The productivity commission report on mental health: Recommendations with negative consequences for clinical care in public and private sectors

In 2018, the Australian Government commissioned the Productivity Commission (hereinafter the Commission) to examine the effect of mental health on economic participation and productivity. The draft mental health report (hereinafter the Report) was released for comment in November 2019, with the final report released in November 2020.

The Report makes recommendations predicated on a model of person-centred care across a wide range of areas including prevention, public and private mental health care, services beyond health and mentally healthy workplaces (Table 1). However, many areas of concern in the Draft Report that we previously highlighted have been retained in the final version, such as the emphasis on youth interventions and neglect of the elderly, as well as discredited market-based funding reforms ^{(Kisely and Looi, 2020)}. We focus here on the negative consequences for clinical care in public and private sectors.

Table 1.

Summary of productivity commission report on mental health recommendations.

Priority	Commonwealth	States and territories
Prevention	1. Mental Health Commission to develop a stigma reduction strategy for complex mental illness 2. Suicide prevention in Indigenous communities	1. Include student well-being as an outcome in National School Reform Agreement 2. Universal screening for pre-natal mental illness 3. Aftercare following deliberate self-harm
Better experiences of mental health care	1. Develop a digital mental health platform An assessment, referral and gateway tool Low intensity on-line therapy 2. Evaluate better access programme 3. Improve access to treatment by videoconference and phone 4. Psychotropic prescriptions to include statement that alternatives and side-effects have been discussed	1. Improved community ambulatory services 2. Alternatives to emergency department care 3. Reduce life expectancy gap in severe mental illness 4. Consider family and carer needs
Services beyond health	1. National Mental Health Strategy to integrate services in health and non-health sectors including care co-ordination 2. Psychosocial placement and support outside the National Disability Insurance Scheme (NDIS) 3. Address homelessness 4. Assist police in responding to mental health crises (state-level)
Mentally heathy workplaces	1. Mental health and safety to be as important as physical health 2. No liability early psychological treatment for mental health-related workers compensation claims 3. Employers’ codes of practice for psychological health & flexible insurance for good practice 4. Minimum standards for Employee Assistance Programme providers
Accountability	1. A new National Mental Health and Suicide Prevention agreement between Commonwealth and states including clarification of roles Shared funding to fill gaps in inpatient (non-acute), ambulatory, community and psychosocial care/ supports Regional commissioning of services with funding tied to needs & reduced incentives for cost shifting via Medicare Benefits Schedule (MBS) 2. Review scope for private insurance to fund the community-based care

Re-orienting healthcare

Given the number of proposals, we highlight those of major concern that will adversely affect clinical care. Action 10.1 – Increasing referral choice – this proposes the listing of the fees, speciality areas and waiting times for all individual psychiatrists, paediatricians and allied health providers of Medicare Benefits Schedule (MBS)-rebated therapy on the Medical Costs Finder Website. This is not a new idea and the Australian Government recently proposed a website allowing people to search fees of all specialists. In practice, it is difficult to quantify, and keep current, wait-times and fee scales, which differ among settings (office, hospital, aged care facility, etc.) and thousands of practitioners. Moreover, an average wait-time may not reflect the time to be seen for urgent referrals. Furthermore, the cost to the patient is not just determined by the doctor’s fee but also the Medicare rebate for outpatients, and any contribution by a private health fund for inpatient hospital treatment. Transparency must therefore extend to both the size of the Medicare rebate and the private health insurance contribution to treatment cost.

Action 10.2 – Mental health related prescribing – The Report recommends that ‘the Australian Government should require all mental health prescriptions to include a statement that clinicians should have discussed possible side effects and propose evidence-based alternatives to medication’ (our emphasis in italics) (Table 1). While the Commission may have sought to address community concerns about over-prescribing, we consider that this is of unclear utility and adds to the administrative burden of clinical practice. Medical practitioners already consider alternatives as well as adjuncts to medication with patients, and discuss the benefits and side effects of medication. Concerns about prescribing and adverse effects are better addressed by medical education and continuing professional development, rather than a tick-box.

Action 10.3 – Psychiatric advice for GPs and paediatricians – an MBS Item for GPs for discussion of patients with a psychiatrist who are not receiving care from a psychiatrist. This seems welcome, but it is unclear why there is a prohibition on a previous or subsequent face-to- face consultation with a psychiatrist.

Action 10.4 – Mental Health Assessment and Referral Tool – Under Australia’s ‘Better Access’ programme financed through Medicare, a general practitioner (GP) must complete a Mental Health Treatment Plan (MHTP) prior to referral to allied health (psychologist, social worker, occupational therapist) for psychological therapy. This proposal replaces MHTPs with a yet to be developed and therefore unevaluated assessment tool (Table 1). It also seems contrary to the Report’s acknowledgement of the critical roles played by GPs in Australia’s mental health system. This recommendation would remove one the few Medicare items that enable GPs to provide longer, more intensive appointments for patients with mental health concerns that has had increased uptake to provide more care, especially for depression and anxiety, and to a lesser degree for lower prevalence disorders such as schizophrenia ^{(Banfield et al., 2019)}.

Action 12.2 – Psychological therapy and psychiatry by telehealth – this is a welcome proposal to continue MBS telehealth items for psychological therapy and psychiatric services that were introduced during the COVID-19 pandemic. However, why are these limited to 12 MBS-rebated sessions per year for psychiatrists, when caps are higher for allied health professionals? This cap is based on data for limited, rural-regional psychiatrist MBS-telehealth-items from 2019, an invalid baseline comparator for geographically unrestricted COVID-19-telehealth-psychiatrist-MBS-Items. In April-September 2020, psychiatrists provided expanded care using the new telehealth items, with up to a 14% increase in overall services compared to 2019 ^{(Looi et al., 2021)}. Furthermore, patients may prefer telehealth consultations for privacy, convenience and the opportunity costs in travelling to appointments ^{(Guinart et al., 2020)}.

Action 13.3 – Delivering bed-based mental health services – this recommends addressing current shortfalls in sub-acute and non-acute mental health bed-based services. However, no mention is made of the more pressing concern of similar shortfalls in acute beds. In fact, community-based and residential services cannot replace acute and non-acute bed-based services, these services are complementary, and accordingly, require commensurate funding for acute and non-acute beds as well ^{(Allison et al., 2020)}.

Market-based commissioning

The Report advocates unproven market-based commissioning and regulatory service models as enablers of reform (The ‘Rebuild’ option) (Table 1). We discussed the dangers of these in detail in our response to the draft Report and unfortunately, most are retained in the final version ^{(Kisely and Looi, 2020)}. These call for the pooling of Commonwealth and State/Territory funds at a regional level, leading to eventual Regional Commissioning Agencies. Similar purchaser-provider arrangements have been abandoned in other jurisdictions because of the increased transactional costs, and lack of commissioner expertise in both planning services and evidence-based practice ^{(Kisely and Looi, 2020)}. In particular, smaller specialties such as consultation-liaison psychiatry fare poorly because of uncertainty as to whether they should be funded by the general hospital or mental health services. This also complicates the funding of tertiary services that may cover several regions. In addition, funding mechanisms that are unique to mental health and separate from the rest of health further isolates psychiatry from medicine as a whole.

If anything, the Commission’s endorsement of this Rebuild model has been strengthened at the expense of a less radical alternative in the Draft Report for regional collaboration between state-based health services and Primary Health Networks (the ‘Renovate’ model). Instead of being an alternative, ‘Renovate’ is now a step towards ‘Rebuild’.

However, these proposals do not just affect public mental health services. While the draft Report proposed that only allied mental health MBS-rebated services be included in these pooled funds, the final version suggests extension to psychiatry MBS-rebated services to enable greater influence over their use – which could constitute an unprecedented change in Australian private mental healthcare.

Conclusion

The Report continues the failed policy directions that have led to Australia’s dysfunctional mental health system, and introduces new, unnecessary complexities. The Report’s strength is an economically based understanding of the social determinants of mental health, focusing on person-centred care, as well as the provision of social and economic supports. However, economic solutions alone are insufficient to address the complexity of Australia’s mental health needs, and reforms should be based on evidence, not theory, especially for clinical practice. Better co-ordination of care may be possible through the ‘Renovate’ model with careful evaluation of the effects, before more radical changes are contemplated.