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5 key questions to drive mental health reform now

When he was reappointed as Minister for Health, Greg Hunt said he had a ‘deep shared passion with the Prime Minister of further strengthening our support for mental health and in particular youth mental health and suicide prevention’. Professor Sebastian Rosenberg and Professor Ian Hickie respond.

[divide style=”dots” width=”medium” color=”#dd3333″]

Sebastian Rosenberg and Ian Hickie write:

Prime Minister Scott Morrison and Minister for Health Greg Hunt have both flagged their welcome attention to the issue of mental health and suicide prevention. Thank goodness – there is so much to do.

Sebastian Rosenberg
Ian Hickie

Australia’s stop/start approach to mental health reform over the past two decades has left the nation’s response to mental illness chronically underpowered and hopelessly fragmented. This has been documented repeatedly in inquiry after inquiry, shortly to reappear as part of current Royal Commission into Victoria’s Mental Health System and the Productivity Commission’s inquiry into mental health.

It is not time for Band-Aids. We don’t mean tinker. We don’t mean trying to pick winners or politically expedient funding to one unevaluated organisation or program or online app over another. This must stop. Please make it stop.

We need to work from basic assumptions about how services work – slowly, carefully and in a joined-up kind of way. We also need to make sure services work wherever you live in Australia.

5 key questions

We have started to conceive of the task around 5 key questions. Here goes.

  1. We need to understand who needs what care in Australia. Mental health and suicide prevention have morphed into an unhelpful blancmange. We have lost sensitivity. People have different needs, problems, diagnoses and concerns. We especially need to understand which clients have complex needs requiring complex responses: for example, youth who are out of school or work, people recently hospitalised, people with physical health or alcohol or drug comorbidities. Similarly, the suicide of a 45-year-old man after repeated hospitalisations for schizophrenia is quite different to that of a school-aged person with no history of mental illness. Call it product differentiation. We need to get past the blancmange to organise highly personalised responses to individual circumstances. Despite myriad pathways and frameworks, most people and indeed professionals in Australia do not have a clear idea about what should happen to a person with depression, bipolar disorder or borderline personality disorder. These care ‘pathways’ remain a mystery or a product of chance rather than regionally-planned or evidence-informed.
  2. We need to agree the right mix of professionals and services necessary to meet the needs of these complex clients – real teams capable of delivering effective care. This means some old-fashioned role delineation between health professionals, including psychiatrists, general practitioners, nurses, social workers, OTs, clinical psychologists, registered psychologists and others. It means finally embracing peer workers. It also means building and arranging the psychosocial workforce, decimated by the haphazard implementation of the NDIS to ensure our response to complexity manages the social context of mental illness. It means real attention to issues like housing, employment, education and social inclusion.
  3. We need to organise the health providers, and their organisations, to work together to the top of their scope, with each other and with psychosocial workers. Who will do what, to whom, in what order and with what expected outcome? What happens next? Who leads? What is the role of online mental health care, how does it knit into the broader service system and can it help to drive real person-centred care?
  4. If we want the health professionals to work like this, how will they be paid? What are funding mechanisms that create the incentives for the providers to work in the way desired? Is it fee for service, pooled, capitated, practice-based, performance-based models? Can we model anticipated returns on investment?
  5. How do we measure the performance of these new services so as to drive their quality improvement? What data do we need to collect from providers, consumers, carers and others? How can we do this in real time? Who do we empower to oversee the local delivery of these services? How will Commonwealth Primary Health Networks really work with state-based local health authorities to ensure accountability in each region?

A new level of frustration

None of this basic infrastructure is in place for mental health in Australia. There is no organisation building it. It is no wonder we are languishing. We sense a new level of frustration across the community about this. As is often the case, mental health care emerged as a significant community issue during the election campaign, with frequent direct questions to the party leaders. This might be the catalyst for some honest conversations that go beyond the naked self-interest which perpetuates fragmentation.

More than ever, Australia needs some serious strategic thinking about how best to organise our response to mental illness, suicide prevention, and the promotion of good mental health.

Given Prime Minister Morrison’s stated priorities, its time to kick-start that process.

Sebastian Rosenberg is a Fellow at the Centre for Mental Health Research, Australian National University, and Senior Lecturer, Brain and Mind Centre, University of Sydney. Ian Hickie is Co-Director, Health and Policy, Brain and Mind Centre, University of Sydney.