Here’s a prediction: in 12 months the neediest people will still be sleeping on the streets and in hospital corridors, because opening shiny centres is easier than funding the everyday chaos of an ED.
What’s in a name?
In the 1993 movie production Philadelphia, there is a scene with the dialogue:
“All right, explain this to me like I’m a four-year-old, okay, because there’s an element to this thing I just cannot get through my thick head.”
The same discourse enters my head when I see media headlines announcing government spending on new mental health services, named Medicare Mental Health Centres (MMHCs).
Mental health, in my view, refers to a person’s emotional, psychological and social wellbeing. Moreover, there’s a sweet spot that is triangulated between healthy diet, sleep and exercise; that, and meaningful social contact.
So, what’s in a name?
The newly titled MMHC provides a puzzle.
First, I would suggest a more appropriate name for these centres would be Mental Illness Centres, as they have nothing to do with Medicare.
Are they established to provide services for those with mental health issues or rather, the “walking well”?
Second, why is there no reference to psychiatry or psychiatric conditions in the name?
In earlier times, every public hospital had a psychiatric unit. Then it was decided to rebrand them as Mental Health Units. Was this due to an image problem or something deeper?
Either way, the name change appears to have coincided with scope-creep in diagnostic characterisations of mental illness. This has resulted in a medicalised mode of care delivery.
People nowadays seem to prefer pills to lifestyle change. Our modern society prefers a label, as a means of leveraging additional supports such as a disability pension and/or the NDIS.
Neurodivergence is a fashionable term, though presenting as normal may be just the median of eccentricity. Others might say it’s a measure of mediocrity. How unattractive.
The federal government has committed $225 million to set up an additional 31 new or upgraded MMHCs to “take pressure off” the Better Access initiative.
The question is – will this prove to be a good return on investment? This depends on access to services by the recipient, and the cost per consultation.
Let me share my view on mental health services in general, by using a fictitious scenario.
As a worker, If I suffer burnout, or, in other words, I suffer from a work-related moral injury, my employer will offer me support via their Employee Assistance Scheme (EAS). This involves my connection to a subcontracted psychology service.
Contemporary literature on the subject tells us 80% of burnout is related to poor working conditions. So why am I being “shamed” in this way by the organisation’s failure to create better working conditions?
For billing purposes, the EAS will need to ascribe an International Classification of Diseases (ICD) code. These are categorical, classifying mental phenomena based on self-reported or clinically observable symptoms.
As a client, I dare say I would attract a diagnosis of anxiety and/or depression. But is it a real diagnosis? To me it’s a label that states I’m experiencing self-reported or clinically observable symptoms compatible with an ICD code for depression.
The real culprit, ie, poor management practice, gets off scot-free.
The same can be said for the social determinants of health. If I’m anxious because I live with a coercive, abusive partner, or have housing instability, will an MMHC help me?
People experiencing homelessness are more likely to face chronic disease, mental illness and preventable conditions, yet struggle to access timely healthcare.
Poor mental and physical health can be predicted by subliminal experiences in the first 2000 days of life. It can be both a cause and a consequence of homelessness, creating a cycle that’s difficult to break.
MMHCs appear to me to be a replica of the headspace model, repurposed for adults.
The RACGP recently claimed that “the current headspace model faces significant challenges to deliver the best outcomes, and expanding its footprint will not address the limitations”.
Headspace, set to receive a further $200 million for 58 new or upgraded centres, and a further $500 million for 20 Youth Specialist Care Centres. MMHCs can be seen as the ambulance at the bottom of the cliff.
My question is – does a further spend give a better return on investment, than money spent on a fence at the top of the cliff or a safety net halfway down the cliff. What is the evidence?
I would now like to turn my attention to workforce.
When headspace opened in my regional city, I was asked to provide some in-service education to the three “clinicians”. I was introduced to three young people. They had all completed an arts degree which included a psychology subject. That was the skill-mix of the service, at that time.
Recently I checked to see what the status was. Headspace now boasts two teams, an intake and access team staffed by two psychology honours graduates, and an intervention team staffed by one registered psychologist and one social worker. The clinical lead is a social worker.
(Most would be aware that social work is not controlled by the Australian Health Practitioner Regulation Agency).
Ideally there is a position for a GP, but that role remains unoccupied. The service provides brief/moderate-term treatment for a maximum of six to 12 sessions.
If MMHCs are intended as a replication of headspace, targeting those older than 25 years of age, then there will be similar skill-mix issues.
Given the workforce shortage in the regions, I wonder whether the service will be able to deliver the required KPIs, when our local headspace struggles to meet its targets.
In theory, each MMHC is tasked to provide free on-call access to a psychologist and psychiatrist. In practice, there are no hard rules on the type of providers who work at each centre, and therein lies the problem.
There is tension between access and quality of care. MMHCs may focus on access, potentially at the expense of quality of care.
It’s possible for services that have excellent access to score poorly on measures of quality of care. The reverse can, of course, be equally true. In healthcare we do lots of tasks very inefficiently … but we learn to do them quickly.
Let’s examine the skill-mix issue more broadly. Self-help groups have proven their effectiveness. My exemplar would be 12-step programs where the skill mix is provided by unpaid lived-experience peer support work.
Many Gen-Y folk are using ChatGPT to obtain advice about their mental non-wellbeing, while many public health services (my own included) use paid lived-experience peer support workers very effectively.
Key to the federal government’s pitch is that the new services will cater to the “missing middle”; people with complex mental healthcare needs, who require an extra level of ongoing support, but not hospitalisation. This cohort includes young people with personality disorders, eating disorders and early psychosis.
The government’s strategic aim appears to be improving access to services, by freeing up private psychologists, allowing them to work to their full scope of practice, spending more time treating people with moderate and high needs.
In my region, clinical psychologists in private practice charge a hefty gap fee. This is a barrier.
I’ll make a prediction here.
Within 12 months, the MMHCs will focus on the higher end of the socio-economic spectrum, and the neediest people will still be sleeping on the streets and in the corridors of the hospital, because opening shiny centres looks so much better than funding the everyday chaos of a hospital emergency department.
My questions are:
- Is better access the driver of MMHCs or is clinical efficacy and outcomes?
- How will the workforce shortage in regional areas be addressed and will we see those with low-level skill sets end up seeing patients in MMHCs as is the case with headspace? (Although described as primary care, the average cost of a headspace consultation — $230 – was double a typical mental health consultation with a GP.)
- Will this investment further exacerbate the increased medicalisation of life?
- What is the comparative investment in primary prevention at a population/public health level?
May I repeat: “All right, explain this to me like I’m a four-year-old, OK, because there’s an element to this thing I just cannot get through my thick head.”
Associate Professor Kees Nydam was at various times an emergency physician and ED director in Wollongong, Campbeltown and Bundaberg. He continues to work as a senior specialist in addiction medicine and to teach medical students attending the University of Queensland, Rural Clinical School. He is also a poet and songwriter.