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Magical Realism and the draft Fifth National Mental Health Plan

 

The draft Fifth National Mental Health Plan is now available for comment and consultation, with face-to-face workshops planned across country during November and December.

It’s already proving unpopular, with former head of the Mental Health Council of Australia, John Mendoza, reportedly urging colleagues at the Asia Pacific International Mental Health Conference in Brisbane yesterday to have nothing to do with it.

According to Sebastian Rosenberg, a Senior Lecturer in Mental Health Policy at the Brain & Mind Research Institute Sydney, in the post below, reading the new Plan is akin to entering into a world of magical realism – where distant and recent events are as but dreams, and ongoing endeavours are not informed by them.


Sebastian Rosenberg writes:

Milan Kundera’s 1979 classic of magical realism, The Book of Laughter and Forgetting, has a sequel. The Fifth National Mental Health Plan appeared this week for consultation.

Reading the draft Plan it’s as if the past twenty-five years of national mental health planning had never happened.  There have been countless reviews revealing deep-set problems affecting mental health in Australia, including most importantly the review undertaken by the Government’s own National Mental Health Commission.

There have also been 2016 election commitments by Prime Minister Turnbull in relation to ‘mental wealth’ and announcing innovations in technology to stimulate change in mental health.  There has also been alarming new data showing an increase in suicides.

According to the draft Fifth Plan, if you look really closely, none of this happened and mental health reform can continue in the same way it has for the past twenty five years as essentially an intergovernmental affair, liberally sprinkled with bureaucrats, committees and glacial reform.  This may be unfair to glaciers given the impact of climate change on their speed.

Let me explain…

The Government will fix mental health?

I think the key concepts underpinning this draft Plan could be summarised like this:

All Australian governments will work collaboratively to develop more integrated national approaches supported by the evidence to enable effective regional stepped care planning by PHNs and LHNs, resulting in better, individually tailored services for consumers at the local level who will drive co-design. Governments will achieve this by reviewing existing spending in mental health to reduce inefficiency.

Apart from winning Buzzword Bingo, the Plan fails to explain the process by which national approaches translate to jurisdictional, then regional, then local and individual action.  Without this explanation, the Plan looks little more than a conflation of du jour catchphrases. And there’s no money.

Perhaps the most disappointing feature of the draft Plan is the focus on government.  Previous plans at least used to refer to the broader mental health sector, the vital role of health professionals, community sector organisations and so on.

This plan contains almost no references whatsoever to nurses, psychologists, general practitioners, psychiatrists, social workers and the like.  Peer workers are not even defined.  In fact the only place where the Plan really discusses the workforce is in relation to reducing the stigmatising attitudes and discrimination by the workforce.

Of the 30 actions the Plan describes, fully 28 of them refer to what governments will do with one more referring to a Principal Committee of bureaucrats.

This leaves just Action No. 5 as the responsibility of Primary Health Networks and Local Health Networks.  Everything else in the Plan requires a deep faith in governments working together.

In this sense, the Fifth Plan actually represents no substantive change from the Fourth which was subtitled An Agenda for collaborative government action in mental health 2009-14.  And as demonstrated by its predecessor, the notion that this Fifth Plan can really drive change because of intergovernmental action is fanciful.

Pre-conditions for Integration

The Plan therefore suggests it can create the “pre-conditions” for better integration, including actions such as:

  • The guidelines for severe and complex support already described above
  • Role clarification between governments
  • Decision support tools like the National Mental Health Service Planning Framework, revised mental health standards and linked datasets

Even if governments are able to establish these “pre-conditions”, the Plan offers very little description of what change we are looking for exactly.  Where are we expecting people to go for care and why?

Beyond the rhetoric of ‘stepped care’, no model or models are provided. Different levels of integration are presented (p.21) but it is not clear what level we are aiming for, or how this change will be achieved.

The document’s strongest theme is probably integration, stating that this Plan is different.  It seeks to foster integration between different levels of government, down to local action, rather than just trying to integrate within one layer of government.

This seems to ignore Priority Area 3 from the Fourth Plan, which sought to:

 establish regional partnerships of funders, service providers, consumers and carers and other relevant stakeholders to develop local solutions to better meet the mental health needs of communities.

The Fifth Plan has a difficult job. It needs to set a platform for a pantomime of change while never fully describing the reason for that change or the practicalities of how that change will occur.  The Plan asserts that much is being achieved by Australia’s mental health service system, but “there are some areas where it is not working as well as it could” (p14) and that “there remain calls to address fundamental problems” (p19).

The Plan does not describe these problems in detail.  Rather, it draws on reports and reviews by the National and NSW Mental Health Commissions to describe systemic characteristics such as fragmentation, inefficiency, difficulties navigation and a lack of role clarity.

The unbearable lightness of mental health funding

 The Plan does not confront issues like inadequate access to care, the variability of care across the country, or the adequacy of funding.  In relation to service quality, the Plan does call for amendment to the national standards, and to mandate their use.

The Plan makes it clear there is no new funding to support implementation, instead flagging continued review of existing expenditure by governments so as to “harness or leverage off existing investments”.

Intriguingly, this section hints at a ‘rebalancing of investments’ but no details are provided about which parts of the system are currently out of balance.

Underfunding in mental health remains a critical issue in relation to the burden of disease, with mental health’s share of the health budget actually in decline.  No amount of leveraging can fix this.

An invisible shift

 Elements of magical realism emerge in the Fifth Plan when one of the most significant achievements of past plans has been a “major reorientation” of care away from hospital settings to community settings.  No evidence for this shift is provided however.

At the start of the National Mental Health Strategy in 1992, grants to NGOs accounted for $2.21 of the $108.88 (2%) spent on mental health per capita in Australia by the state and territory jurisdictions.  By 2013-14, the NGO share of the per capita figure was $15.52 out of a total of $210.59 (7.%).

By contrast, in 1992 public hospital mental health spending accounted for just over 20% of per capita spending.  By 2013-14, it was around 33% of per capita spending in the states and territories.

There has been an increase in public sector community spending but it is not possible to discern how much of this is genuinely in the community and how much of this ‘community’ spending is in fact hospital outpatient activity.  Public hospitals are still the focus of care and spending.  Genuinely community-based mental health services in most jurisdictions are rare.

Avoidance Syndrome –  Secondary Care

The Plan exhibits an unhealthy aversion to secondary care.

Our system has become a simplistic split with the Feds funding primary care, the states paying for hospital care. Finding any service in between the GP and the emergency department of a hospital has become nearly impossible.

Secondary care is only mentioned in the Plan in relation to the link to physical illness and to provide an anachronistic definition of this of care as being entirely the province of medical specialists.

Many in the mental health sector and successive reports and inquiries have suggested that the key to real mental health reform is a concerted effort to build secondary mental health care, to provide clinical and non-clinical support to primary care for people with more complex conditions, to provide an alternative to hospital admission and to provide smoother discharge into the community from acute care.

This dilemma is not articulated in the Plan. Rather, there is a commitment to develop a set of national guidelines:

Governments will work together to develop a set of national guidelines that will support jurisdictions to deliver care pathways for people with severe and complex mental illness that are coordinated and integrated, and bridge the gaps between clinical and non-clinical services to offer person-centred wrap-around care for consumers.

The process to develop these guidelines and how eventual services are to be funded is not described.  The concept of hospital avoidance is not mentioned in the Plan at all.

The problem with community mental health is that it is not clearly ‘owned’ by either the Federal or State governments – this is a recipe for further neglect not addressed in this Plan.

The Past is Another Country

 The Plan enjoins us not to seek immediate answers for all mental health’s problems, instead seeing the Plan as setting a “foundation for longer term system reform”.

This Plan certainly does not dwell on specific achievements or failings of previous Plans, almost as if this was the first plan, not the Fifth.  The Plan ignores a twenty five year heritage of national plans and policies, choosing not to provide any real review of progress or opportunities for learning.  This is a wasted opportunity.

Magical realism re-emerges when the Plan states that despite ongoing work to improve suicide prevention, there had been no significant reduction in the suicide rate over the last decade.  This is indeed difficult to argue when 2118 people died by suicide in 2006, 3027 in 2015, the suicide rate increasing from 10.2 to 12.6 per 100,000 over this period .

“More to the doing than bidding it be done” (Charles 1)

 We are used to great policies and plans.  It’s the implementation which has let down Australian mental health reform. A key theme in these ‘reforms’ is stepped care, for which the following definition is provided:

Stepped care: An evidence-based, staged system comprising a hierarchy of interventions from the least to the most intensive, matched to a person’s needs. Within a stepped care approach, a person is supported to transition up to higher intensity services or transition down to lower intensity services as their needs change.

The Plan provides no detail regarding what evidence is being drawn upon, nor does it describe how these steps flow (if they do) from population health promotion approaches right through to acute mental health care and back again.  It is little wonder PHNs are currently making up their own definitions of stepped care.

The Plan does not provide insight into how to balance traditional population health approaches to planning and service delivery with the more individualised, tailored approaches being promoted. These are also issues Primary Healthcare Networks are grappling with right now.

The document does not say how it fits with state and territory activity, merely suggesting it ‘complements’ existing jurisdictional plans.  The first national plan had financial and political agreements to drive intergovernmental action.  Successive plans have had less of this or none.

The Fifth Plan continues this pattern.  No new funding or agreements underpin this Plan.  While the Plan discusses integration and implementation at length, the significant costs associated with this work are not acknowledged. The Fifth Plan is set up to make as little impact as the Fourth.

Notable omissions

 The Plan makes little or no reference to the specific needs of the Culturally and Linguistically Diverse community.  Massive issues of psycho-education, underservicing and vital data collection affecting large swathes of the Australian community have been left unaddressed. Australia is currently operating with meagre and completely inadequate transcultural mental health resources.

Mystifyingly, the Plan also makes no reference at all the new digital gateway, which was a critical part of the Government’s response to the Commission’s review and its pre-election mental health commitments.

E-mental health services should form a critical element of the next wave of mental health reforms but clearly not in the next five years under this Plan.

When Reforms Clash

 There is a critical if ominous commitment (Action 4) that the Mental Health Drug and Alcohol Principal Committee will monitor and report to Health Ministers about the rollout of the NDIS for people with severe and complex mental illness.

This is welcome and perhaps a response to recent concerns that the NDIS is not yet meeting expected levels of mental health support packages.  For example, the ACT (a whole of jurisdiction trial site) currently has 325 packages, around one third the expected level of packages for people with the most severe disability.

Another key feature and retrograde step in this draft is that responsibility for mental health as defined in the Plan remains firmly in the province of Health and Health Ministers.

The need for innovative approaches to issues like unemployment, training, housing, education and social inclusion are receiving active consideration in other parts of Government but here receive scant attention.

This is surely a long way from the more holistic approaches espoused by the National Mental Health Commission.

Accountability for Hollowmen

 For the fifth time, the National Plan makes commitments in relation to establishing robust accountability.  More specifically, this would be a new annual report produced by government to demonstrate progress against the Plan.

But this is like the system we had, until recently, of national mental health reports published regularly largely relying on federal and state health system data provided three years earlier.

This Plan makes no commitments to fund new and independent ways to collect and report data, particularly on the issues of most import to consumers and carers, such as employment, education and quality of life.

The failure to establish genuine accountability has been one of the major and enduring characteristics of successive national mental health plans.  Without major accompanying commitments, this sad pattern seems destined to repeat.

It also casts some doubt over the future role of the National Mental Health Commission, which, if not undertaking this oversight and monitoring role in a properly independent capacity, may struggle to assert a genuine role in any reform process.

Reform may be elsewhere

Twenty five years of mental health plans and policies have a legacy.  It is a story told in 32 separate inquiries into mental health in the period between 2006-12, which collectively suggest the most apt word to describe mental health in Australia is ‘crisis’.

Wasn’t this why the Abbott Government asked the National Mental Health Commission to do the review in the first place? If not why not?  And even with its constrained terms of reference, the Commission managed to deliver an ambitious agenda of change, some of which needs much more work.

But it did set out a detailed leadership role for the Commonwealth in relation to national mental health reform and a central role for community mental health care.

The Fifth Plan does not do this.  It lets the Commonwealth off the hook, shunting responsibility from Woden to PHNs and others.  In some parallel universe, providing a few tools, guidelines and complementing jurisdictional policies might drive reform but this approach has yet to prove effective terrestrially.

The Fifth Plan and the Commission’s Review are both owned by the Federal Health Department.

As a pilot, Minister Ley now seems to have two choices.  She can take charge of a Fifth Plan aircraft with the most beautiful livery but well known to lack the power necessary for lift off.  At best, this thing will just go up and down the runway.

Alternatively, she can buckle up and take charge of a much more experimental Commission vehicle.  Not sure it will fly.  The thing isn’t painted and the flaps and stabilisers might need to be attached by the states and territories and others, but it certainly has engines.

It will need a skilled pilot. It also has passengers who are sick of being stuck where they are.

Sebastian Rosenberg is a  Senior Lecturer, Brain and Mind Centre, University of Sydney. On twitter @RosenbergSeb

 

 

 

 

 

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