Finding a pathway to better mental health services through local accountability

Professor Ian Hickie

High-quality mental health care is possible, but it will demand structural reform, effective accountability and the will to make it a reality.

Central Coast Newspapers asked one of the lead experts in the field, Central Coast-based Professor Ian Hickie, to pen an article that examines the complex issues of mental health policy, particularly as it relates to local design and service delivery.

Although 2022 is the 30th anniversary of Australia’s national mental health strategy, and after five previous five-year federal-state agreements, we are faced with the reality that affordable access to high-quality care remains out of reach to many of those in greatest need. As with aged care, the COVID pandemic has now highlighted to the wider public those major structural flaws that had been neglected for decades. Contrary to much popular and political belief, these major service problems are tractable in wealthy countries like Australia.

While our nine governments have just agreed on another “landmark” mental health agreement on the eve of the 2022 federal election, the majority of the key recommendations of the 2014 National Mental Health Commission and 2020 Productivity Commission reviews have not yet been enacted. These structural reforms are the necessary actions that now need to precede investments of significant new monies.

More likely, however, is the announcement of many more small program funds, distributed across a wide variety of well-known “brands” and service providers with little attention to the reality that this piecemeal approach has perpetuated the very poor experiences of care that have been documented by various commissions over the last 20 years, for example the Mental Health Council and the Victorian Royal Commission.

So, three questions must be addressed if we are ever to make serious progress. First, what are the key structural reforms that have not been implemented? Second, who will be held accountable for the implementation of these reforms? To use the phrase of the age, we must know “who does hold the hose?”. Third, given the longstanding and bipartisan political commitment to progress, what are the major political or social forces that perpetuate this public policy failure?

The structural reforms required have been well-documented and include a dozen key areas:

  1. Expanding services to provide effective care for up to 15 per cent of the population in any year.
  2. Shifting the balance of service funding (and specialist service provision) from hospital-focused and activity-based to community-focused and outcomes-based reimbursement.
  3. Moving the clinical service system from predominantly a late-intervention and chronic disease focus to prevention and early intervention.
  4. The catch cry for such services should be “Right care, first time, where you live”.
  5. Provision of quality care that is based on highly-personalised assessment, multidisciplinary delivery of care and active use of measurement-based outcome tools.
  6. Active use of population-based and other planning tools at the regional level.
  7. Responding urgently to the opportunities created by new digital technologies.
  8. Recognising the need for real innovation in the delivery of psychosocial services that promote social and functional recovery at all stages of illness.
  9. Insisting that suicide prevention at the population level is strongly influenced by major economic (e.g., employment, financial security) and social (e.g., social connection and cohesion) factors.
  10. Acting to reduce the premature death, and high rates of physical ill-health, in those living with major mental illness.
  11. Development of smart data systems, that provide real-time information on key user concerns
  12. Support for regionally-based accountability frameworks.

The second key question is: who will be held accountable for promoting, funding and implementing these key reforms? Our 30-year history is that each level of government simply retreats to being responsible only for that part under its direct control. So, the states retreat to public hospitals and acute services, while the Commonwealth funds the activity without direct responsibility for the resulting services. At best, we have been left “half-pregnant”.

Both the Productivity Commission and the previous National Review emphasised the need to move to a system of regionally-based accountability, but recognised that this is only possible if the funding and commissioning functions are devolved to the regional level. A solution is therefore at hand if the respective governments agreed to cooperate and implement change at the regional level.

Given the conceptual consensus to shift to regionally-based planning, funding and service delivery, and the recognition of the key structural reforms required, why is there the lack of substantive progress? Many would argue that the funding never moves to match the rhetoric. The proportion of health spending on mental health and suicide prevention has remained static at 7.5 per cent over the last three decades. Given the burden due to mental ill-health is at least 14 per cent of total illness burden, and that suicide remains the major cause of productive years of life lost in Australia, the level of financial investment is grossly inadequate.

The clear reservation of many in power, however, is that many more dollars into our highly dysfunctional system would not result in better outcomes. Despite the many plans, there has never been a move to dismantle the financial and structural underpinnings of this dysfunctional system. This compares poorly with the restructure of disability services under the NDIS. So, the end-result is an ongoing impasse.

A political breakthrough, therefore, is likely to depend on three factors. First, enhanced belief at the community level that these problems are actually tractable. We can fix them by focusing on resolving the issues with less top-down “one size fits all” and much more “bottom-up” one region at a time. Second, by empowering local leadership, capability and accountability at the regional level to drive this process. Third, by governments engaging with twenty-first century approaches to co-design, system modelling and use of smart technologies to empower service users to drive substantive improvement in their own care.

Ian Hickie

Ian is a Professor of Psychiatry and the Co-Director of Health and Policy at the University of Sydney’s Brain and Mind Centre. He’s been heavily involved in helping develop and implement policy in the field for two decades. The abbreviated article above is an edited version of one published by the James Martin Institute for Public Policy.