This report from Dr Sebastian Rosenberg summarises a recent virtual roundtable on the implications of COVID-19 for Australia and the future organisation of mental health care.
It identifies some of the key lessons arising from international experiences and discusses the factors required to mount an effective mental health response, including access to universal public health care, integrated primary-community-tertiary care and a solid psychological crisis intervention model.
The article, the second last in a series by Rosenberg, also addresses the success of the Aboriginal Controlled Community Health Organisations (ACCHOs) in preventing the spread of the virus to Aboriginal and Torres Strait Islander communities and suggests some opportunities for mental health reform arising from the pandemic.
Sebastian Rosenberg writes:
This final webinar focused on the implications for Australia and the future organisation of mental health care. The presenters participating in this virtual roundtable were:
It should be noted that one of the challenges of a roundtable such as this is representation.
Some important voices were not presenting: consumers, carers, Medicare providers, pharmacists and others. Similarly, we were not able to run specific seminars in covering areas such as ageing. Going forward it will be important to ensure these voices are heard.
It was also noted that while many people were clearly concerned about the impact of isolation on mental health consumers, some of this group of people may well be accustomed to isolation, more resilient and better able to cope than the general public.
Key findings internationally
Co-host Professor Luis Salvador-Carulla began stating that this series had permitted participants to understand how 15 different regions and cities had responded to COVID-19, some from areas where the impact had been explosive, others less so.
Some key lessons arising from this experience were:
- The spread of cases very uneven across countries and regions. This has affected the response and determined if services were overwhelmed or could cope.
- In mental health, all forms of care – residential and outpatient – have been affected, in many cases stopped completely. The rise in telehealth is a common feature. But it has been haphazard, unregulated and opportunistic; not systematically monitored/evaluated and without an ethical framework (except in Taiwan).
- All regions expect a ‘rebound’, with existing consumers re-emerging from lockdown very unwell together with new clients placing impossible demands on mental health services. This will include children and others impacted by trauma. There is almost no preparation for this, again excepting Taiwan.
- The centrality of psychosocial supports for both those with existing mental illness and people newly affected by the pandemic through anxiety, loss of employment, bankruptcy etc, was acknowledged by all. Suicide surveillance and support critical.
Co-host John Mendoza then shared some of the key ingredients which had emerged in successful management of mental health care in the context of COVID-19, including:
- access to universal public health care
- integrated primary-community-tertiary care
- well documented and rehearsed pandemic plans addressing bio-psycho-social impacts
- deployment of a solid psychological crisis intervention model
- targeted support for highly vulnerable groups (for example kids with neurodevelopmental disorders in Boston)
- data driven decision making – an absence of data caused difficulties
- rapid response and deployment – hesitation equalled disaster
- national leadership with regional interpretation and deployment – this was key ingredient in balancing national guidance with local action
- high tech application – digital tools and platforms.
The roundtable then considered the key question of how planning for the future of mental health in Australia should reflect the issues raised here.
The roundtable heard from mental health commissions operating in NSW, Victoria and at the national level. Packages of mental health support had been devised and implemented by these governments. NSW had made changes to increase flexibility in the operation of its Mental Health Tribunal, through telephone hearings, extended time between hearings and adjournments.
Victoria had weekly forums between key organisations, including the commission, to update advice and guidance. It had also developed a set of key principles to guide the mental health aspect of its COVID-19 response. These principles make it clear that the responsibility for pandemic response reses with each local health service and should be informed by concern for equity, access and quality.
The principles also clarify that difficult decisions about access, treatment and safety will need to be made by service providers in Victorian Mental Health Services, working with consumers and their families during the Covid-19 pandemic and that local services can consider seeking guidance from Ethics Panels or Committees, that include people with lived experience as members.
Victoria’s model of mental health commission as a complaints body gave it real time access to emerging concerns by consumers, which have so far included:
- concerns about restrictions on visitors to services, and changed working arrangements within services (suspension of leave for example)
- concerns about the risk of contracting COVID 19 in shared spaces in acute units and community care units, as well as social distancing practices in community care
- planned closure (full or partial) of some facilities to repurpose for COVID-19 treatment
- concerns about consumers’ ability to understand COVID-19 risks and restrictions
- availability of community-based treatment, administration of medication and delayed changes to oral medication.
The National Commission is participating in meetings of all the commissions, assisting in the preparation of a national COVID-19 mental health plan and monitoring changes in service use. They are working with national agencies like the Australian Institute of Health and Welfare to assist in tracking trends and providing greater insight into service use and impact.
Aboriginal and Torres Strait Islander issues
Professor Pat Dudgeon emphasised the concerns for Aboriginal and Torres Strait Islander communities, including not just health issues and concern for elders, but the fact that COVID-19 disrupted important social activities, sorry business and other elements of cultural life.
She referred the roundtable to the recent COVID-19 Roadmap to Recovery report, produced by the Group of Eight universities. This paper (as reported at Croakey) referred specifically to Aboriginal and Torres Strait Islander needs and issues and made four key recommendations as shown below.
What was clear so far, however, was the success largely engineered by swift national action taken by Aboriginal Controlled Community Health Organisations (ACCHOs) in preventing the spread of the virus to Aboriginal and Torres Strait Islander communities, including in rural and remote areas.
Dudgeon stated that the ACCHOs had moved to take action to protect communities, stopping visitors and travel and organising quarantine places before governments had acted. There were only 50 COVID-19 cases among Aboriginal and Torres Strait Islander people, all dwelling in urban areas.
This is a stark contrast to the impact of the epidemic on Navajo people in the United States (almost 2300 cases at 4 May 2020). The roundtable also learned of the Indigenous Respiratory Outreach Care (IROC), a specialised respiratory outreach service for Aboriginal and Torres Strait Islander people living in rural and remote communities in Queensland, operating from Prince Charles Hospital.
Dudgeon explained that the Aboriginal and Torres Strait Islander leadership group were meeting nationally to discuss how best to progress these issues and the advice to governments.
The roundtable considered how the distributed model of leadership across Aboriginal and Torres Strait Islander communities was a source of strength during the response to the epidemic.
Opportunities for reform
Dr Chris Lilley pointed out that Australia had benefitted by not being among the first countries affected by COVID-19, affording some time to learn and prepare. He and Dr Daniel Rock both emphasised the incredible work done by new teams to build capacity into services.
He suggested there was benefit in having mental health leaders leading these pandemic teams, making it more likely they consider the mental health needs of affected patients and seem able to deal with ambiguity and change.
Lilley and Rock also emphasised the importance of both access to and training in the use of PPE equipment for mental health staff. Lilley noted that some 100 doctors have died of COVID-19 in the UK. COVID-19 had also fostered service innovation, with drive-in testing clinics starting in Caloundra and virtual clinics to support sites elsewhere.
The key theme of Rock’s presentation was that mental health should not waste a good crisis. The Productivity Commission’s draft report had already reported that:
- The current planning and service delivery models for mental health services in Australia do not adequately meet the needs of individuals or communities
- Much of what is funded has zero, low or indeterminate value
- There is a bewildering choice of services but little commensurability
- There is a disproportionate investment in specialism that leads to queueing, waiting and failure demand
- Service planning and system performance is opaque (at best).
On this basis, WA had already embarked on some important elements of more fundamental and durable reform, including the Practitioner Online Referral Treatment Service (PORTS).
PORTS still offered face to face primary mental health care, but not as default option, using telehealth options first. This was important given inequitable access to Medicare services in rural and remote areas (see Meadows et al).
Rock stated that COVID-19 had highlighted the need for more of this type of innovation, which was beyond simply ensuring a stable internet connection and access to an e-health record.
More fundamental re-design of our current fractured approach was critical now.
Central to this would be to reinvigorate the concept of generalism in mental health care (rather than specialism) and the capacity to scale effective services not only up to meet the needs of more people, but also out, from the cities to other areas of Australia.
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.
This report summarises the eighth and final webinar in a series of e-presentations about the international impact of COVID-19 on mental health, jointly hosted by the Centre for Mental Health Research (CMHR) at the Australian National University and ConNetica Consulting, as a community service to share expert knowledge during the pandemic.
104 people participated in this event and over the whole series there have been more than 1,000 participants and more than 1,400 views/downloads. See here for information on future events.