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Are we going back to the 1960s in mental health?

(Part 8 of a Croakey series on health reform)

In a recent post, Sydney psychiatrist Professor Alan Rosen began the story of “Indiana Rudd” and the unlucky fate of mental health in his CoAG Temple of Doom. Here is the next instalment:

“Mental health reform should have been presented as a core model of what is required for the whole health system: funding the shifting of the centre of activity to the community, providing welcoming facilities to encourage prevention and offering mobile home-delivered assertive care, with acute and longterm follow-up in the community for as long as needed,  and well-integrated hospital care only  when absolutely necessary.

Enhancing the Headspace youth health program to ensure young people access mental health services was essential, and will be much appreciated, but is only part of the solution.  Even these enhancements will only allow assessment and initial engagement of more young people in need, but leave them in the lurch with few early intervention or community mental health teams with any capacity to follow them up. We must also tackle, resource properly and reform gaps in mental health services for all other phases of care and phases of life.

The “health reforms” Mr Rudd signed off with most of the premiers will make uncapped clinical activity or hospital based procedures,  not outcomes, the main game in town. This will cause  currently depleted community health and evidence-based mobile community mental health services, which may well not be beneficiaries or only minor recipients of the new Commonwealth funding streams, to wither even further or just  disappear into hospitals.

Against all expert advice, they are already being retracted onto hospital sites, dismantled and replaced by gestural, sedentary, traditional hospital outpatient services (are we  going back to the 60’s? ), which will not be able to provide viable community alternatives to hospital admissions.

The states have insisted on and won a re-shunting of the new central pool of federal health and their forgone GST funds, back through their health bureaucracies, before being distributed to the Local Hospital Networks. So much for Mr. Rudd’s principles of “funding federally, delivering locally”, and “ending the blame game”.  It will be just that much harder to disentangle the levels of responsibility and blame. As far as who can best run health services, we are between the devil and the deep blue sea.

The Commonwealth Department of Health  & Ageing may be able to write a chook raffle policy, but it has few employees with much experience of running health services, and too many decision-making generic career  bureaucrats  without  any clinical background. It has also presided over the serial down-grading of  the national mental health strategy and standards, so not to  embarrass  any health bureaucracy or minister by committing to any real reform. It seems that even specifying practical goals, targets and timelines for improvement would be seen as far  too “aspirational”.

The states have  much more experience at running health services, though they have done so incredibly poorly in some jurisdictions. However, most states and hospitals have forfeited the right to administer mental health services, as they have siphoned off their resources, often allowing them to shrivel and rot.

Yet Mr Rudd has left the fate of these services in the same hands. He  also chose to exclude community mental health teams working with individuals with significant mental illnesses from co-location with primary health centres, in the centres of their communities, where they should be for easier access and mobility. At the same time he has channelled the funding for their complementary support services (eg the CoAG Personal Helpers & Mentors program)  to primary care via the GP networks. This will cause further fragmentation and cause these support services to move up-market, or their staff to turnover due to lack of immediate clinical back-up by expert mental health teams.

Mental health services will get some access (yet to be specified) to the new $400 million p.a. national investment for 1300  sub-acute beds.  This is welcomed.  However, the bulk  of this funding is likely to  be used up on expensive hospital beds, while in rehabilitation, and especially in mental health, most of these places  need to be located and staffed in the community. Mental health is likely to be low in the pecking order for its share of this funding, as usual. Mental health alone could have used up  most of this amount,  just to replace the loss since the 1990’s  of over 1000 sub-acute beds.  Yet, it is to be spread thinly across many medical conditions.

Why disrupt mental health services further just when they so badly need better organisation?  Why abandon evidence-based community mental health services when they most need rescuing and rebuilding?  Can a chaotic phase really be a creative circuit-breaker?  Is there a brooding hidden opportunity, lurking in the depths of all this seething primeval soup of dismantled and fragmented elements of  service, that has not yet  surfaced?

Is all the “doom and gloom” really  that warranted? Stay tuned for the rivetting climax and conclusion of Indiana Rudd and the CoAG  of Gloom…”

• Alan Rosen is Secretary, Comprehensive Area Service Psychiatrists’ Network; Clinical Associate Professor, Brain & Mind Research Institute, University of Sydney; Professorial Fellow, School of Public  Health, University of Wollongong

Comments 3

  1. Doctor Whom says:

    Alan – you make it sound like all Mental Health services are like the one you work in.

    Here in Victoria the services are far from perfect, but we have widespread community based mental health services that are not being dragged back to hospitals, we have separate but linked Primary Mental Health teams focussed on high prevalence ilness such as depression etc. We have step down – step up units for residential “inpatient” care based in blocks of flats in the community. We have mobile CATT teams. WE have PRSS agencies and support agencies for parents and carers. Sure it could all do with more funding and some with a bit of reform but really it isn’t a huge bloody disaster.

    Our big c oncern, and not only in mental health, is that we will have to make changes for the worst to conform with an Canberra model that only (partly) understands health in terms of what happens in NSW and Qld.

    I’m not being smart here or filled with Victoria is better hubris. We are already seeing “improvements” from the Feds that will require us to offer inferior models and care if we are not careful.

  2. alan rosen says:

    Alan Rosen Replies to Dr Whom

    Dear Dr Whom,

    I too am a fan of Victorian mental health services…up to a point.
    These problems are widespread nationally, and Victoria, though doing a lot better than most Australian jurisdictions, has no cause to be complacent. We should not forget that it was Victoria that provided the title “Not For Service” for the national report on gaping holes in mental health service provision for those who so badly needed them. This prompted an initial though fragmented CoAG response in 2006.

    No region of the state has a full spectrum of services, and all regions lack capacity. Even existing services in Victoria are fraying at the edges. I would agree that Victorian levels of service are among the best of Australian services, with better examples of wholistic coordination between mental health, general and primary health, housing, and NGO rehabilitation services (like the Barwon region, which joins up all these services and provides data linkage between them). But such innovations are in isolated pockets, not everywhere.

    New Zealand would serve much better as our good practice benchmark on the whole. New Zealand is still doing a lot better in terms of outspending Victoria by 33% per capita on publically accessible mental health services for individuals with severe mental illnesses, a better balance towards community-based services by 15-25%, and devolving 150% more of the mental health budget to services run by community controlled organizations. And it has a Mental Health Commission to ensure transparent accountability, independently from service-providers. However, New Zealand may be vulnerable to losing some of this well-established lead under the current government.

    The Victorian Government performance indicators (DHS, Mental Health – Key Performance Indicators – Adult, Quarter 3 2007-08) show that Victoria’s mental health system is under pressure and failing the vast majority of the Government’s performance targets, including:
    
• One third of all mental health patients wait for more than eight hours in the emergency department for a bed

    • 42 per cent of patients fail to get care in the community before entering hospital

    • 33 per cent of patients fail to get care in the community after leaving hospital, resulting in a readmission rate of 14 per cent

    • 38 per cent of inpatient and 66 per cent of community mental health patients do not have a valid assessment recorded at point of admission/contact; this is compared to the Government’s target of 85 per cent.
    A recent Office of the Senior Practitioner report showing that 2036 people had to be restrained or held in seclusion in Victoria in 2008-9, had experts concluding (9.5.2010) that staff would need to chemically or physically restrain people much less often if services were adequately funded to intervene and help clients at earlier stages.

    I agree that neither Victoria nor the rest of us should settle for lowest common denominator services , but neither should we hold up Victoria as providing a nationally acceptable level of mental health service. It just doesn’t compare well to the level of resourcing, early access, consistency, balance and quality of service that some other developed economies enjoy, or that we can expect here for cancer and heart conditions.

    Alan

  3. AgedMH says:

    Dear Dr Whom
    It is marvellous what Victoria can offer someone that has a mental illness. That is until you start to get old. Then all those services including PDRSS disappear. First presentation for consumers is around 65 – 80% and those with a severe depression having difficulties are placed with those with severe behavioural issues from dementia. If you were not depressed before, you soon will be. Physical health and mental health interplay even more but services from Consultation-liaison and access to general health also start to become invisible. Drugs only count if you are still using them but long term effects are too boring to mention. Education for staff and new services also start to become hard to find. If you work in aged residential then you are totally invisible. No one wants to know you. You are neither mental health or aged. No mention in the press or in any discussion forum and training. One size fits all as long as it is adult focussed. One may be surpirsed to kow we have an aging population. For mental health consumers, many have aged issues when they are 45, but we are more likely to increase services from adult services to an age limit of 70 and the rest, if you make it to this age, are an aged issue. Well only if they live that long. Lets hope you don’t get a mental illness when you grow old because you are in for a shock. Having worked most of my career in adult mental health I am shocked and appalled. Maybe one day we will get equal access to CNEs, HDU specialist, and education in any format that is not designed for adult and rolled out to aged if it is an after thought or if it can be afforded.

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