As the sector digests the 1200-page Draft Report from the Productivity Commission’s Inquiry into Mental Health, Croakey will bring you responses to its findings and recommendations from key experts and commentators.
Please contribute to the discussion on this important report via Twitter (see this thread for a useful summary) and/or through commenting on Croakey.
Below, Dr Sebastian Rosenberg, from the Brain and Mind Centre, University of Sydney, provides some initial commentary on the report and reflects on the three priorities he nominated in the lead-up to its release.
Sebastian Rosenberg writes:
I, like many others, expected the Productivity Commission report to have a very strong focus on the things which typically matter most to consumers and their families – opportunities for employment, housing, education and the chance to live ‘a contributing life’.
My initial impression of the sprawling 1200-page report is its surprising focus on the health system, rather than these matters of personal and broader economic concern.
As an example, there is an almost sole focus on Individual Placement and Support (IPS) when it comes to employment. I realise this is the area best evaluated but there are many employment support mechanisms that should be tried and evaluated in order to help find and keep a job. Why aren’t these explored?
This is only the draft report. Clearly the Commission need every encouragement and idea to make the final report as ambitious and aspirational as many hoped it would be. We are well past the time of ‘small fixes’ in mental health.
In the lead up to release of the report, I indicated I was keen to see reform on three fronts. Here is my take on the outcome so far.
1. Commitment to build secondary mental health services to fill gap between GP and hospital
This must reflect both clinical and psychosocial services and deliver hospital avoidance and economic outcomes (employment etc.)
The Commission seems to really struggle with the role to be played by secondary mental health services provided in the community (not hospital), particularly those provided in the psychosocial sector. They seem to see these as significant only for NDIS recipients, in which case these services would be Federally-funded, or for people with chronic mental illness for whom clinical care had failed, in which case psychosocial services would be provided by the states/territories.
With this kind of thinking, it is little wonder this critical element of mental health reform, providing vital hospital avoidance care, has failed to emerge in this country.
And of course it is the psychosocial sector that provides key mental health employment support services.
More generally, the draft report seems to miss an opportunity to address the concept of the ‘missing middle’, failing to describe the landscape of services that should exist here.
I am not quite sure how any model of ‘stepped care’, which the report supports, can emerge in these circumstances.
2. A funding mechanism that prioritises early intervention and integrated care
Physical health is very important here.
The draft report has a significant and welcome focus on childhood and family mental health needs as the Commission sensibly try to respond to the long term costs of failing to give Australians the best start. It also has a big focus on schools and universities as places to drive mental health care, through ‘wellness leaders’ and other initiatives.
How these link in to the everyday work of teachers and schools is a significant question, as well as the call to include more focus on mental health as part of the curriculum and teacher training.
And of course it is likely that kids with emerging mental health needs may well need support after the school bell, which points again to the need for an explicit strategy designed to foster community mental health services, available 24/7.
Despite abundant evidence regarding the intimate link between mental illness and physical comorbidity, the draft report seeks to clearly separate both the funding and the governance associated with the two issues, ostensibly to drive clearer outcome reporting.
This separation has not worked well in relation to mental health and drug and alcohol services. This is an area that needs urgent attention. People are dying early and its not from mental illness.
3. Ongoing mechanisms to oversee and help implement change and systemic accountability
This is where successive previous reports have failed. Especially important here is direct independent feedback from consumers and carers to drive quality improvement.
Tired of Divisions of General Practice? Bored with Medicare Locals? PHNs causing ennui? Regional Commissioning Authorities are coming soon! These new bodies would combine PHNs and state/territory funded Local Health Districts to pool resources in relation to mental health.
This could be powerful and address traditional funding silos.
But how to stop the hospitals dominating community-based care? After all, it is the hospitals open 24/7 and the Commission has already suggested we lack acute care beds as well as something called ‘sub-acute’ mental health beds.
The Report suggest activity based funding could assert this balance but this really needs further exploration.
And while the Report makes the usual gestures towards consumer and carer co-design in planning, it fails to address the reality – that consumer and carer organisations lack the resources and support they need to build sufficient expertise to properly participate as partners in these technical processes. This leaves them as ‘participants’ at best, not drivers of change.
Pooling regional resources does seem sensible, though using existing access to Medicare to calculate this initial pool as the Report recommends would seem to perpetuate current inequity rather than address regional need.
But the real question here is, what kind of skills and support do the regions need if they are to plan well and accurately to meet current and future needs? How well are PHNs and LHD doing this together now? And are we aiming to perpetuate stasis or recovery? What is our ambition? The Report does not present any clear picture.
In terms of accountability, the Report recommends making the National Mental Health Commission a statutory authority. But beyond its legislative ‘teeth’, it will need skills, data, independence, leadership and funding if it is to help regions meet agreed national quality standards and improve their performance.