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A Primary Health Network redesign to address the ‘missing middle’ in mental health

Introduction by Croakey: The many failures of our mental health system have been extensively documented by the recent Royal Commission into Victoria’s mental health system and the Productivity Commission’s inquiry into mental health 

Among other damning comments, these reports described the current approach as having “catastrophically failed to live up to expectations” and being “woefully unprepared” for current and future challenges.

These findings reflect the experiences of mental health care consumers who have been calling for action on these issues for years and – in some cases – decades.

The following extract from the 2006 submission “With us not to us” , prepared by the ACT Mental Health Consumers Network, illustrates this fact:

Our society’s treatment of people with an experience of mental illness has often been, and often still is, shameful. Many people have been and still are, effectively excluded from the social and economic life of our community. Many people have been and still are, stigmatised and discriminated against on a daily basis. Many people with a mental illness are denied the basic rights and protections of citizenship. The law has often been a central tool in this oppression.

This submission will argue that, in the ACT, the ACT Mental Health (Treatment and Care) Act 1994, underpins a policy and service provision framework which relies heavily on the use of coercion and control, without due regard to safeguarding the human rights of people with mental illness, and without seeing the exercise of such powers as a last resort. Network members express a concern that Mental Health ACT services, particularly acute services, see the use of “negative powers”, those associated with involuntary detention and treatment, the use of seclusion and physical and chemical restraint, as the normal way to do much of its business.

Network members express a concern that heavy reliance on these negative powers for day-to-day business encourages Mental Health ACT services to be structured around crisis management, rather than prevention and recovery . Network members perceive this emphasis as explaining, for example, the “prisoner like” processing of persons admitted to the Psychiatric Services Unit, resulting in further and unnecessary trauma for people experiencing a psychotic episode.

The challenge now is to move forward to address the identified problems across our health and social care systems.

Below, the Grattan Institute’s Dr Hal Swerissen and Prof Stephen Duckett identify a major area of failure of the current system and suggest a redesign of the PHN network to deliver a common regional approach to mental health services and better and fairer outcomes for consumers.


Hal Swerissen and Stephen Duckett write:

Australia’s mental health services are in a mess. The Royal Commission into Victoria’s mental health system and the Productivity Commission’s inquiry into mental health have exposed the extent of the problem – and the damage done to Australians needing help. 

The fundamental problem is that Australia has two mental health systems: an uncapped, fee-for-service, Commonwealth-funded system with high out-of-pocket payments for patients; and a capped, hospital-focused, state-funded system that is stretched to meet demand. Coordination of the two is poor, resulting in yawning gaps and duplication, poorly targeted services, and massive inequity in who gets services (the poor get fewer services than the rich; and the city does much better than the country).  

The missing middle

The biggest losers are people who need intensive community support to recover and go on with their lives. These people are the ‘missing middle’ – they fall between inpatient hospital services, and services for people with mild to moderate mental health problems. 

These people need competent, integrated services that provide them with timely, comprehensive care at home and in the community. These services have to be available seven days a week for extended hours. They have to be able to provide individual and group therapy, medical management, safe and supportive environments, and support to families, schools, and workplaces. This requires well-organised, team-based care with a strong focus on recovery and rehabilitation.  

The Productivity Commission’s draft report on mental health makes clear that community services for the missing middle are wholly inadequate. Currently, planning and coordination of mental health services between the Commonwealth and the states is poor. There are no agreed regional plans that establish service models, levels of service to meet needs, resource levels, workforce and service development strategies, data and reporting arrangements, or governance and management accountabilities.  

Looking for solutions

The Commission’s preferred solution would hand responsibility for complex community care back to state governments. But it’s the wrong way to go, because it would risk increasing the focus on hospital care for people with complex needs. It would weaken the link between Commonwealth Medicare-funded services and state-funded services, and it would further separate mental health care from physical health care. Worse, the states already struggle to find the money for their mental health services. 

Nationally, it has been agreed the Commonwealth should have the lead responsibility for primary and community health services. The Commonwealth has established 31 Primary Health Networks (PHNs) to plan, coordinate, and commission a range of health services for regional, community based health services. The Commonwealth funds some community mental health through PHNs. As well, the Commonwealth has progressively taken responsibility for other areas of long-term care, including aged care and disability services. 

Redesigning the PHNs

The existing Commonwealth Primary Health Network should be redesigned to deliver comprehensive services for people with complex, longer-term mental health needs (the missing middle). While inpatient mental health services should remain a state responsibility, PHNs should be given a bigger role in commissioning community based mental health services for people with complex needs – including services currently provided by the states.  

The Commonwealth and the states should negotiate regional mental health agreements for each of the 31 Primary Health Networks. These agreements should specify a common regional approach to determine mental health needs and service responses. Service models that set out access and referral pathways, coordination arrangements, and funding levels should be agreed for each PHN, so patients can move seamlessly through different services. Consistent data, reporting, and accountability arrangements should be introduced to check that agreed goals and priorities are being met.  

Australians needing mental health care deserve better than the mess of services they are currently offered. Regional mental health agreements, along the lines we recommend, would provide a practical framework for the Commonwealth and the states to integrate planning, funding, service delivery, and accountability for mental health services. 

 Hal Swerissen is a Fellow in and Stephen Duckett is the Director of the Health program at Grattan InstituteStephen Duckett is a Director of the Eastern Melbourne Primary Health Network.

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NACCHO Summit 2013
National Rural Health Conference 2013
Oceania EcoHealth Symposium 2013
PHAA conference 2013
2014 conferences
#IPCHIV14
AIDA Conference 2014
Congress Lowitja 2014
CRANAplus conference 2014
Cultural Solutions - Healing Foundation forum 2014
Lowitja Institute Continuous Quality Improvement conference 2014
National Suicide Prevention Conference 2014
Racism and children/youth health symposium 2014
Rural & Remote Health Scientific Symposium 2014
2015 conferences
#CPHCEforum
#CRANAplus15
#HSR15
#NRHC15
#OTCC15
Population Health Congress 2015
2016 conferences
#AHHAsim16
#AHMRC16
#ANROWS2016
#ATSISPEP
#AusCanIndigenousWellness
#cphce2016
#CPHCEforum16
#CRANAplus2016
#IAMRA2016
#LowitjaConf2016
#PreventObesity16
#TowardsRecovery
#VMIAC16
#WearablesCEH
#WICC2016
2017 conferences
#17APCC
#ACEM17
#AIDAconf2017
#BTH20
#CATSINaM17
#ClimateHealthStrategy
#IAHAConf17
#IDS17
#LBQWHC17
#LivingOurWay
#OKtoAskAu
#OTCC2017
#ResearchTranslation17
#TheMHS2017
#VMIACConf17
#WCPH2017
Australian Palliative Care Conference
2018 conferences
#6rrhss
#ACEM18