EPPIC Change Highlights Management Problems in Mental Health

In recent years the increased focus on mental health issues and subsequent increases in federal funding, have created an environment where significant change should be possible.  However, two years after the federal government proudly focused on mental health in the 2011 budget – Sebastian Rosenberg reminds us that announcing the funding is the easy bit.

Many thanks to Sebastian Rosenberg, Senior Lecturer, Brain and Mind Research Unit, University of Sydney. Sebastian writes:

The recent decision by the Federal Minister for Mental Health and Ageing Mark Butler to redirect $247m in funding for new early psychosis treatment centres from the States and Territories to headspace further highlights the moribund nature of our federalism in relation to reform of mental health.

Professor Patrick McGorry’s tenure as Australian of the Year in 2010 brought our national mental health crisis into sharp relief.  Perhaps his lasting legacy however was to persuade the Federal Government to invest in a new nationwide roll out of the Early Psychosis Prevention and Intervention Centres (EPPIC).  EPPIC is a service model McGorry has been running successfully in Melbourne since 1992.  He and his team have worked to develop an innovative and holistic approach to care for young people facing the onset of psychosis.  They have then rigorously evaluated the outcomes of their care which have been remarkable and positive; giving new hope to young people being able to avoid lifelong disadvantage, complete their education and training and instead pursue trajectories towards living what the National Mental Health Commission term ‘a contributing life’.

McGorry’s results attracted first the Federal Opposition’s, and later the Federal Government’s attention.  Prime Minister Gillard had already stated that mental health would be central to her Government’s second term agenda.  An initial allocation of $24.5m was made in the 2010 Budget and a further $222.4m was made in the 2011 Federal Budget – this was the budget of which Wayne Swan was so proud to declare had mental health as its centrepiece.

Together these announcements, would fund a network of 16 new centres like EPPIC to be rolled out and fully complete by 2016. The May 2011 press release issued by Butler announced the EPPICs would be “delivered in partnership with the states and territories”.

Three years on (or two if you ignore the 2010 announcement) and how have we gone?  Not a sod turned.  Not a brick laid.  Not a client seen.  What has happened?

The Federal government entered into negotiations with the jurisdictions about how the EPPICs would be built and how they would knit into the fabric of mental health services run by the states and territories. Inadequate as they may be, the states and territories all currently run specialist mental health services for young people. A National Partnership Agreement was announced as part of the 2011-12 Federal Budget, allocating each jurisdiction a notional amount of the total new funds, pending finalisation of negotiations.

In January 2012, the Victorian Minister for Mental Health, Mary Wooldridge, issued her own press release calling on co-investment by the Federal government to match that state’s commitment so that the new EPPIC services would be “delivered in a partnership of metropolitan public mental health services and specialist mental health services from rural regions in Victoria”.  McGorry’s existing EPPIC in Melbourne operates likes this now, as part of the suites of services run by the Melbourne Health Metropolitan Health Service.

In other words, Minister Butler and the Department of Health and Ageing needed to work consultatively with the states and territories to design mutually suitable arrangements so as to make the new EPPICs fit local circumstances.  Our patchwork national mental health ‘system’ in fact varies considerably depending on where you live in Australia.

Each state does things differently.  This made Butler’s job a little more demanding, but no more so than dozens of his predecessors. And while health generally is a responsibility shared by the Federal and state governments, in mental health and community mental health in particular this split in responsibility is now a ravine.

The jurisdictions have traditionally funded some clinical community mental health teams though these are much reduced nowadays or have been withdrawn from the high street to the hospital campus.  They also run Child and Adolescent Mental Health Services (CAMHS).  These services are stretched and struggling. Nationally and on average, the jurisdictions also direct around 10% of their mental health spending to a range of community-based non-government organisations, typically providing psycho-social support services but increasingly also providing aspects of clinical care.

McGorry’s EPPIC model is a little different again, funded by the Victorian government but not operating from a hospital campus and working hard to link up with a range of psycho-social, employment, housing and other support organisations to deliver holistic care. In any new arrangements aimed at young people, surely good links between CAMHS, EPPICs and headspace would seem most sensible.

The Federal government funds primary mental health care provided by doctors and psychologists under Medicare and very recently, has started funding their own set of psycho-social support services such as Personal Helpers and Mentors, the Day to Day Living in the Community Program and (someday) the $550m Partners in Recovery program.  These Federal community mental health programs provide funds to some of the same non-government organisations funded by the states but this seems very much by coincidence rather than design.

In a nutshell, it is precisely in the area of most concern to mental health reformers; that part of the service system which aims to avoid hospitalisation and provide as many services as possible designed to keep people living well in the community, where responsibility between the Feds and the states is most unclear.

One can never be sure what transpires in these negotiations though it is understood that some states now feel quite aggrieved, that agreements had been close to conclusion and that Butler’s unilateral decision amounted to the Federal government reneging on the initiative as it had originally been announced in Budget 2011-12.

Regardless, the Federal government’s announcement that headspace will now take carriage of the roll out of the EPPICs is the latest signal that the current governance of mental health in Australia is unworkable and cannot deliver a new deal for mental health.  Even when new funds are made available, as they have been in this case, it still seems impossible for us to surmount the federal/state divide to create a more seamless system of mental health care.

The community has been left with a fractured, piecemeal set of services rather than any genuine sense of a system. People with mental illness and their families simply do not care who funds a service.  They just want help.

Minister Butler’s press release commits the Federal government under the revised roll out arrangements to have four new centres up and running initially and two by 1 July 2013.  No apparent action for three years then two new centres in just five weeks!  The four sites chosen are western Sydney, south-east Melbourne, western Adelaide and north-east Perth.  No rationale has been made public in relation to why these sites were selected.  More significantly, the new proposal suggests the eventual national network of EPPICs will comprise only nine sites, not the sixteen originally proposed.

Headspace itself struggles to fulfil its mandate. Funding pressures combine with acute problems finding staff to compromise its capacity to deliver holistic primary mental health care in all its sites (including western Sydney).  Evaluations of headspace have highlighted this along with issues of performance, accountability and clinical governance that this new service model needs to deal with. Moving EPPIC to headspace before these matters are sorted seems risky for both parties.

But headspace is clearly funded by the Federal government this decision means Butler can stop wrangling with the jurisdictions and get on with ribbon-cutting without needing to share the stage with any state counterpart.

The EPPIC model is a world leader.  Butler’s decision represents a significant change to the model. Under the new arrangements, can the now modified national roll out of nine new EPPICS occur with proper fidelity to the original, evidence-based service model?  At what point does the model become compromised?

New investments in mental health are rare and precious, particularly when directed towards evidence-based programs such as EPPIC.  Let’s make the most of this chance.