Federal elections can act as a launchpad or watershed for major health reform. However, despite mental ill-health being the most potent of all disease categories in its contribution to disability, impact on the economy and as a major cause of premature death, it is typically the bridesmaid at election time. Promises of funding always feature “m” words not “b” words; that is, millions not billions. Yet every Australian is directly or indirectly affected by mental illness. It is even more ubiquitous than cancer and typically strikes early in life, not late. Polls always place mental health higher on the list of priorities for voters, especially undecided ones, than politicians acknowledge. The major parties still have time to address this blindspot.
The late Hans Rosling in his liberating book Factfulness shows us that, despite the impression most of us have, the facts show that most elements of our lives and of nearly all societies are slowly, silently, improving. Although many aspects of life remain bad and unacceptable, at the same time they are better than they were, even compared to 20 to 30 years ago.
As someone who has worked in mental health care for nearly 40 years, I would say this is true, even for mental health care. However, in contrast to the dramatic improvements we have seen in funding and outcomes in other areas of healthcare, notably cancer and heart disease, the improvements in mental healthcare are superficial and patchy, and have not had much, if any, positive effect on outcomes, such as suicide incidence and recovery rates. For more complex and severe forms of mental illness, the situation has become worse in terms of access, quality and the humanity of treatment. That is a big statement when one considers we have replaced the old Dickensian institutions and placed the care of the severely mentally ill in the hands of acute general hospitals. But there is a great deal of truth in it if one looks at the facts and the lived experience of people with mental illness and their families.
Although stigma has been reduced for certain mental health conditions, notably anxiety and depression, and federal governments have strengthened the capacity of the primary care system to provide access to people with these milder conditions, the maximum length of treatment available (10 sessions a year) is insufficient to meet the needs of people with moderate to severe mental health conditions. This group of people represent a huge blindspot, a devastating chasm in care that successive governments have never addressed: the “missing middle”. This missing middle is characterised by the hundreds of thousands of Australians, both young people and older adults, whose illnesses are too complex, too severe and/or too enduring for primary care alone to be sufficient (whether via standard GP practices or headspace centres).
I have worked for long enough as a frontline clinician and scientific researcher to know that evidence-based treatments offered by dedicated and gifted multidisciplinary teams of professionals within optimistic cultural oases work as well, if not better, than in other areas of healthcare. With colleagues nationally and around the world we have created these conditions in many places. But the implementation of this achievable goal is the exception, not the rule. Most Australians, rich or poor, struggle to find this quality of care.
Yet there is genuine hope and a clear-cut pathway for progress. The National Mental Health Commission has made the correct diagnosis: that we need to build the missing steps between GPs and the emergency departments for the missing middle. This is where the next Australian government can take some decisive and immediate steps.
What is needed is a national network of specialised community mental health hubs that can provide rapid and expert backup for GPs or headspace centres and meet the urgent and ongoing needs of more complex patients close to home and which have the capacity for extended hours outreach. A version of this has been designed for young people and is ready for implementation since it can be blended with existing headspace clusters nationally, including in the regions. It has been an achievement of successive governments to have built and extended headspace as a trusted stigma-free first step in care. But the capacity of headspace urgently needs to be deepened, a step we have termed headspace plus. The second version, for adults aged 25 and older, would be a new platform and resource for collaborative care with local GPs and emergency departments.
Carefully designed and costed proposals for both these models have been developed and provided to the major political parties. The initial stage would see a modest number of these platforms trialled and evaluated, refined and scaled up in a stepwise fashion across the country, guided by evidence and the feedback of people who use these services and their families. All sides of politics are encouraged to commit to this stepping stone to better mental healthcare and to equity for people with mental illness in our health system.
• Pat McGorry is professor of youth mental health at the University of Melbourne and executive director of Orygen, the National Centre of Excellence in Youth Mental Health. He is board director of headspace and former Australian of the Year (2010)
