Time for a square deal for mental health

  • People standing next to cliff supporting each other
Dr Sebastian Rosenberg
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Dr Sebastian Rosenberg
Fellow, Centre for Mental Health Research, Australian National University
Senior Lecturer, Brain and Mind Centre, Sydney University
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Australia’s mental health services have been significantly out of balance for some time. The recent Productivity Commission report found that rural, regional and remote communities face very significant gaps in access to mental healthcare, as a result of service and workforce shortfalls. But of course, this is just the latest in a queue of such reports. While these documents generally conclude using terms like ‘maldistribution’ and ‘crisis’ overall, they typically refrain from fundamental revision of existing systems. Instead, they often call for better funding, workforce development, or greater use of technology to surmount the systemic barriers and problems standing between non-urban populations and a fair go at mental health care.

To be fair in relation to mental health, urban populations don’t fare much better. But it is in regional Australia that the flaws in our broken system are often most stark.

COVID-19 has served to accentuate this situation. The Australian Institute of Health and Welfare report higher rates of anti-depressant prescribing, more calls to crisis lines and increased use of Medicare mental health items. 

A recent article however reinforced the already well-understood unfairness that is hidden by Medicare’s ‘universal’ reputation. Simply put, people in non-urban areas do not enjoy the same access to Medicare (or other mental health services) as people living in the city. So, boosting access to, for example, taxpayer subsidised psychological care doesn’t mean much if you don’t live near a psychologist. 

Medicare Spending by Remoteness, per capita 2018-19 (AIHW)
Medicare Spending by Remoteness, per capita 2018-19 (AIHW)

Telehealth has helped significantly here of course. Between 16 March 2020 and 27 September 2020, 2.5 million MBS-subsidised mental health related services were delivered via telehealth (as opposed to face-to-face). Some of these services would have been for people living in non-urban areas but the extent to which these satisfactorily address Medicare’s inherent unfairness is unclear.

The recent Productivity Commission report calls for rural-focused workforce development (Action 16.2) but, really, no other specific recommendations. This left the question of how best to promote their laudable concept of ‘person-centred’ care in a rural context rather unanswered.

It is probably time we recognise that the answers required to underpin development of a fit-for-purpose mental health system for regional Australia are unlikely to emanate from one of these statutory inquiry reports. We must look to our own unparalleled understanding of regional needs and support our regional leaders to execute reforms suitable to the places we live.

Fragmentation and duplication of effort, funding and services perpetuates a lack of integration.  Regions must consolidate their efforts. Regions also need to think about mental health more broadly than ‘health’, looking instead at the whole ecosystem surrounding mental illness and its broader impacts on people, communities and economies. A new field of ‘ecosystem research’ is evolving in Australia, demonstrating mental health planning must consider not only beds and health services, but (long-neglected) psychosocial support, housing, employment, education and social inclusion.

Local decision-makers will need a new set of tools and skills to successfully plan like this and meet the needs of their communities. While technology and data will necessarily play a role in this new planning, so too must a core set of principles designed to govern change:

  • Respecting the (equal) rights of rural Australians to quality health care
  • Incorporating the knowledge and skills of rural experts
  • Integrating the principles of citizen participation and community development
  • Combining national and international technical expertise with local, place-based knowledge and expertise
  • Appreciating that local power and control are key to good rural health and that the exercise of power is manifest through funding, planning, and decision-making
  • Valuing the perspectives of rural communities in evaluating health services and programs in rural areas
  • Understanding that critical mass requires effective articulation of available city-based and rural-based workforces and capacity
  • Ensuring the rural constituency has an effective and powerful voice at all levels of governance
  • Making provision for sufficient time and effort for ongoing communication, collaboration, and partnership building work.

There are a few examples where all of these principles have been embodied in rural mental health system design but they remain the exception, not the rule. The country is not like the city. One size does not fit all. It is time for a more sensitive and nuanced approach to rural mental health system design.

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