main programs that were under discussion as part of the Senate's inquiry into the funding and administration of mental health in Australia.
In our concluding comments we were very critical of—and indeed the coalition senators' report and a lot of the evidence that was given at hearings was very critical of—the way the government had undertaken the changes to Better Access. There had been, as usual, scant consultation with key stakeholders to properly assess the impact of the changes that were made by the government, most especially the impact of those changes on patients. Indeed, the government had relied very heavily on its Better Access evaluation, which in itself had been criticised for its deficiencies in methodology and datasets. So I believe it was very clear that the government undertook an evaluation of Better Access with the specific objective of ensuring that this evaluation was set up to then result in the cuts that we saw. If you do look at this evaluation, you see several submitters to the inquiry commented on what they considered to be the weak aspects of the methodology or the limitation of the dataset. One of the most important objectives as to why Better Access was established was better coordination of services between mental health services, and this evaluation did not measure this or indeed did not measure important other objectives of the Better Access program. Questions about this evaluation were raised in estimates and, indeed, this evaluation formed very much the basis upon which the minister and his kitchen cabinet made important decisions about cutting huge chunks of money out of the mental health budget, out of Better Access, and redirecting them to other areas.
It is interesting to note for mental health the big headline of $3.7 billion for the reform package but in the end only $583 million was actually the net spend and one only has to look at all the criticism: GetUp! and the candles and the full bit with the 'Mental health: how important is it?' campaign. And I correct myself: it was $3.7 billion for the ageing package, which of course I have spoken about on other matters; in terms of mental health it was $2.2 billion. But in the end it is all smoke and mirrors because of this: how much of it has actually been rolled out? There was the package that had the suicide prevention money. Remember the promise on suicide prevention? '$277 million is what we are going to spend.' In the first year they were supposed to spend $9 million to roll out important programs but they did not spend $9 million; they spent $7 million. What has happened to the rest? It has taken them a year to spend money in relation to addressing suicide issues in the Kimberley, and we have traversed the long and laborious process that this government has undertaken in relation to addressing that issue in the Kimberley. So what has happened to the suicide prevention money? Indeed most recently we had Professor Hickie criticising what is happening in mental health and we have even had Professor McGorry too, despite Professor McGorry having stood side by side and applauded what the government had done. I think he has now realised that what the government has done has just been a smoke and mirrors exercise when, sadly, we are dealing with some of the most vulnerable people in this country, our mentally ill. One in five Australians has a mental health issue. Almost 45 per cent of Australians will suffer a mental problem in their lifetime. These are huge statistics, so where is the rollout of this money? Quite frankly, we are not seeing it.
The latest insult is this road map that the mental health sector has been waiting for. Last week I raised this issue. It was given out on a Wednesday, and the sector was given until the Monday after—four days to respond to a very important document that is supposedly going to be a road map for the next 10 years. But, as Professor Rosenberg said, 'It is in effect a road map to nowhere.' Having seen the latest iteration of it, it basically recommends the status quo. How can you have mental health reform when you are going to keep matters the way they are?
I too rise to take note of the Australian government's response to the Senate Community Affairs References Committee report on the inquiry into Commonwealth funding and administration of mental health services. I acknowledge the comments made by the government in its response and I recognise that the government is progressing with the budget commitments it made in 2010-11.
I would like to acknowledge that a solid commitment to mental health was made at that time by the government, and it was described by the government at the time as a 'centrepiece', with a view to increasing funding over a period of time. Approximately $1.5 billion of funding was allocated in the five-year package of new initiatives or the expansion of existing ones. The government is rolling out those initiatives and seems on track to satisfy the agenda that was then set, with the recent announcement of 15 new locations for headspace services, the gradual national expansion of the EPPIC model and the commencement of the National Mental Health Commission and its report card, which we are currently anticipating. However, progress is slow and the investment is perhaps not the centrepiece that we originally thought and hoped for, given the extent of the chronic underfunding of mental health services over a long period of time in Australia and the fact that this is continuing to be the case. We know that mental ill-health makes up 13 per cent of the total burden of disease in Australia but that funding for mental health services is only around half of that, at six to seven per cent. Some stakeholders fear that funding is decreasing rather than increasing, given the proportion of mental health funding as opposed to the increases in the overall health budget.
We should be striving towards achieving funding of mental health services that is commensurate with the burden of disease. Research indicates that only 38 per cent of those who have experienced a mental health problem in a year were seen in relation to that problem during that year, so there is clearly still a great degree of unmet need, and that does not even cover those people who do not have or who have not been diagnosed with a mental health problem or issue, although there are also many of those. The absence of effective evaluation and accountability processes also raises the question of whether the money currently being spent is being targeted where it is needed most and whether we are indeed rewarding the right programs, because there are many innovative and effective community based mental health services out there.
Unfortunately, as we have seen with the Mental Health Nurse Incentive Program, it appears that this is not necessarily the case. The Mental Health Nurse Incentive Program, for instance, is an excellent mental health service that assists many of our most vulnerable members in the community to live healthy lives. Funding of the program was frozen in May this year before any valuation was undertaken. There is anecdotal evidence becoming available to me that the freeze in funding has in fact cut services by more than 20 per cent, effectively, across the board. Given the important work that mental health nurses do, often assisting people with severe and persistent mental illnesses to remain as well as possible and to participate in the community, this outcome is very concerning. I am also aware that these nurses provide an essential service in rural and remote Australia, where workforce issues are of great concern and where it is often very difficult to get specialised mental health practitioners.
Another area of concern is indeed the lack of targeted funding to rural and remote mental health services. Despite investments in the 2010-11 budget, gaps in mental health services for people living in rural and remote areas are a continuing serious concern. The statistics bear this out, but so do the stories and experiences that I have been hearing in my ongoing consultation with people in the bush. The Australasian Centre for Rural and Remote Mental Health stated that 'the 2011-12 budget mental health package contained no specific mental health programs or allocations for rural and remote Australians, nothing that demonstrates understanding and care'. Recent reports about high levels of suicide in rural and remote areas have also highlighted the continuing theme of unmet need and lack of access to services in these areas.
In addition, there is an unequal distribution of health professionals between urban and rural and remote areas. We know that 91 per cent psychiatrists have their main practice in a metropolitan area and only nine per cent in rural areas. The unequal distribution of mental health services in rural and regional Australia poses far-reaching consequences for both individuals and their communities. An inability to obtain proper mental health care can affect a person's ability to complete their education, maintain employment, engage in social and community activities and form healthy relationships, and it contributes to a greater risk of developing physical illnesses. It is therefore vital that adequate funding and attention is given to all aspects of mental health in Australia.
In relation to rural and remote Australia we must ensure that equal need equates to equal distribution of mental health services. Given the government's recent injection of funding in the mental health sector, it is timely to review the impact of that funding and whether it is in fact improving the delivery of mental health services throughout Australia in terms of the actual outcomes and the lived experiences of the people who need those services. Identifying current unmet need and gaps in service delivery in regional, rural and remote Australia is something that the Greens are particularly concerned about. As spokesperson for mental health for the Australian Greens it is my view that this is an area of mental health policy that has been neglected for far too long. We want to work towards increasing funding for mental health over coming years so that it is commensurate with the burden of the disease, and we want to make sure that it is reaching those people who need it, that it is well targeted and that, ultimately, we see results which mean that Australians who have need of services are able to access them.
Just one; Senator Wright has done a very good job on the other points. My point is about the letter that came with this. I want to articulate that it first came to the community affairs committee. This is not normal practice. It did in fact come in, but it was a mistake to send it to the committee first. Of course it should be tabled here, and the committee notified the minister's office about that. However, I will point out that it was noted at a committee meeting on 24 April this year and that Senator Fierravanti-Wells was actually there. That note had gone round to the full committee, not just to the committee secretariat. I wanted to make it clear that there was no secrecy or anything like that involved, and that it was transparently circulated to members of the committee.
Question agreed to.