Better access to mental health care and the failure of the Medicare principle of universality.

OBJECTIVES: To examine whether adult use of mental health services subsidised by Medicare varies by measures of socioeconomic and geographic disadvantage in Australia. DESIGN, SETTING AND PARTICIPANTS: A secondary analysis of national Medicare data from 1 July 2007 to 30 June 2011 for all mental health services subsidised by Better Access to Mental Health Care (Better Access) and Medicare - providers included general practitioners, psychiatrists, clinical psychologists and mental health allied health practitioners. MAIN OUTCOME MEASURES: Service use rates followed by measurement of inequity using the concentration curve and concentration index. RESULTS: Increasing remoteness was consistently associated with lower service activity; eg, per 1000 population, the annual rate of use of GP items was 79 in major cities and 25 and 8 in remote and very remote areas, respectively. Apart from GP usage, higher socioeconomic disadvantage in areas was typically associated with lower usage; eg, per 1000 population per year, clinical psychologist consultations were 68, 40 and 23 in the highest, middle and lowest advantaged quintiles, respectively; and non-Better Access psychiatry items were 117, 55 and 45 in the highest, middle and lowest advantaged quintiles, respectively. CONCLUSIONS: Our results highlight important socioeconomic and geographical disparities associated with the use of Better Access and related Medicare services. This can inform Australia's policymakers about these priority gaps and help to stimulate targeted strategies both nationally and regionally that work towards the universal and equitable delivery of mental health care for all Australians.

The future of community-centred health services in Australia: 'When too many beds are not enough'.

The authors welcome a constructive debate on the future of community-centred health services. Therefore, we have written this piece in response to an article published by Cunningham in the previous edition of the Australian Health Review (Cunningham, Australian Health Review 2012; 36: 121-124), which was a very limited analysis and misleading critique of our previous contribution to this journal (Rosen et al. Australian Health Review 2010; 34: 106-115). The focus here is necessarily brief and does not stand in for a detailed analysis of the evidence base. The aim instead, is to draw attention back to the broader political economic and social dimensions of how the retreat from community health services has affected clinical care. We also outline a response to a longstanding assumption, or belief, that too many hospital beds are not enough and may never be enough. How we understand the problem of resource allocation in healthcare shapes the remedies that are considered realistic. We explain that the reasons for the systematic underdevelopment of community health services are complex, historical, and largely relate to political and economic factors, but they are still amenable to change.

The future of community-centred health services in Australia: lessons from the mental health sector.

It is apparent that hospital-dominated health care produces limited health outcomes and is an unsustainable health care system strategy. Community-centred health care has been demonstrated to be a more cost-efficient and cost-effective alternative to hospital-centred care, particularly for prevention and care of persistent, long-term or recurrent conditions. Nevertheless, hospital-centred services continue to dominate health care services in Australia, and some state governments have presided over a retreat from, or even dismantling of, community health services. The reasons for these trends are explored. The future of community health services in Australia is uncertain, and in some states under serious threat. We consider lessons from the partial dismantling of Australian community mental health services, despite a growing body of Australian and international studies finding in their favour. Community-centred health services should be reconceptualised and resourced as the centre of gravity of local, effective and affordable health care services for Australia. A growing international expert consensus suggests that such community-centred health services should be placed in the centre of their communities, closely linked or collocated where possible with primary health care, and functionally integrated with their respective hospital-based services

Australia needs a mental health commission.

OBJECTIVES: The present paper aims to: (i) describe how the Mental Health Commission in New Zealand works and has contributed to the substantial enhancement of mental health resources and services; (ii) determine whether mental health reform policies will ever be implemented properly without an independent monitor with official influence at the highest levels of government; and (iii) demonstrate how variants on this model work in other Western countries and how it can be adapted to the Federated system in Australia. CONCLUSIONS: It is recommended that the Australian National Mental Health Plan 2003-2008 should be complemented by a long-standing national mental health commission (or similarly constituted body), which is also able to report independently from and to the government, with direct access to the Prime Minister, Premiers and Australian Health Ministers. Its aims would be to monitor service effectiveness and identify gaps in service provision, training and performance of the work force, management and government. It would be informed by consumer, carer and provider experience, and by reviews of evidence-based research regarding health needs and cost-effective services. It should accurately cost such service gaps, and advise government on a strategy for implementing them. It could also promote and advise formally on enhancing community awareness, decreasing stigma and discrimination and improving workforce recruitment and retention.