Will PHN-based care deliver mental health reform?

A KEY plank of the mental health service reforms, recommended by the National Mental Health Commission (NMHC) in its 2014 review (and endorsed by the Turnbull government in late 2015), was to consolidate the vast majority of the Commonwealth-funded mental health and suicide prevention programs under a new Primary Health Networks (PHN)-controlled, regionally-focused service purchasing model.

The clear intention of the proposal was to align future mental health development more strongly with the general movement in health towards regionally-based care delivery, and to ensure that nationally-funded programs could be more closely integrated (financially and functionally) with other local state and privately-funded services. The recommendation recognised the reality that many centrally-controlled service programs had previously been introduced with little consideration of existing capabilities, actual needs or local priorities.

PHN-based mental health reform was always a controversial proposal and one received with considerable scepticism by pre-existing non-government and more traditional clinical providers of specialist mental health services. It clearly put local mental health and suicide prevention service providers on notice that the Commonwealth wished to invest in more coordinated, and potentially more capable, providers of both health care and related social support services.

Among the more specialised providers of care there was also concern that under this GP-led model, mental health services would be downgraded to rather simplistic, and often entirely inappropriate, “primary care” or “GP practice” based services. Over the years, various attempts to make complex mental health care conform to traditional family practice-based care systems have received little support from either the specialist providers or users of care. High quality modern mental health care is multidisciplinary and enduring. That is, it is not well suited to solo practitioners (of any professional background) working to more traditional fee-for-service models.

In fact, during the consultations that have surrounded much of this change, I have been asked by some PHN representatives “will these changes be good for GPs?” I’ve often responded quite acerbically that “it’s not about what’s good for GPs, or psychiatrists, or psychologists or mental health nurses; it’s about what’s good for those in need”. At this stage, some of the loudest voices resisting reform are those who represent the professional organisations.

When the reforms were announced there was also legitimate concern that local purchasing would ignore national templates or more evidence-based templates for enhanced service delivery (such as the headspace services model for young people) or suicide prevention (such as the LifeSpan model or the Dynamic Systems Modelling approach). There are widely expressed concerns that the 2016 purchasing decisions have favoured local and often small scale providers with little capacity to deliver more specialised or evidence-based services.

A related consideration is whether any of the PHNs have the capacity to engage the types of provider organisations that could really use the new proposals to cash out Medicare fee-for-service payments and deliver more appropriate, multidisciplinary care for those service users with complex and ongoing needs. To date, we have no data on whether this key reform is being actioned.

As this major shift in the mental health program funding occurred immediately after the initiation of the PHN program, there was also much concern that the new organisations lacked the capability to take on such a major role. An important part of the model recommended by the NMHC, however, was that PHNs should seek to engage with relevant larger academic, state service-based, non-government organisation or other private service providers – including those who are not currently active in their local area. That is, regional purchasing should improve the capacity to bring new services to an area and not result simply in rehiring those who were previously delivering services locally.

Further, the calls from many in the mental health services and suicide prevention sectors to lock down existing contracts for several years has a strong tone of self-interest and clearly runs contrary to the spirit of engaging with genuine reform.

While PHNs had the responsibility of maintaining local services, particularly during the 2016 election period, 2017 should now see the move toward genuine reforms and real service innovations gaining momentum.

As the implementation process enters its second year, the critics have become more vocal. At a meeting in March 2017 between the Prime Minister, new Minister for Health Greg Hunt and leaders of the non-government and academic sectors in mental health and suicide prevention, the various legitimate concerns about the operations of the PHNs purchasing model were openly discussed.

However, there was clear and ongoing support for the concept proposed by the NMHC: that regionally-based service models offer us the best opportunity for developing more effective local services. It was also noted that many PHNs have sought to engage actively with users of care and other relevant national (eg, Orygen Youth Health) and academic organisations.

In the view of this high level group, the rather simplistic national guidelines that, to date, have underpinned PHN-based purchasing are not sufficient to guarantee delivery of these more effective service models. There was a general consensus that much more detailed national templates in the key areas of youth mental health, stepped care, suicide prevention, complex care and incorporation of new technologies are urgently required. A stocktake of 2016 purchasing decisions and proposals for 2017 may also be warranted.

Subsequent to this high level meeting, the Minister for Health announced the establishment of a new review group, to be co-chaired by the CEOs of the NMHC and the peak advocacy group for existing Commonwealth-funded service providers, Mental Health Australia. Exactly how this new review group will function in relation to the purchasing of local services from 2017 onwards is yet to be articulated. An ongoing role for the NMHC in reviewing outcomes of the overall reform programs was previously signalled by the Turnbull government.

The response at the PHN-level to these political developments seems to be one of some frustration. Given the very short timeframes in 2015 and 2016 to establish these new corporate entities and to take on such a new and major specialised reform task, many PHNs feel they have delivered significant changes under very difficult circumstances. It certainly is very early days in a complex process. Serious improvements in local capability will take time to develop and deliver. It would be unrealistic to evaluate the impact of these developments at this time.

Perhaps the most important consideration currently – and certainly consistent with my own role in the NMHC – is whether we will have evidence (particularly over a 5–10-year period) that moving to this new regionally-based model has delivered real improvement for those who are in desperate need of more accessible and high quality services. To be certain of this, and to monitor more closely whether PHNs are actually on the right track, we need to invest now in the health informatics infrastructure that may deliver real answers in real-time frameworks.

Modern mobile technologies have the capacity to permit users of care to provide direct feedback, at scale, to local service providers. To date, these approaches have not been incorporated into standard service settings. There is a major opportunity for PHNs to support such developments among those organisations that they commission to provide care. This approach is radically different to the typical activity-level data that PHNs are now required to report. As Prime Minister Turnbull noted during the March 2017 meeting, we should all now be much more focused on the outcomes of care rather than who gets paid to provide that care.

My own view is that PHN-based mental health reform is the best opportunity we have had in 30 years to deliver real improvements in non-hospital-based and regionally-relevant mental health and suicide prevention services.

What is required now is a common commitment across all service and professional organisations to work productively and collaboratively in the interests of those who need care. From a government perspective, new funds need to be invested in strengthening PHN capability and supporting 21st century outcomes-based data collection – data that genuinely reflect the experiences of those who use our service systems.

Professor Ian Hickie, AM, is co-director of Health and Policy at the Brain and Mind Centre, University of Sydney. He is also a National Mental Health Commissioner.

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