Last week, Professor Alan Rosen wrote an open letter to the PM, calling for health reform to be less hospital-centric and more focused on the provision of community-based care.
Now he and a colleague, Paul Fanning, have written the letter below, suggesting how the Rudd Government could take up their call to action in mental health reform. They write:
“Mr Rudd, if you really mean to bring about enduring transformation of the health system, firstly you need to move beyond playing ‘hospitals’, doctors and nurses, and nail your real colours to the mast.
To reduce pressures on our health system, evidence suggests looking beyond hospitals to how we can deliver much more health care in the community, particularly for preventive care and to claw back quality of life for longterm and recurrent conditions (see our article in the current issue of the Australian Health Review).
The principles that you should have constantly before the public include coordination of community care diverting people from needless emergency presentations, and that all community or hospital service components must be evidence-based to be supported.
Further, the growing mental health community (witness the current Get-Up and Transform Australia’s Mental Health Services (TAMHSS) campaigns) is trying to remind you that there can be no adequate health reform without substantial mental health reform.
This requires Australian governments once-and-for-all to squarely tackle huge gaps and inequities in access to mental health care. Access must be assured to early intervention teams, community respite residences as alternatives to hospital admissions, mobile crisis intervention, assertive community treatment and recovery-oriented teams, psychological, family and vocational interventions for all age-groups and all who need them, wherever they live.
Secondly, you should implement the recommendations of the National Health and Hospitals Reform Commission for the Federal Government to take over responsibility for all primary and community health services, and then re-integrate the system by contracting hospital services as needed.
Whether you do this, or even better, if you decide that the Commonwealth should fund all mental health care on an integrated basis, (as you are rumoured to be considering, and appear to want to do for all aged care), all mental health services should be contracted by regional mental health commissioning authorities. They should purchase services at arm’s length from all providers, whether community or hospital based, or operated by the public, private or NGO sectors.
Such regional authorities work well overseas. They could commission 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. This has been working smoothly in award-winning services in Wisconsin for many years.
By contrast, your proposed Local Hospital Networks seem similar in structure to existing Area Health Services, with similar inefficiencies of confounding commissioning with provision of services, and they seem likely to be dominated by eminent hospital-based doctors pressing for more technical procedures, ensuring that preventive and psycho-social interventions remain poor cousins. We should not make the mistake again of expecting hospitals to look after such services or community health care, especially when the funding chips are down.
Also, if we are to have a federal funding takeover, we should not miss this opportunity to bring together all funding streams provided by the Commonwealth, and integrate all health and support service purchasing and provision in our communities. Recent studies in urban, rural & remote Australia and Canada demonstrate that private practitioners are most receptive to a negotiated blend of fee-for-service and supplementary indirect payments to help rebalance priorities between the needs of the most and least privileged clientele, eg to ensure access to sound physical care for those with mental illnesses.
Thirdly, mental health funding and expenditure, both capital and recurrent, must be much more strictly quarantined and managed separately from other health resources (ie neither by general hospitals nor by divisions of general practice, which often have more clinical procedure-focused priorities). It is time to play “hard ball” in holding on to mental health resources. This separation is now enshrined in legislation in Western Australia, together with the establishment their new Mental Health Commission.
Fourthly, community mental health services should be co-located with primary health in the shopping centres of their communities wherever possible. However, the coherence of discrete evidence-based mental health teams and their budgets must be preserved. Mental health workers should not be merged into generalist teams, even if they are outpost liaison workers with GPs, 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.
Fifthly, governance should be genuinely interdisciplinary, not medically controlled, so that cost-effective and recovery-oriented psycho-social interventions, including expert psychological and family therapies, continue to be developed and supported. Consumers and carers should be routine participants in service development, rather than gestural and erratic consultation at the occasional convenience of mental health administrators, when they are just ticking another box (eg in revising policies, standards, and for accreditation surveys).
Sixthly, the Commonwealth should re-establish the sending of strong monetary signals to oblige the regions to consistently implement evidence-based, recovery-oriented and community-focussed mental health interventions and service delivery systems, which could be assured by your establishing of a National Mental Health Commission or Authority. It should be mandated to independently monitor implementation and outcomes, and provide transparent accountability by reporting to the public, parliament and government. It should also listen to all stakeholders regularly, giving them a voice which is heeded, consistent with real social inclusion.
Finally, you should consider forming a national mental health care working group to reporting directly to you, Prime Minister, as, like motor vehicle accidents, mental health and illness should be an all-of-community and all-of-government concern. Annual deaths due to suicide and car accidents are almost the same, and both impact on many thousands of other Australians’ lives.
This working group could produce a blueprint for an initiative by you of a National Mental Health Program, replacing the recently diluted and downgraded national mental health policy, plan and standards, and the soon to expire CoAG initiatives. It should make recommendations on the range of services required consistent with emerging evidence, budget allocations for a better balance between community and hospital mental health services, and between urban, rural/remote and on-line service provision.
It should consider the commissioning, governance and how to ensure integrated provision of all components of care, key performance indicators, outcome goals, research priorities, adequacy of their funding base, and budget protection mechanisms. It should review the functions of existing state and national mental health commissions and recommend how to establish an equivalent body to ensure transparent accountability.
It should be chaired by an independent person with a good hold on 21st century mental health and public health priorities, eg. Pat McGorry, with an equivalent working group for community health chaired by Kathy Eagar or John Menadue.
Finally, we acknowledge that the destination of transformative health reform may be a difficult course to steer politically, as Mr Obama also found.
But with the wind of a burgeoning movement of mental health stakeholders billowing your sails, may you be buoyed up through the storms to come, and find calmer waters for you and your colleagues, and for all who are buffeted and concerned by mental illness in our everyday lives.
Alan Rosen, Secretary, Comprehensive Service Psychiatrists’ Network, Professorial Fellow, School of Public health, University of Wollongong, Clinical Associate Professor, Brain & Mind Research Institute, University of Sydney.
Paul Fanning, Centre for Rural and Remote Mental Health, School of Medicine and Public Health, University of Newcastle, Orange.