Suc­cess­ful men­tal health re­form awaits struc­tural change

The Weekend Australian - Travel - - Health -

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

Newspapers in English

Newspapers from Australia

© PressReader. All rights reserved.