The public-private divide in Australia’s health system disappeared early in the Coronavirus pandemic when all states signed contracts with private hospitals to ensure private beds were available to meet the anticipated tsunami of hospital demand. The same ‘can do’ approach is now urgently required to respond to the second COVID-19 curve, namely the predicted increase in mental ill-health, self-harm, and suicide.
Shamefully, Australia has no nationally co-ordinated system to meet the everyday mental health needs of many Australians. Most of our capability is stuck in 20th Century-style hospital and specialist clinic settings, with little use of 21st Century information systems to care for people in their home.
Mental health services are especially inadequate for the poor, and for people in outer suburbs and regional and rural areas. Many Australians with complex problems cannot get the co-ordinated, team-based care that would give them their best hope of a better life.
The Morrison Government is working on a 2030 vision statement, developing new partnership agreements with the states and territories, and waiting for a Productivity Commission report. But COVID-19 has made the problems even bigger and more urgent. The Government’s orderly but cumbersome approach is no longer fit for service.
The COVID19 crisis has already led to major changes in mental health care. The most obvious has been the rapid move to Medicare-base ‘telehealth’, largely replacing traditional face-to-face consultations. Day programs in private hospitals have ceased or been replaced by ‘tele’ equivalents. Demand has skyrocketed for free (that is, government-funded) online services such as professionally-supervised cognitive-behavioural therapy.
Befitting the crisis, we now have a new Deputy Chief Medical Officer responsible for mental health, Dr Ruth Vine. But time is running out. As the economic consequences of the lockdown mount, the stresses which have been bottled up will come out. Today’s mental health services are just not ready for this surge in demand.
Two big changes could help flatten the mental health curve. One is greater use of digitally-capable information systems to direct people in need to the ‘right care, first time’. These should be deployed across Australia by the Primary Health Networks. The information can be shared with state services and non-government organisations to ensure people who most need care are getting it.
Primary Health Networks will need more funding and guidance, to ensure they buy the highest-quality programs that will have the most impact in their specific region. While the Government will need to provide more funding, particularly to those in rural, regional and more disadvantaged areas, it will also need to be clear that tender specifications for new or expanded services meet national standards and that funded organisations are held accountable for agreed outcomes. Primary Health Networks will need to work closely with local state services and other NGOs because, sadly, dislocated and chaotic care is the norm right now.
The second change needed is mobilisation of private hospitals and clinics, and their skilled workforces, to support the overloaded public hospitals, Emergency Departments, and community-care teams. Health Minister Greg Hunt has taken the radical step of ensuring private hospitals are paid to help Australians get the emergency care. This now needs to be extended to ensuring they are paid to help meet Australia’s emerging mental health needs.
In mental health, this should have been everyday practice years ago. Instead, we still turn away even suicidal people from our public hospitals.
The private system currently costs private health insurance about $700 million per year. That financial, workforce, and infrastructure resource should be immediately redeployed to provide urgent care to very unwell Australians. Private hospital inpatient care needs to be available to all Australians, and it should promote ‘hospital in the home’ and ‘virtual hospital’ alternatives to in-hospital care. Similarly, the public systems need more help to deploy these innovations in care. At present, ‘community-based care’ often really means almost no care – and so unwell people head straight back to the hospital!
Previous prime ministers, notably John Howard, Julia Gillard and Malcolm Turnbull, have talked mental health reform, but none succeeded in fundamentally changing Australia’s chaotic mental health system. In response to COVID-19, the Scott Morrison-led National Cabinet has a unique opportunity to save lives and secure the long-term mental ‘wealth’ of our nation. If not now, when?
Ian Hickie is Professor of Psychiatry at the University of Sydney