Reforming Mental Health Services
Our Mental Health Systems need comprehensive reform
TAMHSS exists because there are so many areas of mental health services and practice that require reform. From evidence based clinical practices, the essential components of care, the design of service delivery vehicles, to funding and payment systems, as we get exactly what we pay for
TAMHSS comprehensive response to the Productivity Commission Mental Health Report brought together a wide range of previous Mental Health Commissioners, academics, clinicians and people with lived experience.
We specifically addressed:
- Integrated Care & Unitary Regional Strategic Planning
- Efficiency & Real-world Outcomes
- Payment Systems: poor evidence for, and lack of equity on regional & population basis (failure of fee for service and activity based funding for mental health)
- Regional Commissioning Authorities (need expertise to pick best models)
- Headspace primary care model (needs added components and funding)
- Developmental trauma (the biggest public health issue to solve)
- Structural reform (fiscal imbalance between Commonwealth and states)
- National Mental Health Commission (more independence, powers and funding)
- National Mental Health Service Planning Framework (kept hidden to avoid critics)
- Essential Components of Care compendium & tool
- National Role Delineation Guide for mental health services
- Rural, Remote, Telehealth and e-Mental Health
- Indigenous issues
- National Accountability for Quality
- Assertive Community Treatment teams in conjunction with the NDIS
- Workforce Development
We have been concerned about the lack of consensus on the definition of efficiency in mental health services and we have proposed a working definition. We have specifically commented on funding and payment systems, as you get exactly what you pay for, so the payments need to incentivise quality and best practice recovery, with minimum waste.
As the field evolves, new issues arise, and we look to the stakeholders, people like you, to become involved and lead reforms.
Key Issues for Reform identified by TAMHSS
How to define ‘efficiency’ for mental health services
Recovery and maximal social functioning are generally agreed to be the desirable outcomes, but the very wide range of disorders due to genetic and epigenetic factors (developmental trauma, life events, infections etc), ongoing interactions with physical health, behavioural reactions to current stress and social determinants of health, means that many models of care and desired outcomes have to be defined for a specific segment.
However, this can be done by designing models of care for each segment, both in terms of functional and satisfaction outcomes agreed by consumers, carers and the community, and delivery process outcomes in terms of benchmarking activity levels and adherence to fidelity tools. An example is the Early Psychosis Prevention & Intervention Centre model designed by Orygen Youth Health for first episode psychosis in the youth age group (12-25), with 16 components of care, implementation manuals and a fidelity tool with inspections. This can be considered best practice and other programs should be benchmarked against it.
The major criticisms of current outcome measures are that they are mostly based on occasion of service activities or time limited episodes of care, as defined for activity based funding, which rely on very erroneous assumptions:
1. State services are providing adequate quality care, whether inpatient or community based.
2. The only outcome that matters is a reduction in service use and cost.
– Relentless population growth means that even CPI increases are not sufficient to keep pace. Mental health services need to cover the whole of life
3. Medical treatment services in mental health can be seen, funded and evaluated in isolation from the social needs and determinants of health.
Developing Integrated Mental Healthcare in Australia
There is a growing literature related to the development of integrated mental healthcare in Australia involving contributions from several research groups over the last 2 decades and involving authors such as Burrows (2007) Eagar (2005), Perkins (2014) Whiteford (2014) and others.
Rural & Remote Mental Health Services
As many community mental health services have become depleted and partially dismantled they are being incrementally and surreptitiously replaced by essentially fee-for-service Medicare subsidized services with gap payments, private and corporatized telepsychiatry, telehealth, and e-health services.
Troubled Individuals and families with mental health problems in remote regions should not have to just rely on telepsychiatry, other telehealth counselling and e-Health strategies, individual allied professional counselling, or support workers for help with mental health related issues for individuals, families and communities, sometimes without ever seeing them in person, and often in isolation from, and uncoordinated with, familiar local health and mental health professionals.
Community mental health teams in rural and remote regions need re-investment, restoring full team complements, providing upskilling and supervising of staff, pastoral mentoring and stabilisation, so they can work across their regions to a repertoire of proxies for evidence-based interventions and service delivery systems.
Telepsychiatry:
Medicare subsidized doctor and psychology/ allied health telepsychiatry and Telehealth Mental Health Services, where needed for the regional mix of clinical services, should be strictly contracted and regulated by Regional Commissioning Authorities. Under these provisions they should be obliged to:
a) eliminate or severely limit gap co-payments,
b) liaise regularly with GP’s and in rural & regional settings with community MH teams, if risk of presentation to public services, and with families (with permission of the service-user if voluntary),
c) be governed by a single regional MHS plan integrating all public, NGO and any privately
contracted MHS. This plan should have some formal obligation status such as strictly
operated contracting, rather than just a loose in principle service agreement.
Developmental and later Trauma
This is our greatest unsolved public health issue (US Centres for Disease Control)!
It needs specialist action, starting with the most severe and trickling down, rather than starting with the mild to moderate and expecting to learn how to deal with the most severe, personally painful (3/4 of achieved suicides), socially painful (e.g. almost everyone in custody) and expensive outcomes.
Due to failures of the treating professions and academics, assessing and treating trauma needs a commissioned investment in developing and evaluating the promising treatments. Incremental improvements are too slow – the costs of slow action are huge.
Structural Reform is Necessary
The Australian Government and State and Territory Governments should work together to reform the architectural framework of Australia’s mental health system, to clarify federal and state roles in planning, funding and implementing integrated mental health care, so that governments can be incentivised to invest in services that best meet the needs of people with mental health illness and their carers. There should be a greater vertical and horizontal balance in planning and decision making, for the implementation of evidence-based models of care, as well as mandated integration, liaison and cooperation between commissioned services. The National Mental Health Service Planning Framework should be made publicly available to enable expert inputs for progressive improvements that will assist the reforms.
For full review of reforms needed see TAMHSS Response to Productivity Commission Mental Health Report