What does the National Health and Hospitals Reform Commission report mean for mental health?
Thoughts of an ambitious Pollyanna have come to mind for Dr Michael Robertson, Senior Research Fellow at the Centre for Values, Ethics and the Law in Medicine, University of Sydney.
He has filed this analysis for Croakey:
“The parts of the NHHRC relevant to mental health care are short on detail but read as an ambitious agenda, which seems to make the right kind of noises. Mental health clinicians are getting used to such lofty proposals of reform; they are also adept at not holding their breath.
What is wrong with mental health care run at a State level? In short, it is entirely hospital focussed which reflects two fundamental issues. First, there is a culture of risk aversion, which keeps the threshold for admission (particularly under involuntary status) much lower than it should. The second is the fact that the care of most severely mentally ill people is so difficult to coordinate in the community, that the hospital setting serves as the only means of resolving the recurrent crises they face. These crises are invariably born of the myriad of problems confronting such patients – physical ill health, homelessness, poverty and other gross social disadvantage. The asylum role of hospitals never really went away. Only the beds did.
The Federal-State split in mental health care reverberates throughout the patient journey. Primary care and access to Medicare funded clinical investigations, pharmaceuticals and psychological services are under Federal control. But the majority of psychiatrists who care for severely mentally ill patients are employees of the States, and are prohibited from utilising these services in this role, unless they are exercising their right of private practice. This then makes their role Federally funded, even though they remain an employee of the State.
If a State-employed psychiatrist requests a PBS prescription pad or a provider number for pathology services, these are usually refused as the Commonwealth argues that pharmaceuticals and investigations of patients cared for in State-funded clinical settings are the responsibility of the State. And so it goes.
The “big picture” reform agenda of the NHHRC argues for the availability of “Extended care services” – what are currently termed “Crisis Teams” or “Acute Care Services”. Such services already exist; the clinicians needed to fund them do not.
The reform agenda calls for ‘early intervention’ with an emphasis on the early phase of psychosis. Such services exist and do excellent work with the patients and families under their care. Problem is, such services are only effective when they are provided in an assertive (read labour and cost intensive) manner. When the team disengages, the patient’s mental health deteriorates.
What early intervention services appear to represent, is what adequately resourced services can achieve working with mentally ill people. In reality, these services have emerged at the expense of the care of other patient groups – unless an early intervention service is funded by a Commonwealth drip-feed, they have to be scrounged out of existing resources.
The NHHRC does seem to understand the subtleties of the current Federal-State shambles in mental health care. The patience of many fee-for-service providers (like GPs and bulk-billing private psychiatrists) is stretched when the disorganisation or amotivation of chronic mental illness leads to inconsistent attendance at appointments.
The proposed block funding of a case-mix (being paid an agreed amount based upon the likely composition of the mix of patients) is a well-established and sensible solution. The notion of “Connected care” (integrating clinical services across different specialties) acknowledges the fact that the physical health of many mentally ill people represents a greater threat to their well being than their psychopathology.
The NHHRC also acknowledges that the main determinant of one’s mental health is the level of access to social goods and not just access to clinical services. For many people with a mental illness, a safe home, a job or a vocational role, and adequate nutrition are elusive.
If the Commonwealth seeks to guarantee access to stable housing linked to social support services for our mentally ill fellow citizens, bravo.
Other than the forced removal of mentally ill people and mental health services to areas where housing is affordable, jobs abound, and one can buy fresh fruit and vegetables on the pittance the Disability Support Pension provides, I cannot see how the Feds will do this in our horrendously overpriced big cities.
A final challenge is the prospect of “Person controlled electronic health records”. Experience in other jurisdictions, and in abortive trials locally, indicates that mental health information is problematic in such systems. Most mental health records are kept deliberately separate from other health records and many mental health consumers wish to keep it thus.
Given the well-known negativity mental health consumers receive at the hands of other parts of the health system, there will need to be a separate system of recording personal mental health data to the main one.
Good luck guys. You’ll need it.”