Continuing his series on mental health reform, Sydney psychiatrist Professor Alan Rosen argues that the states – well most of them anyway – have forfeited the right to run community mental health services.
“The National Health & Hospitals Reform Commission proposes to hand all community health to the Commonwealth, to be integrated with primary care, but to leave hospitals, including emergency departments and outpatients, in the hands of the States and Territories.
With a few exceptions (possibly Victoria, & the ACT, and potentially WA), the states and territories have forfeited the right to run community mental health services.
They have often been frankly negligent custodians of community health services. They have generally allowed 24/7 mobile community care to wither, and have retreated to “fortress-hospital” psychiatry, providing few community alternatives, leading to access-block in Emergency Departments and overcrowding of inpatient facilities.
Most states have also done a poor job of funding NGOs to provide community-based psychosocial and support services consistently both in urban and rural settings. Moreover, the split in state/federal funding has contributed to cost and blame shifting, fragmentation and gaping holes in service provision.
We should advise the Australian Government to proceed with the Federal takeover, ideally of all health.
If that is not possible, they should at least take over all community health, including community mental health services, and co-locate them with primary health care centres in “one-stop-shops”, as long as:
a) No states are allowed to declare the “community cupboard bare” prior to transfer of community facilities and teams to the Commonwealth, by accelerating the shifting of remaining community services back into hospital-based out-patients buildings before this occurs.
b) Community health facilities in shopping hubs are no longer allowed to be retracted from the community onto less convenient hospital campuses, so that their community sites can be sold to finance the rebuilding of hospitals. The NHHRC final report appears oddly indifferent to this, considering its trajectory.
c) Regional health funding and commissioning authorities, which must be independent of all service providers, are in place to ensure truly integrative service provision between all health sectors, public, private and non-government community managed organizations.
This should include a holistic range of acute and rehabilitative interventions, and the purchasing of inpatient beds, with community based senior clinicians authorized to supervise care for their own clientele while they are inpatients, as has been working well in Wisconsin for many years.
Such authorities could also supplement fee-for-service clinicians’ existing income with indirect incentive payments to provide enhanced, ongoing access to general medical care for individuals with severe mental illnesses.
These blended strategies have been shown to be suitable for Canada in a recent report, and effective in the Commonwealth funded Integrated Mental Health projects in urban, rural and remote Australia.
d) mental health funding and expenditure, both capital and recurrent, is quarantined and managed separately from other health resources, (ie neither by general hospitals or divisions of general practice, who often have more clinical procedure-focused priorities).
e) the coherence of discrete evidence-based mental health teams is preserved. Mental health workers should not be merged into generalist teams, even if they are outpost liaison workers with GP’s, Headspace Youth Health Centres, etc. Only since we have had such teams focusing on particular functions or phases of care, have mental health services been able to demonstrate substantial improvements in outcomes.
f) that governance is genuinely interdisciplinary, not medically controlled, so that cost-effective and recovery-oriented psychosocial interventions, including expert psychological and family therapies, continue to be developed and supported,
g) that consumers and carers are included routinely in service development and related decision-making, rather than gestural and erratic consultation at the occasional convenience of mental health administrators, when they are just out to tick another box (eg in developing policies, plans, standards, and for accreditation surveys).
h) the Commonwealth re-establishes the sending of strong monetary signals to oblige the regions to consistently implement evidence-based and community-focused mental health interventions and service delivery systems, and
i) There is a commitment by the Commonwealth Government to establish a National Mental Health Commission or Authority to independently monitor implementation.
We need to attend to the persistent under-servicing of the Australian community as demonstrated by the ABS surveys of 1997-2007, poor coordination of the care that is available, lack of consistent provision of an adequate and holistic range of evidence-based interventions, over-concentration of all services in hospitals, and the lack of transparent accountability, with real consequences, in terms of monetary sanctions and incentives, which are not issues the NHHRC squarely tackled.
There is an international consensus that we need a shift of the centre of gravity of mental health services from being hospital-centred with occasional community out-reach at the convenience of staff or administration, to becoming community-centred services, with in-reach into hospitals as required.”