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Mental health reform part 2: Should the feds take over community health?

Continuing his series on mental health reform, Sydney psychiatrist Professor Alan Rosen argues that the states – well most of them anyway – have forfeited the right to run community mental health services.

He writes:

“The National Health & Hospitals Reform Commission proposes to hand all community health to the Commonwealth, to be integrated with primary care, but to leave hospitals, including emergency departments and outpatients, in the hands of the States and Territories.

With a few exceptions (possibly Victoria, & the ACT, and potentially WA), the states and territories have forfeited the right to run community mental health services.

They have often been frankly negligent custodians of community health services. They have generally allowed 24/7 mobile community care to wither, and have retreated to “fortress-hospital” psychiatry, providing few community alternatives, leading to access-block in Emergency Departments and overcrowding of inpatient facilities.

Most states have also done a poor job of funding NGOs to provide community-based psychosocial and support services consistently both in urban and rural settings.  Moreover, the split in state/federal funding has contributed to cost and blame shifting, fragmentation and gaping holes in service provision.

We should advise the Australian Government to proceed with the Federal takeover, ideally of all health.

If that is not possible, they should at least take over all community health, including community mental health services, and co-locate them with primary health care centres in “one-stop-shops”, as long as:

a) No states are allowed to declare the “community cupboard bare” prior to transfer of community facilities and teams to the Commonwealth, by accelerating the shifting of remaining community services back into hospital-based out-patients buildings before this occurs.

b) Community health facilities in shopping hubs are no longer allowed to be retracted from the community onto less convenient hospital campuses, so that their community sites can be sold to finance the rebuilding of hospitals.  The NHHRC final report appears oddly indifferent to this, considering its trajectory.

c) Regional health funding and commissioning authorities, which must be independent of all service providers, are in place to ensure truly integrative service provision between all health sectors, public, private and non-government community managed organizations.

This should include a holistic range of acute and rehabilitative interventions, and the purchasing of inpatient beds, with community based senior clinicians authorized to supervise care for their own clientele while they are inpatients, as has been working well in Wisconsin for many years.

Such authorities could also supplement fee-for-service clinicians’ existing income with indirect incentive payments to provide enhanced, ongoing access to general medical care for individuals with severe mental illnesses.

These blended strategies have been shown to be suitable for Canada in a recent report, and effective in the Commonwealth funded Integrated Mental Health projects in urban, rural and remote Australia.

d) mental health funding and expenditure, both capital and recurrent, is quarantined and managed separately from other health resources, (ie neither by general hospitals or divisions of general practice, who often have more clinical procedure-focused priorities).

e) the coherence of discrete evidence-based mental health teams is preserved. Mental health workers should not be merged into generalist teams, even if they are outpost liaison workers with GP’s, Headspace Youth Health Centres, etc. Only since we have had such teams focusing on particular functions or phases of care, have mental health services been able to demonstrate substantial improvements in outcomes.

f) that governance is genuinely interdisciplinary, not medically controlled, so that cost-effective and recovery-oriented psychosocial interventions, including expert psychological and family therapies, continue to be developed and supported,

g) that consumers and carers are included routinely in service development and related decision-making, rather than gestural and erratic consultation at the occasional convenience of mental health administrators, when they are just out to tick another box (eg in developing policies, plans, standards, and for accreditation surveys).

h) the Commonwealth re-establishes the sending of strong monetary signals to oblige the regions to consistently implement evidence-based and community-focused mental health interventions and service delivery systems, and

i) There is a commitment by the Commonwealth Government to establish a National Mental Health Commission or Authority to independently monitor implementation.

We need to attend to the persistent under-servicing of the Australian community as demonstrated by the ABS surveys of 1997-2007, poor coordination of the care that is available, lack of consistent provision of an adequate and holistic range of evidence-based interventions, over-concentration of all services in hospitals, and the lack of transparent accountability, with real consequences, in terms of monetary sanctions and incentives, which are not issues the NHHRC squarely tackled.

There is an international consensus that we need a shift of the centre of gravity of mental health services from being hospital-centred with occasional community out-reach at the convenience of staff or administration, to becoming community-centred services, with in-reach into hospitals as required.”

Comments 5

  1. Ian Haywood says:

    Two points:

    d – Such separation is a retrograde step. I think psychiatry has to get over being in ‘hospital on the hill’ and completely cut off from everything else. This is how a low standard of care which would never be tolerated in other parts of the health system flourished and continues to flourish.

    f – Many mental services often cut back to the ‘barebones’ services: prescription of antipsychotics and basic social work focussed around stabilising accommodation. However this is a funding issue and driven by the bureaucracy, it’s not about the extent of ‘medical control’

  2. peterwo says:

    I agree with much of Alan Rosen’s commentary however re (d):
    The funding of Community Mental Health Services is just one of a range of issues and is often a furphy, even with existing funding the services could be both more efficient and more responsive to actual community need. Core service mix, at least at a State level, ideally Nationally, must be agreed so the public have consistency and choice, this must include real assertive community treatment teams (ie 24/7 continuous and reactive). In addition Child and Adolescent services (particularly in WA) need to wake up to the needs of 11-17 year olds and shrug off the Fountain House legacy, again its not the money preventing this change although CAMHS are currently massively underfunded.
    The NHHRC is a funding methodology proposal, not a solution to service delivery meeting need, thats for MHS’s to get on with, numerous National Plans and Strategies to date have had minimal impact.

  3. Jenny Haines says:

    There is some merit in Alan Rosen’s proposals, but such a Mental Health Commission at Federal Level would need to be an agile, active and responsive organisation to meet the needs for reform in mental health services across Australia, and I doubt if any Canberra bureaucracy can be that responsive.The States have certainly failed their obligations in the provision of mental health services. In ED Departments where patients are mainstreamed due to initiatives several years ago, patients are denied their legal rights under the Mental Health Act to the “least restrictive environment” and expedited processing. Despite the recognition in NSW by a previous Health Minister 5 years ago of the desparate need for more acute beds, the pressure on acute beds remains intense. Community based mental health services struggle along, understaffed and underskilled. Incidents happen, but they are covered up. Politician after politician at State level make promises, which all seem to end up in an intensification of workload for community staff and GPs. Perhaps Federal co-ordination can bring some order, and better standards of care into the mix but I am not convinced that remote Canberra bureaucracies can deliver what is needed on the frontline.

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Croakey Conference News Service 2013 – 2019
2013 conferences
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Closing the Credibility Gap 2013
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Racism and children/youth health symposium 2014
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Population Health Congress 2015
2016 conferences
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2017 conferences
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