Uncertainty about the future of reforms to hospital financing is attracting considerable media attention in the lead-up to next week’s COAG meeting. (For eg, here is Michelle Grattan in The Age and Jessica Irvine in the SMH.)

Perhaps one of the more important questions – for those who care about population health and equity, rather than simply the bottom line – is what the shifting sands of health reform will mean for the community-based health sector and primary health care.

Following on from his recent post warning of the perilous state of community-based care, psychiatrist Professor Alan Rosen warns that the powerful medico-hospital lobby is often the enemy of a fairer health system.

Alan Rosen writes:

Flood and cyclone relief and repair is threatening to swamp all outstanding government priorities. Can a timid one-off levy on taxation for flood infrastructural rebuilding forestall the dashing of all the unfulfilled hopes for reform and resourcing of community health, Aboriginal, dental and mental health? Not bloody likely.

For the time being, community health services try to stagger on, but hospitals in charge of expenditure continue to siphon their meagre resources for more acute and high-tech purposes.

If community health just becomes part of hospital activity based funding, the Local Hospital Networks, dominated by hospital-based medical elites and priorities, will continue to plunder community health and mental health budgets, to resource ever more growth in medical and surgical procedures.

Hospital and assets management dominated health administrations have already demonstrated their true colours by dismantling community health and community mental health centres and mobile home delivery teams, which had been purposefully placed in the centres of their communities, near the main shopping and transport hubs.

This has been done largely so that the now valuable real estate could be sold to help pay for the rebuilding of general hospitals. Most of these teams have been withdrawn from the community to the bowels of less accessible, bleak buildings on hospital sites at some distance from the town centres. Here, they lose access to the passing public, lose ease of mobility as their cars are pooled elsewhere, and become a shriveled-up shadow of their former functional selves, just becoming sedentary outpatient services crowded in together (for further info, see this Australian Health Review article.

This is outdated hospital-centric planning, convenient only for shortsighted hospital administrators and traditionally minded clinicians. Not for the public, who want convenient one-stop-shops where they already mingle. We are heading back to the 1950’s again. NSW is the worst offender, but there are glaring instances throughout Australia.

As I argued in these columns some days ago, the even better question may be: What can we do to stop the state and national impact of these floods and other climatic catastrophes being used as an excuse to decrease public community health, Aboriginal health and mental health service spending, just when demand for them is likely to grow exponentially and plateau at a new peak, because of the irretrievable losses, long-lasting “slow-burn disaster” and wearing-down effects of these events?

The effects of bushfires, drought, cyclones, storms and floods impinge more squarely on the core constituency of community and mental health services:  the more socio-economically deprived, rural/remote, vulnerable and under-insured or uninsured parts of the population, including indigenous, transcultural, mentally ill, drug and alcohol impaired individuals and those with long-term disabilities of all kinds, and their families.

Not only do we need to avoid further short-circuiting of funding and skimping on community and mental health, we need at least double the existing mental health and substance disorders budget nationally, to run reasonable services nationally on a par with cancer and cardiovascular services.

So what can be done?  Just learn to live in the new health environment of fee-for-service privatised piecework?  Who will coordinate and integrate all the facets of community health and support services required?

There are signs that the Commonwealth is hoping to devolve this role to the cheapest and least trained workers, who will never have the expertise or clout to herd these professional cats together.

Can we appeal to Julia Gillard, with her family and political mental health experience, and to Mark Butler, with all the expert advice he is receiving, who both should know better?

Nicola Roxon probably needs a radical re-education or a change of portfolio.

The Federal Government needs to heed its own Health Reform Commission findings and come up with a strategy to preserve and regrow what is left of community health and community mental health services.

This must include an effective funding enhancement and protection strategy, particularly for salaried community based services. At the same time, fee-for-service mental health professionals’ time, presently concentrated in more affluent areas, needs to be more equitably rationed and targeted.

Maybe that is why the West Australians may be onto a good thing by removing the entire mental health budget from WA Health and putting all of its disbursements at the discretion of the relatively new Mental Health Commission.

A recent international survey tells us that the Australian public is even more aware of, or better educated about, the pressing need for better mental health services than comparable Western countries: it places mental health among its top 3 concerns, together with the global economic crisis and climate change.

Maybe the answer will have to be a  “Proposition 63” type solution: a recurrent 1-2% tax levy on high income packages, including bonuses from the big end of town, which goes directly to child, youth, adult and elderly mental health services, as the good people of California voted in and imposed on themselves, for the greater good of all.  In place since 2004, and reconfirmed by a further plebiscite, it cannot be diverted for other purposes, and cannot be used to replace the existing mental health budget. It has had its hiccups, as “governator” Schwarzenegger was able to find a loophole and delay the distribution of these funds for a while. But he’s gone and this mechanism is still there.

Maybe the great, fair-minded and compassionate Australian public would be ready to make a similar move, if they could, particularly if our politicians can’t show the leadership required to prioritise and fund these aching needs otherwise?

By continuing to ignore them, our governments may preside over a surging tide of untreated mental illness, a largely avoidable tsunami of distress, disability, traumatic deaths and communal peril.

• Professor Alan Rosen holds positions with the Brain & Mind Research Institute, University of Sydney, and School of Public Health, University of Wollongong.

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