Will the Australian Government's response to its 'National Ice Taskforce' deliver more treatment as promised?

Abstract

On Sunday 6 December 2015, the Prime Minister of Australia, Malcolm Turnbull, announced the release of the much-awaited final report from National Ice Taskforce, which was established in April 2015 under the Abbott Government to address growing concern about the use of ‘ice’ (ice being the street name for the crystalline form of methamphetamine) 1. Although the use of methamphetamine and related stimulant drugs have been a long-standing concern in Australia and elsewhere, recent public attention has arisen from a sharp rise in the availability and use of this high purity smokeable form of the drug 2, which has been associated with a doubling of the estimated number of Australians dependent on methamphetamine (from ~72 000 in 2010 to ~160 000 in 2013 3) and a corresponding increase in treatment demand (with closed treatment episodes increasing from 10 027 in 2009/2010 to 28 886 in 2013/2014 4)—this placing increasing pressure on already over-stretched and under-funded specialist alcohol and other drug (AOD) services. As Ritter and Stoove explain 5, fewer than half of those seeking AOD treatment in Australia are currently able to access appropriate treatment, indicating a need to shift the current focus on funding law enforcement to increasing investment in cost-effective treatment to reduce the substantial costs from harmful AOD consumption. With a much welcome shift in attitude, the Prime Minister reiterated the words of the Taskforce Chair, former Victoria Police Chief Commissioner Ken Lay, that ‘we cannot arrest our way to success’ 6; $241.5 million of the almost $300 million commitment to tackle the methamphetamine problem would be for the delivery of further treatment services 7. This commitment represents new funding that will supplement the Federal Government's direct ongoing contribution to non-government operated AOD services via its two major granting rounds (the non-Government Organisation Treatment Grants Programme and the Substance Misuse Service Delivery Grants Fund) 8. Although the public reception to the announcement was warm 6, many people in the sector were bewildered by the lack of detail or strategy accompanying the response 9, with this presented in a two page glossy action plan, Taking Action to Combat Ice 10 (subsequently supplemented with a more substantive National Ice Action Strategy 11). The main cause of this angst was that, unlike previous drug treatment funding allocations, the new funding would be delivered via Primary Health Networks (PHN; replacements for Medicare Locals, and prior to that, Divisions of General Practice). This is an entirely new and uncharted funding model for the AOD sector in Australia, and a surprising shift given that the core business of the PHNs is to increase the efficiency and effectiveness of primary care medical services provided to patients 12; they have no significant prior experience providing treatment services for AODs. The principle behind commissioning treatment via local PHNs was that they could allocate the funding according to local needs, and that this should, as Minister Fiona Nash explains, ‘ensure local coordination and better patient management’ 6. The nature and scope of services that will be provided via the PHNs is not yet clear as this will be based on each PHN's local needs assessment. Although this new model of funding has the potential to provide a more integrated service platform at a local level, a significant risk lies in what PHNs may not know about existing AOD treatment infrastructure, including their knowledge about best-practice in the field, evidence-based treatment and the gaps in knowledge in encouraging better management of patients with substance use problems in both primary care and specialist AOD services. It may also leave existing service providers out-of-the-loop and result in sub-optimal assessment and commissioning of specialised AOD patient care. What needs to be appreciated is that this announcement is not specific to methamphetamine-related services but that it signals a broader shift in how federally funded AOD services are provided, following on from the move to provide a range of other federally funded health care services via the PHN model, with this having included the evolution of ‘GP Super Clinics’ to manage chronic disease risk, maternity services and local mental health programs. Both the Ice Taskforce action plan 10 and a PHN circular released in early February this year 13 forecast this phasing in of AOD funding under the PHN model. During this time, contracts for existing AOD services will be extended for 12 months (until mid-2017), and these services will be given ‘early advice’ about federal funding arrangements thereafter 8. As explained in the PHN circular, the additional $245.1 million to PHNs will not be exclusively for the commissioning of methamphetamine-specific services. It is intended to increase the capacity of the AOD treatment sector broadly to adequately and effectively deliver treatment services responsive to local needs. Importantly, this will ensure that primary care solutions are part of the response, and it will also ‘support improved access to services, within the primary health sector, for people that need help, but do not qualify for specialist treatment services’ 13, in order to meet the unmet demand for drug treatment both for methamphetamine and for other drugs. It remains unclear to what extent funding will support primary care services versus existing or new specialist AOD services. A pressing question is then whether existing specialist non-government AOD treatment services will be able to access the treatment funding allocated under the national Ice Taskforce (or under federal funding thereafter), adding to the considerable uncertainty about their ongoing funding and the complexity of their current funding arrangements 5. There are also questions about what capacity PHNs will have to fulfil their new role, which forms a small component of their broader mandate. Although the allocation of $241.5 million ostensibly represents a major injection of funding to the AOD treatment sector, a breakdown of this funding allocation against the costs of providing AOD services in Australia shows that it is relatively modest. Specifically, the Commonwealth is estimated to currently contribute 31% of the $1.26 billion invested in Australian AOD treatment services each year [or around $390 million, with the remaining funding provided by state and territory governments (49%) and the private sector (20%)] 8. Compared with these estimates, the additional federal contribution of $241.5 million, which will be dispersed over a 4-year period, represents a 5% increase in the total investment in AOD treatment, and a 15% increase in federal funding, per annum. Spread across 31 PHNs nationally, this equates to just under $2 million per PHN per year. Whether this will be sufficient to substantially improve services for either people who use methamphetamine or other drugs will become evident in time. However, with the substantial number of competing health care priorities and a focus specifically on primary health care, delivering all of this funding via the PHNs has made some people understandably nervous. It is easy to imagine the Ice Taskforce funding being absorbed in a homogenous model of service provision, catering to the base common denominator across competing health priorities, leaving limited scope for funding or providing specialist non-Government AOD services for either methamphetamine use or for other drug use. On a positive note, the allocation of funding via the PHNs provides the opportunity to develop new and more flexible models of treatment and service provision, which are sorely needed, and which may help cater for the breadth of patient needs (e.g. brief interventions through to more intensive long-stay residential treatment options) and foster a multidisciplinary approach to help address associated physical, mental and social comorbidities 2. Where PHNs are well informed about specialist services, and links between services are already well established, this additional funding may make available a wider array of services for consumers and facilitate better service integration (e.g. linking residential rehabilitation with primary care and other out-patient support services), providing a continuum of care that is often not currently afforded. This new funding model will also give PHNs the flexibility to commission local services that are most effective and appropriate given the local context. However, these potential benefits are offset by significant risks, as noted earlier. The new funding model is also unlikely to address the immediate problem of long waiting lists for existing specialist AOD treatment services, and it poses a potential threat to the sustainability of non-Government specialist treatment services and the sector-specific capacity that they represent, not to mention the often severely disadvantaged and marginalised AOD clients who rely on these services for care. Further investment is also needed to improve outcomes for these specialist treatment options 2, particularly to overcome high relapse rates seen for methamphetamine use 14. In sum, early indications suggest that the provision of additional federal treatment funding under the guise of the National Ice Taskforce signals a shift from a predominantly specialist model of AOD treatment to a primary health care model of treatment provision. This shift has far more broad reaching implications for the AOD sector than is apparent from the Ice Taskforce action plan. It not only affects methamphetamine-related treatment services (which, ironically, are not specifically funded under the Ice Taskforce response) but also all federally funded AOD treatment services. Substantial responsibility has been placed with the PHNs in delivering services for AOD use, and although the Prime Minister has noted that the government will be watching the outcomes closely 7, this is a shift that the research community should also be paying careful attention to. Currently, there is a paucity of research to guide how AOD services should best be funded or any evaluation of various funding models 5. Research needs to be put in place that will accurately document the impact of this new funding model on service access, quality of care and broader outcomes, such as drug-related harms.