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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.

 

Comments 11

  1. Great post, thanks Michelle.

  2. ravenm says:

    Hi Sebastian. You have said that EPPIC is evidence-based and has been rigorously evaluated. What are you basing this on? Please could you cite specific references? Thanks. Melissa Raven

  3. srosenberg says:

    Hi Melissa

    I understand you have already been furnished with considerable evidence directly from Prof McGorry and others. It seems you do not find this evidence convincing.

    EPPICs are not the only part of what will be required to reform mental health in this country. In addition to a range of new services and programs, I think there is also an urgent need for a review of governance arrangements to address the federal/state ambiguities which have contributed to neglect of mental health over decades.

    I note the comments you made on The Conversation some time ago, in which you stated your belief that the existing public mental health system is not “beyond redemption” and would be a better place to direct new invest than to EPPIC:

    http://theconversation.com/evaluating-evidence-for-early-psychosis-prevention-and-intervention-centres-eppic-3604#comment_11595

    I am not sure what evidence you are drawing on to assert this but it is an odd turn of phrase. It is to my mind of course not the system that needs redemption, but the consumers and carers now being let down daily by this ‘system’.

    Frankly I do not share your confidence that real reform of mental health can come from within the public mental health system, particularly if we are to push community-based care and early intervention. Over recent years, the public system has run these services down and new funding has been directed to old models of hospital-based care. In this context, services like EPPIC become very important.

  4. ravenm says:

    Thanks Sebastian. I am happy to answer your question about the evidence basis for the comment I made a year and a half ago, and I will do so later today (I need to refresh myself on the context and issues and evidence). Meanwhile, please could you answer my questions about the basis of the comments you made yesterday about the evidence-base and rigorous evaluation of EPPIC? You are correct that I do not find the evidence convincing, so I am wondering what evidence you find convincing.

  5. srosenberg says:

    Hi Melissa

    There is now a wealth of data in this area which has convinced me, both Australian and international, including that listed under the Publications area of the the EPPIC website. I also refer to feedback provided to me by service users and their families, and also from the NGOs with which EPPIC works.

    Hope this helps.

    Sebastian.

  6. ravenm says:

    Hi Sebastian
    You said EPPIC was ‘rigorously evaluated’ and is ‘evidence-based’. Surely, as a Senior Lecturer and published academic author, you can cite a specific reference that actually supports each of those claims, rather than referring to non-specifically to ‘a wealth of data’?
    Thanks, Melissa

  7. ravenm says:

    Hi Sebastian
    You asked what evidence I was drawing on in asserting my belief that the existing public mental health system is not “beyond redemption” and would be a better place to direct new invest than to EPPIC.
    I did not advocate funding the existing system without substantial change – there is a lot wrong with it (and with the broader health system). Redemption involves substantial change (and I find your suggestion that it is consumers and carers who need redemption odd, because redemption implies failings that need to be fixed).
    I said that there were multiple possible options apart from massively boosting EPPIC, including but not limited to increasing resources to existing child/adolescent and adult mental health services. I also mentioned boosting community services, which it seems we both advocate. I mentioned vocational support as one type of community service, and I think there is also a huge need for investment in housing/accommodation (in terms of both housing stock and support services).
    I also think that real reform of mental health cannot come from within the public mental health system – it needs much broader change than that, within the broader health system, the welfare system, education, employment, the legal/justice system, both for people with mental disorders and for the broader population (social determinants of mental health need to be addressed, not just social inclusion of people with problems).
    In terms of evidence that the existing public mental health system is not beyond redemption, the ‘People living with psychotic illness 2010’ survey http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-pubs-p-psych10 found relatively high levels of satisfaction and needs being met on multiple indicators (e.g. 62.2% of those with a case manager (69.2% of participants) reported being very satisfied with their case manager), as well as low levels on other indicators (particularly non-health-related outcomes)) – lots of improvement needed, but not grounds for writing the system off.
    NB: The people included in the survey are not representative of all people who develop psychosis, many of whom substantially recover:
    Mojtabai et al. 2003 Clinical Characteristics, 4-Year Course, and DSM-IV Classification of Patients With Nonaffective Acute Remitting Psychosis http://ajp.psychiatryonline.org/article.aspx?articleid=176532
    Zipursky et al. 2012 The Myth of Schizophrenia as a Progressive Brain Disease http://schizophreniabulletin.oxfordjournals.org/content/early/2012/12/04/schbul.sbs135.long
    Psychosis is not inexorably progressive/chronic (despite many such claims). Many potential EPPIC clients would have much better outcomes than the people in the survey, without specialist early intervention services.
    But long-term evidence for people with less chronic disorders is hard to find, because people whose problems resolve have much less contact with treatment services (fuelling the clinician’s illusion). And most Australian mental health service statistics are about provision of services, not outcomes.
    Still waiting for you to cite specific reference(s) to support your much stronger assertions about EPPIC being ‘rigorously evaluated’ and ‘evidence-based’.
    Melissa

  8. srosenberg says:

    Hi Melissa

    Thanks for this and your reply. The best reference which pulls together the evidence I refer to is the report prepared by Orygen for the now defunct National Advisory Council on Mental Health. You can find the report here:

    http://www.health.gov.au/internet/main/publishing.nsf/Content/C1A49DEC3BC514E5CA25792B00781998/$File/earlypsy.pdf

    Hope this is helpful.

    Seb.

  9. ravenm says:

    Thanks Sebastian
    So no primary references? Just an Orygen report that misrepresents pre-EPPIC as ‘standard care’ (pp. 22, 29, 30) – and misleadingly implies that a sample of 32 patients is a ‘large sample’ of 723 patients (p. 16)?Melissa

  10. johnny says:

    the reality– psychosis and all mental health/psychiatric diagnosis are misery claims by people with misery in their eyes, drugging people sick with poison, nothing more nothing less,that’s right insanity in the mix,and that’s without a doubt,and if i am wrong let them who say otherwise,allow those their poisoning to put it to a test, they wont will they, that’s a fact also,I’ve never seen anyone being poisoned not to get sicker and sicker as time goes by,more in despair,sadder and sadder, I’ve never seen any get better, that’s a fact also,the fact is everyone can have a severe mental health problem that can be seen as any one of the 300 odd sick tags available in the psychiatric bible,how dare anyone call anyone sick till the end of time, and then poison them with insanity until the end of time,when these people just want to be free of that insanity being forced into them, play with the clever words as much as you want, but you will never take that out of the mind or the heart of the oppressed,or their family’s heart and mind,who have to watch as these tyrants poison and destroy the life the trust and the hope out of their loved one. And to anyone who challenges that with blah blah blah,i just hope someone does it to you, and then when you come into a blog page to tell your truth, your pain, your reality , someone scoffs at you, and tells you your wrong, and then injects you with some more poison so you can get better, because that,s how these tyrants are responding to the cries of the people they oppress and poison, our children, our brothers and sisters, our mothers and fathers,us. And that’s a FACT. Your sick, take this, be sick,get sick, act sick , stay sick, there is no recovery, there is only management by, us, the people poisoning you with sick, in words and poison, incarceration and when all that fails as you reach tolerance to all the different poisons and combinations of poisons,we are going to electrocute you silent, and so broken down you will never challenge us again.

  11. ihaywood says:

    I never quite worked out what the EPPIC “secret sauce” really is: from the outside they seemed to offer the same CATT team/case-management/inpatient ward model as the other State area services.
    Despite 6 years of psychiatry training in Victoria, much of it in the West, I’m forced to guess how our flagship evidence-based service actually works. Yes, I could have taken better notes in the I think 2 lectures we got from Orygen consultants, my point is for all their clinical successes they have failed woefully to engage with psychiatrist training.
    After 20 years they should have a significant cadre of consultants all over the place who have worked there and know what they do, instead from a training point of view it’s like Willy Wonka’s chocolate factory (“no-one goes in and no-one comes out…”)
    In fairness it’s not all their fault: it’s not like McGorry could have just put an ad for psychiatry registrars in the Age classifieds: training is tightly regulated by the psychiatry college, but over the years EPPIC could have done a lot more to integrate with existing adolescent psychiatry training and make training positions available.

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