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Why the new national mental health service standards are an opportunity lost

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.