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National Review of Mental Health Programmes and Services

[Publisher’s Note: Many years ago in the early 1960s, my father drove out of the Mary Street Psychiatric Clinic in Brisbane. I was in the car with Dad and he told me something I have never forgotten … ‘don’t ever take the drugs those bastards give you, they will ruin your life’. It was not till many years later I discovered that my father, who was suffering from anxiety and depression, had been prescribed Largactil (Chlorpromazine) which has serious side effects. I do not know if this drug contributed to Dad’s early demise, but within a few years of Dad telling me this, at the age of 50, he had a sudden heart attack and died.

It seems that the medical model and the drug industry have combined to give people suffering from mental illness a deadly cocktail of expensive medicines without getting to the real cause of the problem.

Posted here are all four volumes of the Review conducted by Alan Fels two years ago. I have not read the entire document but the summary (below) suggests that there has been little improvement in dealing with Mental Health since the 1960s.

Thanks to Hugh Childers and Dan O’Neill at the Group of 17 talk for raising these important issues of Mental Health in Australia. It is time to see if the reforms proposed by this review have had any effect of our Mental Health system and political system that controls it.  — Ian Curr, November 2015]

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National Review of Mental Health Programmes and Services

Perhaps the most prominent theme to emerge from this exercise was that the way the mental health ‘system’ is designed and funded across Australia means that meaningful help often is not available until a person has deteriorated to crisis point. This is either because mental health supports are not accessible to them, do not exist in their area, or are inappropriate to their needs. Along the way, they may have lost their job, their family or their home. Countless submissions pointed out that this makes neither economic nor humanitarian sense. — Allan Fels

Summary
The four volumes of this report present the findings of the National Review of Mental Health Programmes and Services. The Review responds to the specific Terms of Reference provided by the Commonwealth Government early in 2014.

This first volume contains immediate recommendations and priorities for action over the next 1-2 years. It builds the platform for further changes which have been identified in the second volume as goals to be achieved over the longer term of 3-10 years.

In conducting this Review, the Commission’s primary areas of focus have been the efficiency and effectiveness of Commonwealth services and programmes, as well as overall investment and spending patterns. The Commission did not evaluate specific clinical treatments and could not evaluate state and territory-funded programmes, services and systems.

The Review has been informed by the Contributing Life Framework – a whole-of-person, whole-of-life approach to mental health and wellbeing. Accordingly, we have undertaken a cross-portfolio assessment of the strengths and weaknesses of the mental health system as a whole.

Our approach recognises the interaction between mental health and personal characteristics (such as genetic make-up, age, family situation, cultural background, gender and sexuality) and social, economic and other life circumstances. These life factors include employment, housing and chronic physical illness, and related factors such as alcohol and substance use and past experiences of trauma or abuse.

While a whole-of-government perspective has informed our thinking, it was beyond the scope of this Review to make specific recommendations across all of these areas. Instead, our objective was to identify proposals for a whole-of-government system recalibration at the federal level that ultimately would improve the lives and opportunities of people who experience mental illness as well as their families and other support people.

Our findings
The Review’s findings clearly show that Australia’s patchwork of services, programmes and systems for supporting mental health are not maximising the best outcomes from either a social or economic perspective. Many people do not receive the support they need and governments get poor returns on their substantial investment. Total mental health spending by Commonwealth, state and territory governments is about $14 billion per year. This is without taking into account the hidden costs of mental illness as measured by lost productivity, both for those with a mental illness and those impacted by that illness, including families and other support people.

At a service level, we found there are many examples of wonderful innovation and that effective strategies do exist for keeping people and families on track to participate and contribute to the social and economic life of the community. The key feature of these strategies is that they take a person-centred, whole-of-life approach.

We found no real evidence that specific Commonwealth-funded services or programmes were not adding value or that they should be defunded due to lack of impact. However, it is notable that in a number of cases the information available to make this assessment was limited. In particular, there was a lack of state and territory information at the programme and regional levels, and about nongovernment organisation (NGO) performance. Of data that was available, most focused on activity, rather than the achievement of outcomes.

Strikingly, however, it is plain that there is significant inefficiency and overall the system as a whole could not be judged as cost-effective.

We found some areas of duplication (for example, online and telephone supports), services where lack of flexibility means access is not necessarily matched to need (such as Better Access), and substantial gaps in services, especially in supporting at-risk populations and consistency of supports across different geographical areas.

Of critical concern is the dire status of the mental health and wellbeing of Aboriginal and Torres Strait Islander people. Indigenous people have significantly higher rates of mental distress, trauma, suicide and intentional self-harm, as well as exposure to risk factors such as stressful life events, family breakdown, discrimination, imprisonment, crime victimisation and alcohol and substance misuse. Service and system responses to these poor outcomes are inadequate, and have generally not been designed with the particular needs of Aboriginal and Torres Strait Islander people in mind.

Nationwide, resources are concentrated in expensive acute care services, and too little is directed towards supports that help to prevent and intervene early in mental illness. Of total Commonwealth spending of $9.6 billion, 87.5 per cent is in demand-driven programmes, including income support, and funding for acute care. This means that the strongest expenditure growth is in programmes that can be indicators of system failure–those that support people when they are ill or impaired–rather than in areas which prevent illness and will reap the biggest returns economically and ‘future proof’ people’s ability to participate and live productive, contributing lives.

Problems experienced by people with mental illness often are dealt with in isolation, with structural, cultural and practice barriers to integrated, wrap-around supports leading to system inefficiencies and poorer mental and physical health outcomes for individuals. Red tape places undue burden on service providers–particularly in the community sector– which are required to manage multiple programmes and contracts with different data collection and reporting requirements, placing pressure on programme administration and diverting resources away from frontline service delivery.

The Review found inefficiency due to issues such as lack of economies of scale, and multiple organisations needing to provide back-office support services. But by far the biggest inefficiencies in the system come from doing the wrong things – from providing acute and crisis response services when prevention and early intervention services would have reduced the need for those expensive services, maintained people in the community with their families and enabled more people to participate in employment and education.

In fact, there is evidence that far too many people suffer worse mental and physical ill-health because of the treatment they receive, or are condemned to ongoing cycles of avoidable treatment and medications, including avoidable involuntary seclusion and restraint. These challenges are compounded by a mental health workforce under pressure, with services experiencing shortages, high rates of turnover and challenges in recruiting appropriately skilled and experienced staff. Too frequently, the voices of people with lived experience, their families and support people are ignored, misheard and undervalued.

Our ability to identify key challenges and pursue emerging opportunities is limited by poor information design and management. Across the system, information about mental health services is incomplete, inconsistent and often inaccessible, including no nationally consistent approach to outcomes measurement, collection and use.

Our use of evidence is impeded by research priorities predominantly driven by investigators instead of the needs of people with mental illness, service providers and policy-makers. Findings are not consolidated or communicated, meaning examples of success often are not scaled-up or translated into practice.

The case for reform
Overall, the findings of this Review present a clear case for reform. The status quo provides a poor return on investment for taxpayers, creates high social and economic costs for the community, and inequitable and unacceptable results for people with lived experience, their families and support people.

The Commonwealth bears significant financial risk as a consequence of this imbalanced system. This Review identified that 60 per cent (approximately $5.7 billion annually) of Commonwealth expenditure on mental health is through the income support system, predominantly through the Disability Support Pension. The income support system also is the area of greatest growth in spending on mental health and currently is projected to remain so. The largest health portfolio programmes are the Medicare Benefits Schedule (MBS), Pharmaceutical Benefits Scheme (PBS) and payments to the states and territories for hospitalrelated activity. Expenditure in all of these areas is essential to support the health and wellbeing of the population: however, the current balance is wrong and the Commonwealth is not necessarily accessing interventions which could be described as the “best buys” for the considerable amounts it is spending. Certainly the MBS and PBS in particular support treatment and secondary prevention responses to developed risk factors, while funding for hospitals and emergency departments provides responses to crises and acute illnesses.

However, a “best buy” approach would shift the pendulum in Commonwealth expenditure towards primary prevention, early intervention and a continuous pathway to recovery.

Managing these costs effectively and sustainably requires a carefully designed programme of practical reforms that rebalance the system to reduce demand for services in the first place and improve the range and appropriateness of support options. This will deliver better mental health outcomes for individuals and promote economically and socially thriving communities.

Our recommendations
In this report, the Commission proposes new system architecture to redesign, redirect, rebalance, repackage and ultimately reform the approach to mental health in Australia. Central to this is a person-centred approach where, through an integrated stepped-care model, services are designed, funded and delivered to match the needs of individuals and particular population groups. This model includes the continuation of national programmes designed to support the wellbeing of the Australian population, with a particular focus on those most at risk, supported by pooled funding arrangements controlled at a regional level to respond to local need. This model will promote flexible, person-centred services for people with lived experience, their families and other support people, while at the same time achieving better value for money for governments.

Our report also is underpinned by the definition of roles and responsibilities of the Commonwealth in mental health, including through a new National Mental Health Agreement with the states and territories.

The Commission has adopted a principle that there should be no net reduction in overall investment in mental health. At the same time, the Commission is proposing that its recommendations be implemented within existing resources. There is a significant level of expenditure within mental health but it needs to be spent on the right things. So if, as we recommend, there needs to be more money spent on prevention, early intervention, community-based services, then those funds have to come out of somewhere else within the system. There needs to be a rebalancing and our recommendations advise on how to do that.

Over the next two years, the Commission proposes a process of transformational change, guided by 25 recommendations across the following nine strategic directions:

  1. Set clear roles and accountabilities to shape a person-centred mental health system.
  2. Agree and implement national targets and local organisational performance measures.
  3. Shift funding priorities from hospitals and income support to community and primary health care services.
  1. Empower and support self-care and implement a new model of stepped care across Australia.
  1. Promote the wellbeing and mental health of the Australian community, beginning with a healthy start to life.
  1. Expand dedicated mental health and social and emotional wellbeing teams for Aboriginal and Torres Strait Islander people.
  1. Reduce suicides and suicide attempts by 50 per cent over the next decade.
  2. Build workforce and research capacity to support systems change.
  3. Improve access to services and support through innovative technologies.

Over the next 10 years, the Commission proposes further reforms which build on the initial reforms to create a quality, high-performing mental health and suicide prevention system so that all Australians achieve the best possible mental health and well-being.

Here are PDFs to the four volume review:

NMHCreview Vol 1

NMHC Vol 2

NMHCReview Vol-3

NMHCReview Vol 4-Combined-with-Cover

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