One-stop youth mental health shops work, but more reform needed

AUSTRALIA’S “one-stop shop” youth health services have paved the way for similar services around the world, but further reform is now needed to build on these foundations to ensure that all young people are well supported for their major health problem in the transition to adulthood, says Professor Patrick McGorry.

Professor McGorry, the architect of headspace, the National Youth Mental Health Foundation, said that the development in 2006 of the headspace youth health care model – incorporating physical, mental and social care services under one roof – had been an “amazing achievement” for Australia.

“But there are, definitely, some threats that need to be addressed, and some areas that can be built on to take it to the next stage,” he said.

“This is an evidence-based reform movement that is taking shape in many countries around the world because there’s a huge level of logic and unmet need. Around 75% of mental disorders emerge before the age of 25 years, and countries have to do something,” said Professor McGorry, who is executive director of Orygen, the National Centre of Excellence in Youth Mental Health.

“headspace is a successful prototype, and there is encouraging evidence around its value, but we need to do more research and development to assemble more evidence on the model and how to improve it.”

Writing in the MJA, Professor McGorry outlined his vision for the continued development of headspace and identified areas where further reform was needed. His editorial was published alongside an MJA supplement featuring three studies examining the building blocks of youth mental health care in Australia and around the world.

The research articles examined targeted mental health care by clinical stage and diagnosis, the attributes contributing to cost-effective youth mental health care, and a global review of “one-stop shop” youth health care models.

On 8 November 2017, Australian researchers also reported that adolescents with a prior distress disorder (indicated by scores < 50 on the Mental Health Inventory from the Short Form Health Survey) were twice as likely to drop out of high school than those without any history of a disorder.

Professor McGorry said that recruiting GPs to headspace centres had proved challenging within existing funding structures. headspace’s young patients were often short of money and relied on bulk-billed services, and sometimes missed appointments.

“It takes only the most dedicated and youth-oriented GPs to do this, so there has been a recruitment problem in getting onsite GPs in all of the headspaces,” Professor McGorry told MJA InSight. “We have to find a way of compensating and incentivising GPs, so they are not financially penalised for working in this youth-oriented environment … it might require the use of different item numbers or additional payments.”

Professor McGorry said that “substantially expanded investment” was also needed in the provision of care for more complex and severe cases, including a review of the 10-service annual cap under the Better Access initiative; improved access to specialised services for complex mood disorders, psychosis, and eating, personality and substance use disorders; and funding for home-based and outreach interventions.

He said that this strengthened capacity and that expertise should be fully integrated within headspace platforms and not dispersed of fragmented.

“Many young people are ending up in emergency departments as the first port of call for crises and acute situations and that’s really aversive. Emergency departments are not the right setting and ED clinicians, perhaps understandably,  are simply unable to create right mindset to respond appropriately to mental health crises. This can lead to traumatic experiences for young people and families, and worse still, preventable deaths from post-discharge suicides,” he said, adding that the lack of commitment of state governments to community mental health care had resulted in a “relentless wave” of mental health presentations in EDs.

“Rather than locate the capacity for more specialised and complex care in tertiary hospital-based, traditional mental health services, or even in private psychiatry practices – we’d like to see this expertise incorporated into an enhanced multidisciplinary primary care model.”

Professor McGorry said that the introduction of early psychosis programs in six headspace centres since 2014 had shown how such enhanced primary care models could work, but this program needed to be expanded over time to other locations and also cover other complex diagnostic disorders.

He also called for a review of the cap on allied mental health services. He said that cutting back the Medicare-funded Better Access to Mental Health items from 18 sessions per year to 10 in 2011 had been problematic.

“If people need more than 10 sessions, there should be a reassessment. It might not just be more of the same care, it might be stepping up in terms of expertise and intensity,” he said, and noted that such a reform could be applied beyond headspace to the broader community. “We don’t see these arbitrary caps on chemotherapy sessions for cancer. Patients should be able to access care according to need and evidence.”

Funding responsibility for headspace was transferred to Primary Health Networks (PHNs) from July 2016, and Professor McGorry said that there was some concern at the time that the move would dilute the trust and reliability associated with the headspace brand.

“As with all health commissioning, service specifications of models of care should be nationally agreed and adhered to, in order to avoid reinventing the wheel. If there was too much flexibility at the local level [with the PHN funding model], then you might see some of those benefits of standardisation disappear, but fortunately the federal government unequivocally committed in 2016 to maintaining headspace as the Australian gold standard approach,” Professor McGorry said.

“The PHNs will continue to commission high-fidelity headspace services with a national accreditiation mechanism in support, [although] PHNs can strengthen them with additional funding if they wish, which is great. We can aspire to a situation where we have [the best] of both worlds – a centralised model and a more flexible local model. The youth severe funding provided to PHNs is a new source that should be utilised to enhance headspace‘s capacity.”

Professor McGorry said that in 10 years’ time he hoped Australia would have a youth mental health system that echoed the vision set out in the 2013 International Declaration on Youth Mental Health, where every young person could expect to have “the knowledge, the services and the skills to help them make a successful transition to adulthood and to deal with their major health problems, which are often mental health-related”.

“We hope to have a seamless, stepped-care model, as envisaged by the National Mental Health Commission, which is stigma-free, supported by the community and achieves much better results: many more lives saved, preventable deaths reduced and much better functional outcomes for our young people. [Too many young people] are unnecessarily ending up on the scrap heap – in prisons, homeless or dead.”

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