To the Editor: Yet another report has been published highlighting the parlous state of mental health services in Australia and the plight of the mentally ill and their families.1 In the words of Mr Keith Wilson, Chairman of the Mental Health Council of Australia, they are the “untouchable and untouched”,2 the pariahs of Australian society. Summarising the findings of the report is unnecessary, as the issues (poor access to services, lack of continuity of care, and a dwindling workforce among others) have been much in the public eye and are all too familiar to most medical practitioners. More important is whether this report will succeed in generating change for the better where scores of others have failed.

The difference this time is that consideration has been given to a Commonwealth Solution:2 the Commonwealth government taking over the management and funding of these services across Australia. As state governments have made such a mess of mental health services and have repeatedly failed to sort out the well known problems, that seems an attractive option. This solution would stop passing the blame between the states and the Commonwealth, would reduce cost-shifting, may standardise (if not improve) care across Australian jurisdictions, and may result in more adequate funding. There might be light at the end of the tunnel after all.

The counterbalance is that having the Commonwealth in charge of mental health services will pose new problems, least of which is the creation of a parallel health bureaucracy. One of the few achievements of the past 30 years has been the “mainstreaming” of mental illness; that is, bringing psychiatric disorders out of the asylums and into the general health services and hospitals. If the Commonwealth takes over, demarcation disputes between mental health and general health services are likely to flare up, especially in emergency departments and hospital wards. Because general health services are themselves stretched and under-funded, clinicians and administrators will be tempted or even forced to push mental health patients out of the general hospitals and try to unload anyone with psychiatric problems, whether physically ill or not, into the Commonwealth-run services. “Mental illness is no longer our responsibility”, many relieved administrators and clinicians will say. Endless arguments and meetings will ensue about where these Commonwealth-run services should be located and where patients with both mental and physical illness belong. The only way to avoid this retrograde leap would be for the Commonwealth to take over all health services — too simple and rational a solution to be adopted.

As the report eloquently depicts,1 mentally ill people and their families are desperate. In that context, any change can be perceived as better than nothing, certainly better than the hopelessness that currently pervades these services. Such a solution may also be tempting to a stretched and demoralised mental health workforce.3 Can the Commonwealth be more effective or enlightened than the states? The Commonwealth’s track record of compassion, of emphasising individualism, the survival of the fittest, does not augur well for its ability to care for the mentally ill. By and large, psychiatric patients are neither the “fittest” nor the best equipped people to compete in a free marketplace. The Commonwealth does have a track record of expediency. In that context, it is not too far-fetched to imagine the now empty refugee detention centres being reconditioned into outback psychiatric facilities for the severely disturbed. “This is a provisional but necessary measure to meet the urgent need for more psychiatric beds” will undoubtedly be the words used by the incumbent health minister. We may even be blessed with a “Pacific Solution” to mental illness.