The international review of the National Mental Health Strategy, completed by Dr Ronald Manderscheid, Deputy Director of the Centre for Mental Health Services, US Department of Health and Human Services, summarised Australia's position as follows:
"Australia has articulated a national mental health policy through the National Mental Health Strategy, has provided flexible resources to facilitate system transitions from an inpatient to a more balanced service delivery system, has engaged consumers and carers in focal roles and has emphasised concerns with quality and outcome as major system goals. Taken together, these four elements reflect the cutting edge of mental health at the international level...
The Commonwealth, State and Territory mental health leadership are to be commended for this achievement, which has occurred in a time span of less than five years. More remains to be done, but Australia is prepared and energised to accomplish these things and even more over the next three years."
These comments, made by the Deputy Director of an organisation with extensive authority in the international mental health community, provide powerful endorsement of Australia's efforts to reform its mental health system.
They also reflect the view developed by the Committee during its two years of evaluating the National Mental Health Strategy. The evidence is compelling that the shape of mental health services has changed substantially over the five year Strategy period. Overwhelmingly, there is broad agreement that it has created the impetus for change and guided reforms that followed.
Equally, there is concern that current services fall far short of the Strategy vision for Australia. Service improvements are uneven, across and within jurisdictions. Many areas are yet to experience a tangible benefit from the National Mental Health Strategy reforms, indicating the structural reform agenda is not finished. Concerns about poor service quality and client outcomes have only begun to be addressed.
The theme of 'unfinished business' is the essence of the committee's final report to AHMAC. We urge the Commonwealth, State and Territory policy makers to recognise that what has been started will need continued policy attention. Many initiatives taken, particularly those focusing on service quality and outcomes, will not deliver results for several years and will need the momentum maintained. In a number of critical areas (e.g. workforce training), action is yet to commence.
The adage that 'in the field of institutional reform the first twenty five years are the hardest' has much applicability in this context. The foundations laid in the first five years of the mental health policy provide a solid footing for building the future.
Close to the final stages of this evaluation, the Commonwealth government announced its commitment to continuation of the Strategy. Future Commonwealth funding to the States and Territories for mental health reform will be negotiated under the Health Service Agreements.
The period ahead will differ from the recent past. The change in funding arrangements underlines that the States and Territories will need to take the lead to ensure new services are maintained, and maintain momentum for further change.
The new focus should be on issues where national leadership and coordination are required. The committee proposes that the areas outlined below should be priorities in the future national mental health work program.
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1. Service standards, quality and outcomes
2. Extending the role of consumers and carers
3. Defining mental health need
4. Defining mental health workforce core competencies
5. Strengthening rehabilitation and personal recovery
6. Responding to people with special needs
7. Population approaches to prevention and promotion
8. The place of the mental health private sector in national reform
9. Strengthening the role of primary care
10. Rural populations
11. Developing planning and performance benchmarks
12. Funding tools to drive change
13. Technical support for service innovation
14. An information infrastructure for mental health services
1. Service standards, quality and outcomesThe focus of the new Strategy needs to move from the current emphasis on service inputs and structure to service standards, quality and outcomes. Much of the criticism of mental health services concerns its alleged failures in these areas.
Initial steps to develop outcome measures and service standards have been taken that, as indicated by the international review, place Australia at the forefront of initiatives in these areas. Considerable development work is required to take these to a point where they will be fully accepted and implemented in the field. It is work of this type where national leadership is essential.
2. Extending the role of consumers and carersConsumers and carers now have a place at the policy table, yet have only limited influence on local services, even when it concerns their personal treatment. It is essential that a national group of consumers and carers be maintained and extended to signal that the policy agenda is far from complete.
Guidelines and assistance to local agencies, public and private, need to be established to accelerate the empowerment of consumers and carers at that level.
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3. Defining mental health needThe most common concern raised throughout this evaluation relates to use of the term 'serious mental illness', and its widespread application in restricting access to services.
The 1992 National Mental Health Policy argued the need to set priorities for mental health to ensure that resources went to people who were most in need. It stated '... priority in the allocation of resources should be given to people with severe mental health problems or mental disorders who, because of the nature of their condition, require ongoing and, at times, intensive treatment".
The policy also recognised that there are others in the community who require assistance with mental health problems: " the policy also recognises the impact of mental health problems more generally on individuals, their families and the community. . . The development of effective mental health promotion, prevention and early intervention strategies and the enhancement of training and support for primary care service providers, is fundamental to the achievement of these objectives.'
The term 'serious mental illness' represents the simplification of these complex ideas. Once it appeared in the mental health lexicon, its use spread rapidly and was subject to variable interpretation.
The fact that no definition of mental health priorities was offered in the policy is the chief source of the problems that have arisen. Alternative phrases have been offered to capture the policy intent, such as 'serious mental health need', but these are equally flawed.
In the absence of an authoritative definition of priorities, terms such as these will be subject to local interpretation. Unless defined, they are incapable of being audited to ensure that service rationing is conducted in an ethical manner.
The problem is not unique to Australia. Internationally, mental health services struggle to respond to community demand, and embrace undefined concepts like 'serious mental illness' as tools to restrict access.
Two steps need to be taken. First, the extent of community need must be determined so that local priorities and service gaps can be properly identified. The national mental health population survey commissioned under the Strategy, due to be completed in 1998, will provide a basis for this.
However, it is essential that the implications of the national survey be translated to useable planning tools that can be applied by local services in estimating community need.
Second, a national definition of service priorities should be developed that takes into account clinical diagnosis, personal functioning and suffering. While this will not be easy, it is important to note that a definition of 'serious mental illness' has been recently legislated in the United States, balancing the concepts of illness and impairment, which may serve as a base for similar developments in Australia. 11
4. Defining mental health workforce core competenciesNew models of care challenge both the attitudes and traditional skills of the mental health workforce. Early in the Strategy, the 1994 National Mental Health Report made the following observation.
"A challenge facing those States with large institution-based workforces is to ensure that movement of staff into new community services is accompanied by programs to facilitate development of the skills required for effective community practice. These do not come automatically with changes of work location; experience elsewhere has taught that the culture of institutions can survive a hospital closure." (p122)
This evaluation has highlighted that little has been invested at the national level to address the workforce implications of changes in service delivery.
There is considerable confusion about the values, attitudes and skills required to work in mental health, and the extent to which consumers and carers can influence these. The terms 'consumer participation' and 'consumer-carerprovider partnership' are used loosely and to some extent, tokenistically, without adequate consideration of the implications of these concepts for defining core competencies needed by mental health professionals.
Similarly, the concepts 'multidisciplinary teamwork' and 'multiskilling' are too often used interchangeably. Special skills needed to work with mentally ill and psychiatrically disabled people have been neglected in the generic training programs introduced over recent years.
The mental health industry needs to define the core competencies required, particularly staff values and attitudes, and to develop these in collaboration with consumers and carers. These then should be used in negotiations with the tertiary education sector and form the basis for professional development initiatives within the industry.
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5. Strengthening rehabilitation and personal recoveryThe impacts of mental illness frequently remain long beyond the acute episode. For many consumers, effective treatment of symptoms needs to be accompanied by approaches that emphasise personal recovery, integration, and rehabilitation. Where the illness is of a long term nature, or recurrently episodic, services are needed to assist the person to restore their lives as much as possible, and find ways to adapt to living with a chronic illness.
The skills required to assist consumers in these ways are under-emphasised in favour of models promoting the treatment of acute symptoms. A better balance of approaches is required to improve long term consumer outcomes.
In this area, consumers appreciate the roles played by the non government sector and advocate for their expansion. The Committee agrees with this view, while recognising that personal recovery and rehabilitation services cannot exist in isolation of treatment services. The challenge in achieving a balance of illness and rehabilitation approaches requires coordination of services rather than segmentation.
6. Responding to people with special needsA single approach to mental health service delivery cannot meet the diverse mental health needs in the Australian community. Since its introduction, the National Mental Health Strategy has argued that there are identifiable groups with special needs, for whom unique programs need to be developed. These include: Aboriginal and Torres Strait Islander peoples; people from non English speaking backgrounds; children of parents with mental illness; survivors of torture, trauma, or child and sexual abuse; people with dual disabilities; homeless youth; and others.
Service development for these groups is variable, and needs to be strengthened in future years. This will have workforce training implications and requires incentives to be established for health professionals to pursue specialist interests.
7. Population approaches to prevention and promotionMarginalisation of mental health from the broader health system has contributed to the limited effort made in the area of primary prevention and promotion. This has left mental health providers to take up the role, but they are unwilling to sacrifice their treatment responsibilities to engage in prevention and promotion activities.
The separateness of mental health has also isolated it from public health expertise and its broad approaches to improving population health.
Initiatives in the area of primary prevention need to integrate mental health with general health programs and be based on a partnership between public health and mental health experts.
Advances made in the Community Awareness Program also need to be consolidated and extended. Specific groups need to be targeted, for whom the broader campaign was not appropriate. These include those from non- English speaking backgrounds, Aboriginal and Torres Strait Islanders, and those in rural areas.
To complement the community-wide approach, efforts should also be targeted in areas where new services are being established, which are compromised by local community attitudes.
8. The place of the mental health private sector in national reformLittle credit can be taken by the National Mental Health Strategy for any changes in the culture and mix of service provision in Australia's private psychiatric hospitals. This service sector was not included in the original Strategy negotiations, and felt marginalised during the early period. This is now acknowledged as poor policy and recent efforts have begun to address issues relevant to the sector and its place in the overall provision of mental health services.
Issues relating to community service development, consumer participation and linkage to other mental health services should be at the forefront of these discussions. Finding new models of reimbursement will be necessary to overcome barriers to change.
Psychiatrists engaged in the private sector were similarly given little attention in the early policy period. Several reports have been commissioned under the Strategy. that identified a wide range of policy options to resolve chronic problems separating private psychiatrists from public sector practice. Most of these are yet to be implemented, and should be pursued in the next policy period.
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9. Strengthening the role of primary careThe relationship between general practitioners and specialist mental health services is relatively undeveloped in Australia. But by contrast, considerable research has shown that general practitioners carry the burden of responding to the majority of mental health need in the community.
Barriers claimed to inhibit stronger links between the specialist mental health services and general practitioners include funding disincentives, lack of training and attitudes of mental health providers. A range of shared care and training models has been trialed over recent years that demonstrate these can be overcome.12
The task now is to move from an approach based around isolated pilots to a structured program of change.
10. Rural populationsThe general problems faced by rural communities in accessing health services are particularly evident when specialised mental health services are needed. A range of initiatives have been taken under the National Mental Health Strategy, and other national health programs, to improve rural access to mental health services.
It is essential that these be expanded in the years ahead. Most importantly, solutions need to be tied to broader strategies to improve health services to rural Australia, and particularly linked to relevant initiatives in primary care.
11. Developing planning and performance benchmarksThe value of the National Mental Health Strategy lies largely in the values it espouses and its broad map of service development. From a planning perspective however, it is short on detail. For example, while it advocates a change in the balance of services, the
Strategy does not prescribe a specific service mix, leaving this to be developed in response to local needs. Similarly, the Strategy advocates monitoring of progress made in particular areas, but does not specify targets.
The Strategy implied that it was not appropriate to set benchmarks, as these would not take account of the different histories, circumstances and priorities of the State and Territory jurisdictions. This cautious approach reflected the early stage of development of mental health policy in Australia.
Lack of planning and evaluation benchmarks creates ambiguity in the field. In seeking a target against which to monitor performance, several States and Territories have adopted goals such as 'to develop a 50:50 mix of inpatient and community services', or 'to maintain expenditure on mental health'. The committee does not see these to be sufficient goals to guide a major reform program.
Service development at local level would be facilitated by nationally agreed planning targets. These would not be prescriptions but act only as guides to be refined in accordance with local population differences and resource constraints. Similarly, performance benchmarks need to be developed for use in the evaluations of all mental health services at national, State and Territory and local levels.
New Zealand has followed this course and recently published national planning benchmarks.13 The committee believes that sufficient experience and consensus has been achieved in Australia for a 'first cut' of these to be defined.
12. Funding tools to drive changeMental health services largely remain funded on an historical basis and are yet to embrace models developed elsewhere that fund on the basis of outputs.
Funding policy is the vital force in driving change. Tools need to be developed that fit the requirements of mental health services, which both reward efficiency and quality, as well as emphasising continuity of care across hospital and community boundaries. Funding tools designed in the general health sector are widely recognised as inappropriate for mental health.
Innovative work has commenced under the Strategy to achieve these ends, but will need to be extended before tangible benefits flow.
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13. Technical support for service innovationA role yet to be developed at the national level is the provision of training and support to agencies undertaking service innovations. Generally, both the initiative and the momentum are expected to be generated locally.
It is clear that knowledge needs to be transferred from place to place to advance the reform agenda. This includes documentation, on-site support and use of new communication tools. The National Mental Health Strategy should take the lead in this field.
14. An information infrastructure for mental health servicesInformation in mental health is grossly undeveloped. The lack of nationally comparable data on service outputs, costs, quality and outcomes places major limitations on the extent to which the National Mental Health Strategy can achieve its objectives.
A precondition to the changes proposed above is the existence of an information infrastructure built from the clinical services level that contributes to individual consumer care and service quality improvements as well as feeding into higher level planning and policy review. The models exist elsewhere and have demonstrated that much is possible. Putting such systems in place needs to be identified as an imperative for the next Strategy period.
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