Implementation the key to structural reforms in mental health

The changes announced by Minister Susan Ley do not offer a neat new bundle of funded programs. But they do offer two important structural reforms with very significant potential, including in relation to funding.

First they place Primary Health Care Networks (PHNs) squarely in the leadership role for regional planning for mental health.  Given the size of some of the PHNs, they may need to make more than one plan to ensure they are truly reflecting local needs.  But it is clearly in their remit to ensure the mental health needs of their communities are properly understood and that there is an organised response.  Central to this response is the concept of ‘stepped care’. 

At the moment there are very few services available between the GP, the psychologist and the front door of the emergency department of the local hospital.  Australia’s mental health system needs some more steps.  Australia largely failed to invest in these community mental health services following deinstitutionalisation.

As successive reports have shown this is a tested recipe for poor care, inefficiency, rapid re-admission or disaster.  By mixing clinical and psycho-social support, including vocational, educational, housing and other services, people with a mental illness are likely to find the community supports they need to keep them living well and out of hospital.  They will have a better chance of fulfilling their own goals in life.

The Government’s support for this stepped approach highlights the limitations of the existing fee for service arrangements.  Simply sending people off for a set number of psychology sessions is inadequate, particularly for people with complex conditions.  Where conditions are more straightforward, the changes announced by the Minister flag a much greater role for Australia’s world-leading e-mental health services to offer online support and therapies. 

Where more complex support is necessary, new pooled funding arrangements mean PHNs can move beyond the constraints of fee-for-service towards the establishment of more effective multidisciplinary team approaches.  This care is more effective than individual service provider care. This means PHNs can commission the establishment of teams engaging more mental health nursing, occupational therapists, peer workers and psycho-social support staff as well as psychologists in the delivery of care. 

This shift to flexible funding is most welcome and, to my understanding, would be welcomed by many health professionals working in the field now, who recognise the existing system as functioning poorly. It should also be recognised that at least for now, this capacity to cash out Medicare payments is uncapped, meaning the more often PHNs choose to pursue this option, the more funds are released.

These reforms raise several questions.  PHNs are very new organisations.  What capacity do they have to lead this process of mental health reform?  What skills do they need? New funding for new leadership is not obvious in the package of reforms announced. 

The PHNs will clearly need to partner with community organisations, particularly those with strong track records in providing psycho-social and clinical support.  Many of these organisations have been greatly affected by the advent of the National Disability Insurance Scheme (NDIS).  Ongoing contracts and staff have been lost in the changes.  This sector was already an unfortunately small component of Australia’s response to mental illness.  When the PHNs go looking for partners, let’s hope they can find some.

While the National Mental Health Commission’s Review runs to 900 pages, the Government’s response is 28.  The Review raised many issues as yet unaddressed.  Key programs like Partners in Recovery (PIR) and Personal Helpers and Mentors are not mentioned at all in the response.  While the NDIS may cater for the 60,000 Australians most severely affected by mental illness, there are around 500,000 more with severe, episodic illness.  This is the so-called ‘missing middle’ – not sick enough to qualify for hospital care but with complex issues needing more than GP care.  The PHNs will need programs like PIR if they are to reach this cohort effectively.  Similarly, while the response suggests a new approach to suicide prevention, no details are provided.

Fundamental system change is not possible unless there are strong connections to state and territory-run mental health services.  The strength and nature of these connections vary wildly from place to place.  The Federal reforms place huge stock in the capacity of a fifth national mental health plan to deliver these connections.  Based on the experience of the previous plans, this hope is surely misplaced. 

There will also need to be strong and robust accountability across Australia demonstrating where things are working well and where improvements can be made. 

This accountability must illuminate the issues which matter most to consumers and carers and relate to employment, education, housing and social inclusion. 

Unless this kind of accountability is in place, perhaps supported by a properly equipped and independent National Mental Health Commission as monitor, then this push to regionalise mental health could be regarded as further fracturing an already fractured system.  Access to a good quality mental health service should not depend on where you live but be a national asset.

Prime Minister Turnbull’s concern is to see Australia grow its mental wealth and human capital.  Mental illness is a direct threat to these assets.  Success of these reforms depends on persistent, forceful, persuasive and funded implementation.

Sebastian Rosenberg is Senior Lecturer, Brain and Mind Centre, Sydney Medical School, University of Sydney