Successful mental health reform awaits structural change
WE have now reached a critical point in the most recent cycle of mental health reform. For the first time we now have two of the major elements for success. Firstly, there are real new resources, due largely to the $1.9 billion Australian Government investment announced in May last year and a commitment by the states and territories to match that investment over the next five years.
Second, we have the high-level political leadership required to cut through the bureaucratic and professional barriers. This new political and social movement has been headed by the Prime Minister and the Premier of New South Wales. Without their personal engagement little would have been achieved, and the extraordinary deficits in day-to-day care described in the 2005 Not for Service Report would still be accepted by health officials as everyday practice.
Unfortunately, we do not yet have the third critical element — real structural change.
The bureaucratic systems are the same, except that now more federal and state departments are involved. The public and private health systems struggle to respond to new challenges, such as the burden of mental disorders in 15 to 25-year-olds. People continue to pay large out-of-pocket expenses for care, including for the new psychology and psychiatry services.
We have no national community-based or independent body responsible for reporting on progress. In the alcohol and drugs arena, the Howard Government established the Australian National Council on Drugs so that it could get a real handle on outcomes. That body (which I have only recently joined) reports on whether government activity is having any effect on rates of alcohol and drug use and whether there has been an improvement in treatment services. In mental health, we urgently need a similar high-level body.
We must also start to collect appropriate measures of health and disability-related outcomes. Simply spending the new money in the old ways, and continuing to fail to collect the essential outcome data, will result inevitably in the same failures.
We need new competitive measures to drive the health and welfare systems to deliver more appropriate forms of care. We need to pay for genuine outcomes, not simply more activities. Being busy is easy for health practitioners. If we simply provide new Medicare funds to more and more psychologists, psychiatrists, GPs, mental health nurses and personal carers — without organising those professionals into coherent and accountable health care organisations — we have little chance of meeting the needs of those who do require integrated medical, psychological and social services.
There are now many new commonwealth and state programs relevant to the needs of those with mental health problems and their families. They are not only supported by the new mental health funds, but also by changes in general practice, new services for those with alcohol and other drug-related problems and big improvements in the support services for families and carers. What is not happening is sensible organisation of all these new services to meet the needs of the community.
Government agencies are rolling the new funds out as fast as they can to as many organisations or individuals who can complete the paperwork. A sensible framework for integration of the initiatives is largely absent.
For the new cash to deliver real benefits, we need desperately a new type of service provider — ideally, a regional or local organisation that can arrange the new money to meet the actual needs of the patient. Currently, we expect the person (or their family) to stumble unassisted through a forest of multiple, and often unresponsive, health and social services. Each office interrogates you as to whether you meet their specific criteria for service and, if you do, you then need to retell your story to their own set of practitioners. Each is funded for occasions of service — not on the basis of whether they actually help solve your problem.
Currently, there is no real competition in the mental health sector. Any service is good enough. If one state or local health service performs better than another, they receive no additional funding. If one state or regional authority works better with non-government organisations, or reorganises itself to meet the desperate need for accessible new services for those aged 12-25 years, or those who are experiencing their first major episode of illness, they go unrewarded.
Competition between states and regional health authorities for available new funds is essential. However, competition should also operate at the local or regional level. Regional organisations, such as divisions of general practice, could organise local services, hold government funds and compete with other smaller doctor-run practices or other private or corporate healthcare providers. Other notfor-profit operators from the welfare, employment, university and charitable sector may well enter the market.
However, we need to compete for quality, not quantity of services, and to reward genuine health outcomes (such as reduced suicide attempts) and social gains. Our fundamental expectation must be that services assist people to stay in school or work or get back to education, training or employment as quickly as possible. Our current system abandons people once major symptoms have resolved.
In the previous election the Opposition proposed a national body to report to the prime minister to oversee progress. That needs to be back on the agenda.
Finally, the greatest opportunity for real social and economic rewards in mental health lie with early intervention programs. The Howard Government has started to fund specific services for 12 to 25-year-olds, and some states such as NSW have begun to respond with additional funds. These initiatives need to occur nationally and with sufficient funds to achieve real outcomes. The actual cost of such services is in the order of $300 million annually. If we organise ourselves properly, such national programs are both affordable and highly desirable. Professor Ian Hickie is executive director of the Brain and Mind Research Institute in Sydney. This article is based on the Grace Groom Memorial Lecture delivered at the National Press Club in Canberra last week