Now more than ever, we must bring together both ends of the mental health system so that all Australians benefit, particularly those who are vulnerable and most at-risk. From prevention and early intervention, to supporting people with more complex mental health conditions, we need to put the mental health and welfare of Australians first, and re-direct energy to collective action.
Poor mental health is distressing, with negative consequences for individuals who are unwell, for their families, for peers who may be at school or in the workplace, employees and wider society. I applaud psychiatrists Jeffrey Looi, Stephen Allison, and Steve Kisely for their efforts and advocacy to hold governments accountable to the corrosive effects of insufficient supply of resourcing, infrastructure, and workforce[1]. We need affirmative action for a very neglected area of public health. To be effective we need to be working together as a coalition for mental health system reform, where prevention is valued as much as high-acuity mental ill-health, including when people are in crisis. To do that we need to look at the whole mental health continuum of care, to catch people from falling through the cracks.
Despite having a world class system with highly skilled practitioners, Australia’s mental health system is failing to provide adequate mental health response, as evidenced by the increasing number of people turning to emergency departments (EDs), often by ambulance after exhausting all other options. The Royal Australia New Zealand College of Psychiatry (RANZCP) has presented a brief to the Commonwealth health ministers, including Minister Butler, stating that inadequate resourcing, infrastructure, workforce shortages, bed closures, and stretched frontline services is contributing to a ‘crumbling mental health system’. The workforce shortages are also resulting in excessive workloads that contribute to stress and burnout, with around 80% of workers reporting feeling exhausted, with declining job satisfaction and motivation[2].
The problem is serious and can no longer be ignored. In the past 30 years our population has grown by 42%, and this is met with a decrease of mental health beds by 7.7%[3],[4]. Concerningly, not only are more people presenting to EDs with mental health issues, but the severity of their conditions is also escalating. Data indicates that a rising number of these patients are using ambulances to reach EDs. In 2020-21, half (50%) of those seeking emergency care for mental health conditions arrived by ambulance, compared to less than one-third of patients with other conditions[5]. Federally funded programs are failing to influence tertiary care and avoidable hospitalisations. Lack of data linkage and shortfalls in Medicare-reimbursed models of care, means people are increasingly relying on EDs and hospitals.
In Australia, a proportion of the population will require hospitalisation for severe mental health illnesses. We also know suicide is the leading cause of death among those aged 15 to 44, and is higher here than the OECD average[6]. We also have to do better to support our young people who are exposed to societal shifts; impacts from climate change, exposure to harmful social media content, expectations of greater education and economic insecurity[7]. These are contributing to a rise in anxiety, eating disorders, unhelpful perfectionism, loneliness, and social isolation[8]. The wave of distress has led to a doubling of calls to Kids Helpline for suicide-related contacts in the last five years[9], blow out of wait lists, and flowing of young people experiencing suicidal ideation, and suicidal self-harm behaviour into emergency departments around the country6. The evidence base demonstrating the causal relationship between these trends is growing and must be prioritised with education and interventions co-designed with young people.
Chronic under-funding of Medicare and GP workforce shortages, have contributed to access and affordability issues which have flow on impacts for everyday Australians. The RACGP’s 2023 Health of the Nation Report revealed that 72% of GPs reported psychological factors as the main reason for patient visits in general practice, with the load especially being taken by women[10].  The 2020 Productivity Commission’s report into Mental Health Service system identified the need for investment in downstream support[11]. Investment in prevention education, primary care, and high-quality community care to support people at-risk of onset of mental ill-health, together with supporting people with more complex mental illness through a recovery model. Getting the balance of service provision across the system right has been futile. Essentially, we have completely failed to build the community-based system and supports to absorb unmet need as the population has grown and hospital beds have reduced. While soft entry points for early intervention into the system is effective for some, the back-up system for the people with more substantial needs, characterised as the ‘missing middle’, together with those with more serious complex issues is insufficient [12].
Australian people need a better long-term solution. Systematic failures in disjointed, siloed funding has led to public discourse – where the very people working in the profession who are doing their best for their patient populations, are battling against each other for scarce dollars. We need our mental health sector to come together from all ends of the continuum. This must include people and carers with lived experience, GPs, psychiatrists, mental health professionals, and specialist education services with a track record in safety and quality. We also need policy makers around the table, along with Primary Health Networks (PHNs) who have the levers to commission wrap-around services needed to match people’s mental health needs, when and where it is needed most.
Australia is an innovative country, and we are moving in the right direction in opening up mental health literacy and priorities for prevention. Digital mental health services are playing a key role – providing the safety and quality checks and balances are in place. The space is crowded, making it tricky for consumers, and organisations supporting mental health and wellbeing, to navigate which providers have best-practice quality measures in place. The Australian Commission on Safety and Quality in Healthcare have rolled out The National Safety and Quality Digital Mental Health (NSQDMH) Standards, which aim to uplift service delivery and protect users from harm by ensuring the standards of safety and quality are met[13]. They set world-leading standards in digital mental health, addressing the increasing need for high-quality digital mental health support post-COVID, and rise of new digital services and technologies in recent years. Mostly they help to foster trust and raise the bar for ensuring person-centred, safe, and effective care on digital platforms. Accredited providers go through a thorough assessment process and are reviewed by an independent agency that are trained to identify quality and safety issues. This is important when considering the debate that funding should be limited to digital mental health services and supports, as we now have the safety and quality benchmarks in place.
Ultimately, we need to address the root cause of why our system is failing, and work together as a collective. It is now time to prioritise mental health resourcing across the full continuum of care. The 2024 Public Hospital Report card reveals that our mental health system, especially hospitals, are at breaking point4. Health ministers must commit to real reform, aligning the health system with an injection in resourcing for public hospitals, together with more investment in primary and intermediate care to ease the strain on hospitals and enhance Australians’ mental wellbeing. We must also continue to invest in prevention-focused approaches that translate evidence into practical resources, programs and approaches that are fit for purpose across different sectors and communities. The growing burden of mental ill-health means we cannot continue on the same path of siloed mis-aligned policy and programs and expect a different outcome. Coordinated and collection action is needed now.
Dr Kylie Armstrong
[1] Looi, J., Allison, S., Kisely, S. (2024) The corrosion of adult mental healthcare in Australia: Can we meet the needs of those who need it most? Journal of Australasian Psychiatry. First published online June 6, 2024 https://doi.org/10.1177/10398562241259675
[2] RANZCP (2024)Â Burnout and moral injury: Australian psychiatry at its limits. Melbourne, VIC, Australia.
[3] AIHW (2024) Profile of Australia’s population. Available here.
[4] Australian Medical Association (2024) Public Hospital Report Card. Available here
[5] Australian Medical Association (2023) Public Hospital Report Card, Mental Health Edition. Available here
[6] AIHW (2024) Suicide and self-harm monitoring, deaths by suicide in Australia.
[7] Orygen (2024) Responding to the social and economic drivers of youth mental health, Policy Lab. Available here
[8] ABS (2022) National Mental Health and Wellbeing Survey 2020-2022
[9] Kids Helpline (2023) Kids Helpline Impact Report 2023. Available here
[10] RACGP (2023) General Practice Health of the Nation 2023. Available here
[11] Productivity Commission (2020). Report into Mental Health Services. Available here
[12] PcGorry, P. (2022) The reality of mental health care for young people, and the urgent need for solutions. Med J Aust (2): 78-79
[13] Australian Commission on Safety and Quality in Health Care (2024) National Safety and Quality Digital Mental Health (NSQDMH) Standards. Available here
