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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.

Comments 12

  1. ACHS says:

    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).

  2. Tully Rosen says:

    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.

  3. Rena Zurawel says:

    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?

  4. carol93 says:

    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.

  5. Maggie says:

    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:
    http://stopthrashingaround.wordpress.com/2010/09/01/the-recovery-model/

  6. Douglas Holmes says:

    Sebastian

    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

    Douglas Holmes

  7. Douglas Holmes says:

    Tully

    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

    Douglas Holmes

  8. Douglas Holmes says:

    Maggai

    SAMSHA has just come out with another definition we could have lengthy discussions about how this matches with the new Supporting Recovery standard released in November.

    SAMSHA new working definition of Recovery is as follows:

    A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.

    “Over the years it has become increasingly apparent that a practical, comprehensive working definition of recovery would enable policy makers, providers, and others to better design, deliver, and measure integrated and holistic services to those in need,” said SAMHSA Administrator Pamela S. Hyde. “By working with all elements of the behavioral health community and others to develop this definition, I believe SAMHSA has achieved a significant milestone in promoting greater public awareness and appreciation for the importance of recovery, and widespread support for the services that can make it a reality for millions of Americans.”

    A major step in addressing this need occurred in August2010 when SAMHSA convened a meeting of behavioral health leaders, consisting of mental health consumers and individuals in addiction recovery. Together these members of the behavioral health care community developed a draft definition and principles of recovery to reflect common elements of the recovery experience for those with mental disorders and/or substance use disorders.

    In the months that have followed, SAMHSA worked with the behavioral health care community and other interested parties in reviewing drafts of the working recovery definition and principles with stakeholders at meetings, conferences and other venues. In August 2011, SAMHSA posted the working definition and principles that resulted from this process on the SAMHSA blog and invited comments from the public via SAMHSA Feedback Forums. The blog post received 259 comments, and the forums had over 1000 participants, nearly 500 ideas, and over 1,200 comments on the ideas. Many of the comments received have been incorporated into the current working definition and principles.

    Through the Recovery Support Strategic Initiative, SAMHSA has also delineated four major dimensions that support a life in recovery:

    ■Health : overcoming or managing one’s disease(s) as well as living in a physically and emotionally healthy way;
    ■Home: a stable and safe place to live;
    ■Purpose: meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income and resources to participate in society; and
    ■Community : relationships and social networks that provide support, friendship, love, and hope.

    Guiding Principles of Recovery

    Recovery emerges from hope: The belief that recovery is real provides the essential and motivating message of a better future – that people can and do overcome the internal and external challenges, barriers, and obstacles that confront them.

    Recovery is person-driven: Self-determination and self-direction are the foundations for recovery as individuals define their own life goals and design their unique path(s).

    Recovery occurs via many pathways: Individuals are unique with distinct needs, strengths, preferences, goals, culture, and backgrounds ? including trauma experiences ? that affect and determine their pathway(s) to recovery. Abstinence is the safest approach for those with substance use disorders.

    Recovery is holistic: Recovery encompasses an individual’s whole life, including mind, body, spirit, and community. The array of services and supports available should be integrated and coordinated.

    Recovery is supported by peers and allies: Mutual support and mutual aid groups, including the sharing of experiential knowledge and skills, as well as social learning, play an invaluable role in recovery

    Recovery is supported through relationship and social networks: An important factor in the recovery process is the presence and involvement of people who believe in the person’s ability to recover; who offer hope, support, and encouragement; and who also suggest strategies and resources for change.

    Recovery is culturally-based and influenced : Culture and cultural background in all of its diverse representations ? including values, traditions, and beliefs ? are keys in determining a person’s journey and unique pathway to recovery.

    Recovery is supported by addressing trauma : Services and supports should be trauma-informed to foster safety (physical and emotional) and trust, as well as promote choice, empowerment, and collaboration.

    Recovery involves individual, family, and community strengths and responsibility: Individuals, families, and communities have strengths and resources that serve as a foundation for recovery.

    Recovery is based on respect : Community, systems, and societal acceptance and appreciation for people affected by mental health and substance use problems – including protecting their rights and eliminating discrimination – are crucial in achieving recovery.

    For further detailed information about the new working recovery definition or the guiding principles of recovery please visit: http://www.samhsa.gov/recovery/

    Douglas Holmes

  9. Douglas Holmes says:

    Sebastian I wonder which of the assertion ACHS agree with

    ‘The Australian Council on Healthcare Standards (ACHS) refutes many of the assertions about it in the post.’

    Douglas

  10. Smith Tina says:

    Doug, The standards mapping activity that Tully referred to was towards developing ROSSAT (the Recovery Oriented Service Self Assessment Toolkit).

    ROSSAT is a quality improvement tool. It was developed by the NSW Consumer Advisory Group (CAG) – Mental Health Inc. and the Mental Health Coordinating Council (MHCC) in partnership with people affected by mental health problems and service providers.

    ROSSAT has been designed to assist organisations and staff to:

    •Assess their level of recovery oriented service provision
    •Reflect on both individual and organisational practice in relation to recovery oriented service provision
    •Identify and work on areas requiring improved practice in delivering recovery oriented services.

    The six Key Indicator Areas considered by the ROSSAT are:

    1.Relationships
    2.Respectful practice
    3.Consumer self-directed focus
    4.Belief in consumers recovery
    5.Obtaining & sharing knowledge and information
    6.Participation and social inclusion.

    More information about ROSSAT can be found here: http://www.mhcc.org.au/rossat/default.aspx

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