Time for structural reform in mental health: who is up for the challenge?

Mental health reform is again in the news – for both the right and wrong reasons. On the upside, following his recent election victory, Prime Minister Scott Morrison has put youth suicide prevention, and more general mental health services initiatives, at the top of his personal priorities. This follows on from the Turnbull Government’s commitment to invest in growing the ‘mental wealth’ of Australians.¹ Across the Tasman, Prime Minister Jacinda Ardern has surprised many by framing a 21st century national budget focused not simply on economic outcomes but rather national ‘wellbeing’, with a very strong emphasis on major new investments in mental health services. In California, new digital technology-based initiatives are being used to underpin a new state-wide effort to transform mental health and wellbeing.

On the downside, overwhelming numbers are presenting with mental ill-health or suicidal behaviour to Emergency Departments, ongoing high suicide rates among vulnerable populations including Indigenous Australians and war veterans, the inadequate reach and depth of early intervention services and tragic deaths among those with severe mental illness, homelessness and comorbid substance misuse continue to attract national headlines.² The collection of new enquiries – including the Royal Commission in Victoria into state-based mental health services, the national Royal Commission into Aged Care and the proposal of a Royal Commission into Veteran’s Mental Health – compound the sense of ongoing crisis in the sector.

So, in 2019 where are we really headed? The answer is that major opportunities for structural reform are on the agenda but it is unclear whether the respective government or professional organisations responsible are up to the challenge. The danger is that we see much more emphasis, once again, on increased awareness-raising and transferring the responsibility for action to those affected and their families rather than the hard decisions that were set out in the 2014–15 recommendations of the National Mental Health Commission to the Turnbull Government.³

Here’s the list of challenges:

1. Invest (money, infrastructure, governance, partnerships) in the Primary Health Networks to oversee the continuous implementation of high-quality and regionally-relevant mental health programs;

2. Work with the proposed reforms of the Medicare item numbers for mental health services to back team-based multi-disciplinary care for those with more complex and impairing disorders. This will require overt rejection of the self-serving proposals of the various individual health provider organisations;⁴

3. Respond positively to the draft report of the Productivity Commission in October 2019 and the final report in May 2020, with regards to fundamental reorganisation of the purchasing of services;

4. Move the emphasis in services investment from simply increasing access to assessment to the development of quality multi-disciplinary interventions that can deliver real functional outcomes (i.e. back to school and back to work!);

5. Promote the tools (planning, evaluation, technology-enabled delivery and data collection and integration) that support serious system-level and structural reforms, not simply expand the number and breadth of existing national programs that deliver interventions that are disconnected from other regional federal, state or community-based organisations;^5,6

6. Support genuine regionally-based trials of new service models in mental health or suicide prevention that can also be scaled. That is, those that incorporate high-quality evidence, local governance and long-term systematic evaluation but are not ‘one-size fits all’ in their design or implementation;

7. Recognise the wider economic and social significance of ‘mental wealth’ and ‘wellbeing’, and the broad social context in which these concepts are embedded. Inevitably, related programs in education, employment, welfare, housing, early childhood and ageing need to be linked regionally to mental health initiatives. Ensure that real functional outcomes – that is, more productive lives lived are the key returns on these large and complex investments; and,

8. Be willing to reduce or cease funding to less effective service models that have operated regionally or nationally.

Professor Ian Hickie was an inaugural Commissioner on Australia's National Mental Health Commission (2012–18). He is the Co-Director, Health and Policy at the Brain and Mind Centre (BMC) University of Sydney. The BMC operates an early-intervention youth services at Camperdown under contract to headspace. He is the Chief Scientific Advisor to, and a 5% equity shareholder in, Innowell Pty Ltd. Innowell was formed by the University of Sydney (45% equity) and PwC (45% equity) to deliver the $30m Australian Government-funded ‘Project Synergy’ (a three year program for the transformation of mental health services) and to lead transformation of mental health services internationally through the use of innovative technologies.