Submission to Senate Select Committee on Health Inquiry into Health Policy, Administration and Expenditure

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Submission to

Senate Select Committee on

Health Inquiry into Health Policy,

Administration and Expenditure

Suite 5 Mayfair Plaza 236 Sandy Bay Road Sandy Bay TAS 7005

Phone: (03) 6224 9222

Fax: (03) 6224 8497

Email: ceo@mhct.org

Contact: Darren Carr

Chief Executive Officer Prepared by: Elida Meadows

Policy and Research Officer

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Introduction

The Mental Health Council of Tasmania (MHCT) is the peak body representing the interests of consumer, carer and community mental health sector organisations, providing a public voice for people affected by mental illness and the organisations in the community sector that work with them. We advocate for effective public policy on mental health for the benefit of the Tasmanian community as a whole and have a strong commitment to participating in processes that contribute to the effective provision of mental health services in Tasmania.

The MHCT welcomes the opportunity to provide input into the Senate Select Committee on Health’s Inquiry into Health Policy, Administration and Expenditure.

To begin with the MHCT would like to stress the issue of the vulnerability of people living with mental illness and their carers in terms of being adversely affected by additional medical costs, reduction in benefits and added insecurity in their access to health care. People living with mental illness and their carers are often faced with significant barriers to secure and healthy lifestyles, which include living in poverty and disadvantage,

unemployment, family dysfunction and stresses, other health issues and comorbidity, and little opportunity for appropriate and secure accommodation. As a result of their illness, people living with mental illness often lack life skills, including social and occupational skills. All of these issues can exacerbate the symptoms of their illness and contribute to social isolation.

As described in the recent MHCT study, Stuck in Myself: Isolation and Mental Health Consumers, “paranoia, agoraphobia, and extreme social anxiety are among the many symptoms experienced by people with mental illness. This results in difficulty, often fear, of interacting with a group of strangers. We heard about the difficulty of getting access to information and appropriate referrals to rehabilitation and community social support services. We also heard about financial constraints and difficulties with accessing transport. Almost all the consumers and carers interviewed spoke about the stigma and shame

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associated with mental illness and how this can prevent people from accessing clinical and community supports and participating in society.”1 On average people in rural and remote areas have lower incomes, lower levels of education and lower health literacy. They are also more likely to smoke, consume harmful levels of alcohol and exercise less and are exposed to a broad range of physical risks related to occupation. As well, people with severe mental illness often do not acknowledge that they are ill and in need of treatment. For these and other reasons, the issues of access to appropriate care and treatment for people living with mental illness are more critical than for the general population.

With these issues in mind, the focus of the MHCT’s submission is on:

• The importance of maintaining universal health care and the sustainability of

Medicare;

• the impact of additional costs on access to affordable healthcare; and

• the impact of reduced Commonwealth funding for health promotion, prevention and

early intervention.

1. The importance of maintaining universal health care and the sustainability of

Medicare

ACOSS and other leading community and health consumer groups have described the Federal Government’s plan for mandatory medical co-payments as representing “a first step towards the breakdown of universal access under Medicare.”2

Australia’s health system was designed to be universal, based on the idea that everyone has the right to quality health care. The Commonwealth Government’s apparent intention to go down the path of a US-style managed care health system is particularly alarming for those

1

Stuck in Myself: Isolation and Mental Health Consumers (2014), Hobart, Mental Health Council of Tasmania, p. 47.

2 ACOSS, AMA co-payment plan knifes Medicare principle of access for all

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people on low wages or benefits or who are living with disadvantage. Medicare was

designed so that all Australians could access medical services as required without having to find the money to make a co-payment in order to access healthcare. For people living with severe mental illness, who are often unemployed and living on extremely constrained budgets, being bulk billed when they visit a GP makes healthcare accessible.

MHCT agrees, along with ACOSS and other organisations, that the government recommits to the principle of universalism within the health system and to Medicare as a mechanism to provide accessible, affordable and appropriate healthcare to all Australians, especially those who are living in very constrained circumstances.

2. The impact of additional costs on access to affordable healthcare

There is widespread evidence from both Australian and international research that co-payments for health care adversely impact upon population groups already experiencing difficulties accessing care. These groups include the elderly, people on low incomes and those with chronic illnesses, including people living with mental illness.

People with mental illness often have to buy a number of medications for their mental and physical health conditions. In a recent consultation with mental health consumers and carers, the MHCT was told that, even with the current Pharmaceutical Benefits Scheme, some mental health consumers found it difficult to pay for all of their medications. This is a particularly significant problem for consumers who have complex healthcare needs and are also on a low income.

The high cost of medications as a barrier to healthcare for people with mental illness was also identified as an issue in a 2009 survey by SANE Australia. The survey found that one in six (17%) of the 371 mental health consumers surveyed were spending at least $100 a month on medications, and almost a third (32%) of the respondents had not registered with the Medicare Safety Net. It also found that over half (54%) of the respondents had not been

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able to afford treatments recommended by their doctor, and 42% had not filled scripts for medication they had been prescribed because of the expense.3

In a recent study, general practice researchers Clare Bayram, Christopher Harrison, Graeme Miller and Helena Britt from the Family Medicine Research Centre at the Sydney School of Public Health found that in 2012-13, 5.8% of people delayed or did not see a GP because of cost, and this was a greater barrier for those from disadvantaged areas.

The authors claim that, “It is likely that the increased costs due to these policies would deter more people from seeking early treatment or from taking necessary medications. This is a concern when areas in Australia already have 13% of their population delaying or not seeing a GP due to cost, and 15% doing the same for prescriptions”, and they go on to demonstrate that “Overseas studies have shown that there is little evidence of health care cost reduction from introducing co-payments. The evidence suggests that long term health costs will be higher due to patients deferring necessary care, resulting in increased hospitalisation and progression of disease.”4

While the research on co-payments in the Australian context is not extensive, there is evidence that existing co-payments are creating barriers to access among some groups of consumers, in particular those with chronic conditions. The Commonwealth Fund’s 2013 International Health Systems survey5 and its 2008 Survey of Sicker Adults6 found significant evidence that co-payments were creating an access barrier for many consumers. Among the survey’s findings were:

• 16% of Australians surveyed reported delaying access to treatment due to cost

issues;

3

SANE Australia (2009), - Money and mental illness, Research Bulletin 9,

http://www.sane.org/images/stories/information/research/0907_info_rb9money.pdf

4

Michelle Grattan (2014), Co-payment will hit harder than expected, Sydney University study finds, The Conversation, http://theconversation.com/co-payment-will-hit-harder-than-expected-sydney-university-study-finds-28871

5

David Squires (2013), Multinational Comparisons of Health Systems Data, 2013 Commonwealth Fund.

6

Cathy Schoen and Robin Osborn (2008), The Commonwealth Fund 2008 International Health Policy Survey in Eight Countries, The Commonwealth Fund.

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• 20% of Australians with a chronic condition reported not filling a prescription in the

past year due to cost issues

• 21% of Australians with a chronic condition reported delaying or avoiding seeking

medical treatment due to cost issues

• 25% of Australians with a chronic condition reported not having a recommended test

or follow-up treatment due to cost issues

• Overall 36% of Australians with a chronic condition reported experiencing a cost

barrier to care in the past year

The report Empty Pockets: Why co-payments are not the solution states that, “Australian-based research and consumer feedback also indicates that consumer co-payments also impact differently on people according to their geographic location and their specific type of illness or disability.” The authors note that, “People living in rural areas typically incur higher co-payments for health services than do people in urban areas for the same services. This is due to a number of factors, including the higher cost of delivering care in the bush and lower levels of competition in rural areas which often have medical and health workforce shortages”7 referring to the 2013 paper by Walker and Tamiz.8

3. The impact of reduced Commonwealth funding for health promotion, prevention

and early intervention

Early intervention prevention and promotion programs, far from being costly and unnecessary, deliver long-term health and financial benefits to society and government. Health care agencies commonly refer to the economic benefits of prevention in terms of reduced hospital admissions and other forms of treatment at the level of the individual. However, as noted by the World Health Organisation, “indirect costs of mental disorders such as work disability or family burden may far outweigh the direct costs of care and treatment. For example, an educational programme to prevent depression and suicide introduced on the island of Gotland in Sweden resulted in a significant reduction in the suicide rate and produced considerable economic savings to society (a cost-benefit ratio of

7

Jennifer Doggett (2014), Empty Pockets: Why Co-payments are not the solution, Manuka ACT Consumers Health Forum of Australia, p. 20.

8

Christine Walker and Jo-Anne Tamy (2013), The Cost of Chronic Illnesses for Rural and Regional Victorians, Chronic Illness Alliance, at Melbourne public hearing 3 July 2014.

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1:30 in direct costs of care, but 1:350 in terms of productivity gains and mortality reductions).”9

The MHCT urges the Australian Government to increase funding to health promotion, prevention; given the evidence that Health promotion and disease prevention, including action on the social determinants of health, are actually proven to cut health care costs in the long term. We believe that reduced Commonwealth funding for health promotion, prevention and early intervention will have a profound impact on people with mental illness and their carers. It will impact on:

• The capacity of individuals, families and communities to understand health risks; • knowledge of the signs that should lead people to seek help from doctors and other

health professionals in a timely fashion; and

• decrease the capacity for people to make informed decisions about their health.

This potentially leads to poorer health outcomes, increased risk of adverse health incidents and higher system costs in the longer term.

The evidence now exists that, when properly implemented, interventions and approaches aimed at mental health promotion and prevention are effective and lead to a range of positive health, social and economic outcomes.1011 Importantly, mental health promotion is a cross-sectorial and multifaceted process involving not only public education and broad determinants of health for the general population but many other aspects and strategies including:

1. Creating Supportive Environments

• Creating better housing options and conditions provide structured, goal focused and

individually tailored services at a level of intensity and duration appropriate to consumers’ needs

9

Prevention and Promotion in Mental Health (2001), WHO, Geneva, Switzerland) p. 23. 10

Promoting mental health: concepts, emerging evidence, practice: a summary report. Geneva, World Health Organization, 2004 (http://www.who.int/mental_health/evidence/en/promoting_mhh.pdf).

11 Prevention of mental disorders: effective interventions and policy options: a summary report. Geneva, World Health Organization, 2004

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• Funding services that assist the consumer engagement in meaningful daytime

activity and employment

• Reducing stigma through a variety of approaches, e.g. Changing Minds(CMHA

Newfoundland Division, current) instructional models based on real people’s experiences, for community education about mental health and mental illness

• Supporting students with mental illness in higher education.

2. Building Individual Skills

• Mental health clubs to enhance resilience and promote social competence • Adult literacy programs to promote confidence and inclusion

3. Developing Healthy Public Policy

• Workplace policies that support employee participation in organisation and design of

their work

• Policies for direct provision of funding to consumer controlled organisations • Raising public awareness of mental health and mental illness and promote positive

mental health and emotional well-being

4. Reorienting mental health services

• Providing integrated programs across life stages and settings, including early years,

children and young people, later life, employment and working life, community mental health and well-being, and public services

• Intervening early in psychosis with an expectation of recovery, e.g. EPPIC • Taking a consumer-centred, strengths-based approach Recovery model

• Promoting service models that support independent living, enhance participation in

community life, and link to natural supports such as religious institutions and interest groups

• Supporting programs that address the social determinants of health

5. Strengthening Community Action

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• Building collaborations between school and community

• Funding services which are delivered in community settings intended to promote

community engagement and social connectedness

The MHCT notes that there are a number of programs that have been trialled and evaluated both here and overseas and these represent good models for system reform but, more often than not, the opportunities for positive change that they represent are not pursued. A good example of this is the South Australian Individual Psychosocial Rehabilitation and Support Service (IPRSS) program which was independently evaluated in 2011. This evaluation demonstrated that IPRSS is effective in supporting individuals to build a better life in the community and reduce the need for unplanned admissions to bed-based services. The evaluation showed reduced incidence of hospitalisation for mental health reasons by 40% and reduced average length of stay by 16%. For every 54 people supported during the period of the study, there was a reduced demand for hospital services by the equivalent of one hospital bed per year.

“Open Dialogue” is an innovative approach to acute psychiatric crises developed by Jaakko Seikkula, Markku Sutela, and their multidisciplinary team at Keropudas Hospital in Tornio, Finland. Starting in the 1980’s, there have been a variety of research studies of Open Dialogue and its outcomes with early psychosis. Garnering widespread international attention, the results consistently show that this approach reduces hospitalisation, the use of medication, and recidivism when compared with treatment as usual. For example, in a five-year study, 83% of patients had returned to their jobs or studies or were looking for a job (Seikkula et al. 2006), In the same study, 77% did not have any residual symptoms. Such outcomes led the Finnish National Research and Development Centre for Welfare and Health to award a prize recognizing the Keropudas group for “the ongoing development of psychiatric care over a period of ten years.”12

The Like Minds, Like Mine campaign in New Zealand is a particularly good example of a targeted Anti-Stigma campaign that has managed to demonstrate proven results in reducing stigma and improving public perception of those with mental health issues. The New

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Zealand campaign also evaluated the effect of the de-stigmatisation project through a cost benefit analysis. Independent economic analysis showed that the Like Minds Like Mine campaign saved the New Zealand Government $13.80 for every $1 it cost to run the campaign.13 This benefit is further increased when taking into account the value the community and individuals living with mental illness and their families of increased employment opportunities for people experiencing mental health issues.13

Conclusion

The MHCT agrees that there are inefficiencies and waste in the current health system. However, we do not believe that this should be addressed by imposing extra costs on vulnerable consumers, or dismantling a universal health system that guarantees healthcare to all people regardless of income.

As demonstrated in this submission, there is already evidence that some people do not access GPs or fill prescriptions for necessary medications due to costs. The MHCT has major concerns that this policy will introduce a further access barrier to groups in the community that need support the most, including people living with mental illness and their carers. Looking at this scenario against the background of other financial pressures on the most disadvantaged, it is not hard to see that high costs of housing, decreasing income support payments (either directly or due to lack of indexation), the increasing cost of education transport costs and the increases in cost of living are issues which will only be compounded by a rise in healthcare costs, however “small” these may seem..

The government is linking the co-payment to medical research, but there are more equitable ways of securing this funding and to address the sustainability of the health budget. Along with many other commentators, the MHCT proposes that the government looks to raising revenue, which is falling in large part due to very recent tax cuts, to balance the budget. We are among the lowest taxed countries in the world and the government could reverse some of the income tax cuts of the last 15 years, as well as increase taxation on large multinationals and domestic companies making super-profits. The Government

13

Phoenix Research, Ministry for Health (2010) Cost Benefit Analysis of the New Zealand National Mental Health De-stigmatisation Programme, ‘Like Minds Programme’.

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could also remove a range of very generous payments in the form of tax breaks primarily benefiting the wealthiest Australians (including superannuation, capital gains, and negative gearing related tax expenditures).

People living with a mental illness are much more likely than the general population to be on a low income, with poorer physical health, and poorer access to education and paid employment. For this group, any increases in costs to accessing healthcare could mean that they do not seek treatments from GPs, and forgo much needed prescription medication, when they are experiencing critical warning signs of deterioration in their physical or mental health. This group of Australians, along with others suffering disadvantage, should not be expected to bear the burden of what the government describes as an unstainable health system, particularly when considering there are many fair and viable options for raising revenue.

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