For richer, but not for poorer: How Australia’s mental health system fails those most in need

Australian pride in our universal health system is partly derived from our belief that services should be most available to those who most need them. Logically, this should apply just as much to mental health as to other parts of the health system.

But our new research finds Australia’s mental health care system is not equitable in this way.

While Australians living in the most disadvantaged areas experience the highest levels of mental distress, they appear to have the least access to mental health services.

Mental health disparities

To understand levels of mental distress across the population, we looked at data from the Australian Bureau of Statistics (ABS). The ABS has classified levels of mental distress according to the Kessler Psychological Distress Scale (K10).

Using this information, and demographic data from the census, we calculated 29% of working-age Australian adults in the lowest-income households experience elevated mental distress. This is compared to about 11% in the highest income households.

About 6% of working-age adults experience “very high” mental distress, indicating serious distress and very likely a mental disorder. Our analysis showed about 14% in the lowest-income households reach this threshold, compared to only 2% in the highest-income households.

This clear link between mental distress and socioeconomic disadvantage exists both in Australia and globally.

Mapping inequity

We first examined federally-funded Medicare mental health services, largely provided under the Better Access initiative, to establish how equitably – or not – these are distributed. These services are delivered by GPs, psychiatrists, psychologists and allied healthcare professionals (social workers and occupational therapists).

Better Access showed some strong initial results in lifting overall access to mental health services in 2006-10. However, more recent data suggest this has plateaued.

We calculated the total number of Medicare-subsidised services provided in a year, and divided this by the number of people with the most need for those services.

We defined this group in our study as those with “very high” mental distress according to the K10 scale. This gave us an average number of services available per person. For our calculations we assumed all services were accessed by those in most need of care.

In 2019, if all people with the most need had equal access to mental healthcare, on average, each person would receive 12 services. The map below highlights regions where the average is higher (darker shades) or lower (lighter shades). It shows significant inequity and service gaps.

Traditionally, comparing mental health service use between areas has been challenging due to differing levels of need for care. So as part of our research, we created something called an equity indicator.

The equity indicator allows us to compare apples with apples, focusing on a key group – those most in need of mental health services. Essentially, we can take an area with wealthy residents and another area with a poorer population and compare them to see how those most in need are accessing services.

We found the equity indicator was six for Medicare-subsidised mental health care in 2019. This means, among those in most need of care, people living in the poorest areas received six times fewer Medicare-subsidised mental health services compared with those living in the richest areas.

Looking back to 2015, the indicator was five. So inequity has increased with time.

Community mental health services

We then looked at public community mental health services. These are mostly public hospital outpatient services, and some other community services not funded by Medicare. We wanted to understand whether poorer Australians are accessing these services, evening out Medicare’s apparent inequity.

When we included these services into our calculations, the equity indicator did drop from six to three. In other words, people with the greatest need for care living in the poorest areas received three times fewer mental health services (community services and Medicare-subsidised services) compared with those in the richest areas.

In 2015, the equity indicator was 2.6, again demonstrating inequity is increasing.

How can we bridge the gap?

Rates of mental distress and demand for mental health services vary across socioeconomic areas. But our analysis paints a picture of a two-tiered mental healthcare system, where the “poor” are more reliant on public community mental health services, while everyone else uses Medicare.

People with the greatest need for mental healthcare living in the poorest areas might access fewer Medicare mental health services for a number of reasons. For example, out-of-pocket costs are increasing, which is likely to create financial barriers for many. There’s also a lack of services in a large number of rural areas, many of which are relatively disadvantaged areas.

While community mental health services appear to be partially mitigating the socioeconomic disparity in Medicare-subsidised mental health services, the two service types cannot be viewed as equal or comparable.

Medicare services are largely provided to people with less severe mental healthcare needs. Conversely, public community mental health services typically treat people facing serious or complex mental illness in times of acute distress.

Community mental health services are increasingly stretched and not a replacement for Medicare-subsidised mental healthcare in socioeconomically disadvantaged areas.

Improving access to Medicare mental health services might even help to prevent some of these more acute episodes, potentially alleviating some of the pressure on community mental health services.

A big part of the problem is these two programs were not designed to complement each other or work together. They operate separately, mostly for different clients, rather than as part of an overall “stepped care” model.

We need to properly configure these larger elements of our mental health service jigsaw into a more contiguous design, making it less likely people will fall through dangerous cracks.

This can be achieved through better and more coordinated planning between federal and state mental health services, and funding research to better-understand who actually accesses current services.

This article originally appeared on The Conversation and was co-authored with Sebastian Rosenberg, Brain and Mind Centre, University of Sydney.

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