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Redesigning mental healthcare to reduce number of people falling through the cracks

Introduction by Croakey: Continuing with business as usual in mental health policy will fail, according to a recent article by Professor Vikram Patel and colleagues in The Lancet.

They argue that effective responses to the growing global mental health crisis are hindered by the “dominant framing of mental ill health through the prism of diagnostic categories”.

According to Patel and colleagues, this has resulted in excessive reliance on interventions that are delivered by specialists, insufficient promotive, preventive, and recovery-oriented strategies, and a failure to leverage diverse resources within communities.

To transform mental health systems globally, they recommend applying a whole of society approach to prevention and care, redesigning the architecture of care delivery to provide a seamless continuum of care tailored to the severity of the mental health condition, investing more in what works to enhance the impact and value of the investments, and ensuring accountability through monitoring and acting upon a set of mental health indicators.

The latest prevalence data by the Australian Institute of Health and Welfare shows that approximately 20 percent of Australians have experienced a mental illness in the previous year.

To ensure people experiencing mental ill health have access to efficient and affordable mental healthcare, redesigning Australia’s “fragmented and dysfunctional” mental healthcare system is required, according to Dr Sebastian Rosenberg, Senior Lecturer, Brain and Mind Centre, University of Sydney.

Below, Rosenberg discusses a framework for redesigning Australia’s mental healthcare system.


Sebastian Rosenberg writes:

The University of Melbourne handed its evaluation of the Medicare Better Access program to the Federal Government in December 2022. The Government is yet to respond to the report fully, though it has already moved to limit the number of psychology sessions, ostensibly to boost broader community access.

People wait a long time for care, face considerable out of pocket costs with rates of access varying considerably depending on where you live. We can’t build the necessary workforce quick enough, and we can’t afford for this workforce to operate in the same way as it does now.

So, the task of designing a fit for purpose primary mental healthcare system remains undone. It is understood Minister Butler will establish an advisory group to help.

Well, as they say on the cooking shows, here’s one we prepared earlier – just published this month.

We recognise that some of the key professional groups, particularly general practice and psychology, may feel threatened by some of the suggestions we make here.

However, our focus has not been on bolstering individual services or roles, but instead on system design. This is difficult work, rarely undertaken in mental health, which is reasonably characterised as fragmented and dysfunctional.

The clearer reconceptualisation of primary mental healthcare shown in the diagram below relies on the development of several new functions.

Figure 1 – New consumer pathways in primary mental healthcare

Redesigning mental healthcare

Primary Health Networks (PHNs) must shift from their current marginal role in mental health to become central players in the management and coordination of the primary care response to mental illness in their regions. PHNs are currently, frankly, funded to fail in mental health, receiving only around 10 percent of federal expenditure on mental health.

For them to fulfil their regional planning and coordination mandate, they will require considerable additional support and infrastructure, including the capacity to monitor and track the mental health of their citizens.

One of the striking features of our current dysfunction is the length of time it often takes a person to find the right support. People often waste time bouncing between different providers with their underlying issues unaddressed or unidentified. People lose hope, get lost, fall through cracks.

We can fill these gaps, partly through establishment of a new and central role for specialist assessment, review and support, to be provided by psychiatry, clinical psychology, other expert mental health professionals or mental health nurses.

Australia’s psychosocial system, despite a burgeoning evidence base, has never been funded in Australia, typically garnering around six percent of total national mental health spending.

A properly organised primary care response to mental illness must include the establishment of a new national system of psychosocial support services (commissioned regionally), to operate as partners with clinical service providers.

In New Zealand, 30 percent of funded mental health services are provided by psychosocial service providers, offering a much greater variety of social prescribing and other services than currently available to Australians. General practitioners need more tools than pills or referrals, in addition to the services they provide themselves.

The aim of these three new functions is to promote the effective staging of the mental health service response, across both psychosocial and clinical services, so that the person gets the right level of help at the right time. The need for better, quicker triage and assessment in mental health has already been acknowledged by the Federal Government, which has invested in development of a new tool – the Initial Assessment and Referral Decision Support Tool (IAR-DST).

However, we must ensure any such triage tool can adequately differentiate the various clinical and psychosocial needs of individuals presenting to services.

Finally, these functions also depend on the ongoing monitoring of individuals. This means transparent reporting (aggregated and deidentified) of individual-level outcomes, to check the impact of the care provided. It should then be possible to determine further individual or organisational actions as needed, should the person’s health improve or worsen.

Underpinning this new primary mental healthcare system must be clinical and digital infrastructure to help people:

  • Enter the mental health system more easily and at low (or no) personal cost
  • Express their own specific clinical and psychosocial needs
  • Find the right clinical or psychosocial service the first time they present
  • Carry relevant prior and current treatment information across relevant clinical and psychosocial service providers
  • Assess the impact of various clinical and non-clinical interventions and services
  • Dynamically coordinate the service systems responses to a person’s needs.

This clinical and digital infrastructure needs to be regionally-deployed, to underpin rapid assessment and smart triaging to appropriate levels of clinical and psychosocial care. Additionally, it needs to play a central role in ongoing coordination of care.

This digital approach will empower new people to enter the system, become active consumers in their own healthcare journey, prevent the loss of key information over time and drive the healthcare system towards greater accountability for the provision of evidence-based therapies.

Removing barriers

This new system requires some major changes to the way people can access more specialised psychological care. It proposes removing one barrier, namely referral via a general practitioner, which is restricted by availability, cost and geography.

We also recognise that many people would prefer to access psychological care directly and independently of their other primary healthcare or psychosocial needs.

Consistent with our dynamic system modelling of what would deliver optimal outcomes for service users, it maintains an essential triage function that would assist people to access the ‘right care, first time, where they live’. It does not propose a Government-funded ‘open-access’ to psychological or psychosocial care.

For those who think all this seems magical thinking, many of the specific and desired service components of this new primary mental healthcare service system – as shown in the figure below – have been tried before, evaluated as effective but then disappointingly, defunded.

Components of contemporary primary mental healthcare

It should be the aim for our mental health system that every time someone seeks help for care, their needs are appropriately assessed and responded to in a personalised but standardised way, and with equity and consistency.

As The Lancet just published in relation to mental health policy, “business as usual has failed”.

Just adding more money or more professionals will not drive the deep, scaled reform required. More fundamental change is necessary.

Dr Sebastian Rosenberg was a public servant for 16 years, working in health in state and federal governments. He was Deputy CEO of the Mental Health Council of Australia from 2005-2009. He is Head of the Mental Health Policy Unit at the Centre for Mental Health Research at ANU and holds a position as Senior Lecturer at the Brain and Mind Centre, University of Sydney.


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