The recent release of revised national standards for mental health services is not the good news that it could and should have been.
Sebastian Rosenberg, a regular contributor at Croakey on mental health issues, has provided an overview of the history of the original and the revised standards, highlighting some of the gaps and hitches in their development and implementation.
Sebastian Rosenberg writes:
Without much fanfare, the Commonwealth recently released the revised National Mental Health Service Standards. This brought to blissful conclusion a three-year odyssey for all involved.
The 2010 version replaces the national standards first published in 1996. These original standards reflected the optimism of mental health reformers at the time, fitting as they did into the shiny new policy infrastructure of the first national mental health plan. Designed to apply to all mental health service settings, the original standards were widely respected by service providers, consumers and carers alike as the proverbial light on the hill. The standards combined practical guidance for service quality improvement with aspirational goals to inspire excellence.
While the 1996 infrastructure was highly valued, the standards fell down in their implementation. Accreditation became a mechanical tick-a-box exercise for many mental health services and there was little if any funding provided to encourage or reward quality improvement activities.
When the Commonwealth tendered for the standards to be revised, it was welcomed by the mental health sector. After 10 years, they needed to be updated to better reflect contemporary models of service provision and mental health care.
However, the selection of the Australian Council of Healthcare Standards (ACHS) to undertake the revision was met with considerable concern at the time.
While not wishing to criticise the ACHS, as the body chiefly responsible for the implementation of the standards there was a strong perception of a conflict of interest. The group auditing the standards was now also writing them.
There was every prospect the standards would reflect the needs and issues of the auditors rather than the consumers and carers desperate to see them effectively drive quality improvement.
The project did not run smoothly. Continual staff turnover precluded the ACHS from delivering continuity in project management. More regularly, members of the expert advisory panels established to assist the ACHS were not able to see their advice reflected in project development. This was a significant change from 1996 where the whole process was largely driven by a collaborative, multidisciplinary group and much effort was spent eliciting a sense of inclusion and ownership by the sector. Things were different this time.
There were fundamental methodological issues too. At the start of the project, primary care settings were clearly in scope, sensibly given the federal government’s massive new investments in the Better Access Program (among others).
Somewhere along the line, primary care was dropped by the project team, without reference to the advisory group. Towards the end of the project and once this change became clear, it was rather hastily agreed to build what was called an ‘interpretive guideline’ to assist in the application of the new standards to primary care settings (rather strangely called ‘office-based settings’).
The dominant focus in the Standards on the public acute system is further highlighted by the fact that this was not the only such guideline developed. Others were necessary in order to promote the use of the new Standards in Aboriginal and CALD settings, alcohol and drug services as well as for the community-managed mental health sector. A series of bandaids were applied.
As the ACHS lost control of the standards development process, responsibility fell increasingly to the Federal Department of Health and Ageing. While they drove the project forcefully, the advisory expert groups became even less influential in the project.
At some point in the project’s design, it had been agreed to develop one specific standard to be called the ‘consumer recovery standard’. Rather than imbue all the standards with a recovery ethos, it was deemed preferable to try to wrap the concept up in its own standard. If this wasn’t controversial enough, unfortunately the project timing precluded useful consultation with consumers and carers about ‘their’ standard, diminishing their understanding of the standards and sense of ownership.
The 2010 version of the Standards provides no new specific funding to enable implementation, as usual leaving it up to jurisdictions to carry this out. There is no audit of this process proposed, nor any oversight committee specifically established to monitor the standards and even to start planning their next revision.
Given the at best patchy implementation of the 1996 mental health service standards, there will be those who may posit that the net impact of the 2010 revision process is not that important.
In fact the Australian mental health system has now lost an important element of its infrastructure, swapping a holistic, respected set of standards for one that is primarily focused on public acute mental health facilities and is largely devoid of its aspirational element.
But perhaps most significantly, consumers and carers have lost a light on the hill guiding them towards better quality mental health care. We are all a little more lost.
• Sebastian Rosenberg is Director, ConNetica Consulting Pty Ltd, and a Senior Lecturer, Brain and Mind Research Institute Sydney Medical School
• For more background, see this article, “Australian National Standards for Mental Health Services: a blueprint for improvement”, published in the The International Journal of Leadership in Public Services in October, 2009.
The Australian Council on Healthcare Standards (ACHS) refutes many of the assertions about it in the post.
First and foremost, when ACHS won the contract from the Commonwealth it was a requirement that the project be compelted according to directions set down by the Commonwealth Department of Health and Ageing (DOHA).
The fourth national standards are good and useful in many ways. We should be glad that we have a new set of standards and the that sector isn’t expected to work with a 14 year-old audit mechanism.
However, this lowly mental health worker once tried to match the new standards to a respected set of recovery-oriented service delivery indicators with the hope that there would be a large amount of crossover – thereby allowing services/organisations that want to both meet the standards AND be recovery-oriented to avoid having to complete different (time-consuming and costly) audit requirements.
It was a less than successful endeavour. One set was about focusing on the needs and rights of consumers and carers. The other was primarily about risk-management.
The whole mental health issue is akin our education ills. Everybody wants more money but we do not know the cure.
For a small country (population wise) like Australia, with a very good climate, good standards of living and enormous resources, why do we have so many sick people?
Why so many mentally ill people? Do we know the reason? Do we want to kow the reason?
We have so many mentally ill people firstly, because the global rate for the three most severe biological, incurable disorders, schizophrenia, bipolar 1 and clinical depression, (according to the World health Organisation/WHO) is 2.5 to 3% persons per 100. For Australia’s population, this means some 550,000 to 600,000 seriously mentally ill. Secondly, there are many other mental illnesses which can be helped and an increasing number of mentally ill who suffer from alcohol and other drug addictions.
The first group are those most neglected by all governments, with an increasing hidden suicide rate (WHO, 2008, shows a 21.4 per 100,000 suicide rate, twice that published in Australia, and almost three times the rate of 8 per 100,000 road deaths).
The most seriously ill have a life expectancy 25 years lower than average, 55 rather than 80 years. Mr Rosenberg’s article offers no hope for improvement of policy or care. Recent research, covering 1916-2004, shows that, for the seriously mentally ill, good physical health and life expectancy have decreased in these 88 years. “There are no gains.”
The seriously mentally ill, in 2016, begin their second known century of decline.
As one of the incurables mentioned above and a big user of mental health services I for one am happy that a specific definition of “recovery” has been included. The previous position where every standard was imbued with the Recovery ethos only resulted in every worker having a different view of what was meant by “recovery”.
This led to disempowerment as consumers couldn’t have a logical discussion about what “recovery” meant in terms of services delivered. The latest definition I have heard was that “Recovery is life”. Try to respond to that in an argument about how services should be delivered.
We now seem to have a clear definition and I will be referring to it quite a lot. I thought the standards seemed quite good.
I have an article about potential problems with the Recovery ethos here:
Great article, unfortunately due to a busy schedule and the ‘seduction of businessess’ that happens when one works in a busy Mental Health Service I hope I haven’t missed the opportunity to comment on you article.
NSW Heath made much fanfare about the newly released National Mental Health Service Standards with a poster and video competition. My entry CoAT Workshop recieved a special mention and can be found at this web site address http://www.health.nsw.gov.au/mhdao/standards/winning_artwork.asp.
The prize of $500.00 was not to be sneezed at I donated it to the Caritas Starwards Special Purpose Trust Fund. A new way of making peoples stay on the ward more interesting. It a program from UK with 75 ideas to improve the way an acute ward works http://www.starwards.org.uk
Lynda and I are developing our own web site http://www.coatconsulting.com.au specificially designed to audit the new National Mental Health Service Standards, we would be interested in yours and other feedback.
I would agree that 1996 infrastructure was highly valued by consumers; many of us saw it as a promise to fix a broken system, the promise fell down in how it was implementated. The Commonwealth’s own 2003 report on the Evaluation of the Second National Mental Health Plan (Australian Health Ministers’ Advisory Council 2003) highlights this and can be found at this address http://www.health.gov.au/internet/main/publishing.nsf/content/32F3D4FD46CD6E1DCA2571F800067BE6/$File/eval2.pdf
It would be interesting to see how the following three paragraphs taken from page 10 would be answered today if we were to ask for this information under Freedom of Information if one had the time and energy to write a request:
Review of Mental Health in the Australian Health Care Agreements
A review of mental health in the Australian Health Care Agreements (AHCAs) was undertaken by an expert Reference Group set up by the Australian Health Ministers. This review was part of a wider investigation of nine health areas within the AHCAs carried out by different Reference Groups. These reviews were undertaken to inform considerations about future health care reform.
The Mental Health Reference Group considered national objectives for the provision of mental health care, opportunities to improve the performance of the health service system and minimise barriers, initiatives that could be progressed through the health care agreements, and those that could be progressed outside the health care agreements.
In its report on how to progress mental health within the Australian Health Care Agreements 2003-2008, the Reference Group paid particular attention to the International Mid-Term Review of the Second National Mental Health Plan and the October 2001 AHMAC Response to the National Mental Health Working Group, Workplan for 2001-2002.
You also make an interesting point about ACHS role in the review process of the standards and many consumers will watch with interest to see what happens as the new Mental Health Commissions start to take shape around the country
I would be interested in talking further with you about how we can continue to keep this issue on the agenda especially with the many other competing issues that seem to take the focus once an announcement is made and we then get overtaken due to a busy schedule and the ‘seduction of businessess’. I wonder if this will be included in he new DSM V when it is released
I would be interested in see the work you did with matching the new standards to a respected set of recovery-oriented service delivery indicators.
Would you have a document that you could place on the web so your work does not get loss
SAMSHA has just come out with another