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TWO years in the making, the Royal Commission into Victoria’s Mental Health System produced 65 commendable and ambitious recommendations, framing a bold new roadmap to inform, invigorate and reform Victoria’s mental health system.
Preliminary reception of the interim and final reports has been favourable, with the Victorian branch of the Royal Australian and New Zealand College of Psychiatrists being one of the first to welcome the recommendations as a “step in the right direction”. Having recently proposed the articulation of a similar position to the Royal Australasian College of Medical Administrators myself, through its state jurisdictional policy advocacy process, the reform agenda in redesigning our mental health system is greatly welcomed.
One of the most interesting aspects of the new reform agenda recommended by the Final Report of the Royal Commission is not in fact the call to action for an integrated regional governance framework for equitable distribution of services, or the anticipated identification of mental health services throughout a patient’s lifespan. It is the surprising realisation that much of the agenda appears to be derived at least in part from what is in fact value-based health care principles.
Value-based health care’s central tenet is that the overarching principle in redesigning health care delivery systems must be value for patients. Value is defined as the outcomes that matter to patients (relative to) the costs to achieve those outcomes.
The final report discovered that “the [mental health] system is complex and fragmented … largely operates in crisis mode … [and] due to system constraints, services are often inaccessible at the times when they would make the most difference”.
The recommendations for reform span across key themes as highlighted within value-based health care frameworks, such as creating new integrated structures to support the system, challenging traditional mental health treatment models and calling for focus on patient and community-centred outcomes.
The recommendations call for the development of a Mental Health and Wellbeing Outcomes Framework to inform government investment processes and assess economic benefits of the strategies proposed. This alignment of outcomes with the costs of care provision is a fundamental tenet in value-based care models.
The report goes further to stipulate these outcomes (and progress against measuring the outcomes) be publicly reported on a regular basis at a service, system and population level. According to the International Consortium for Health Outcomes Measurement (ICHOM), a focus on measuring and tracking the outcomes that matter most to patients (based on a disease or a condition) are poised to elicit a range of benefits for individual patients, health providers and health funders. These are cited as ranging from improving the level and quality of care delivered, to developing a “universal language” with which to benchmark health services across geographical regions and to leverage in financial reimbursement models.
Interestingly, there are already established standard outcome sets for mental health services that have been developed by the ICHOM which potentially could be adapted in the development of the new Victorian Mental Health and Wellbeing Outcomes Framework. Standard sets that are currently available for health systems to incorporate include those in the areas of adult depression and anxiety, children and young people depression and anxiety, obsessive compulsive disorders, post-traumatic stress disorders, and psychotic disorders. These include functional outcomes, measures of recovery, and treatment tolerance measures in addition to symptomatology.
Australian institutions that have already begun incorporating these particular standard sets in the measurement of mental health outcomes include some of our very own interstate counterparts at the Illawarra Institute for Mental Health at the University of Wollongong, the NSW Ministry of Health, and the Children’s Health and Hospital Services in Queensland, to name a few.
The Royal Commission’s Final Report also recommends moving towards integrated regional governance (recommendation 4), and ensuring the core functions of mental health services are integrated across treatment models, and that education initiatives and care coordination between primary and secondary health care services are shared (recommendation 5).
Developing new models of care for both bed-based and community-based mental health services underpinned by an integrated regional governance framework will strongly assist in a more equitable distribution of services and access to vulnerable patient cohorts. Such an approach will align mental health service planning, delivery and evaluation towards better value and sustainability across the broader health care system in Australia.
True application of value-based health care models requires a cross-sector strategy with national coordination, as opposed to siloed implementations of individual aspects of what constitutes value-based care. The approach that is proposed by the Royal Commission echoes this tenet. It recognises the simultaneous reforms that would need to be made to not just primary, secondary and hospital mental health care, but also education and occupational sectors. Promoting inclusive workplaces that are free from stigma, addressing workplace barriers and supporting employees experiencing mental health at work are key outputs cited in the report to adequately resource. Acknowledging the breadth of socio-economic impacts and addressing the entire spectrum of factors that affect a person’s wellbeing and their mental health, and aligning other institutional systems, such as the criminal and justice system and housing sectors, will reinforce and enhance the inclusiveness of the services reforms that are recommended.
The final report recommends “new ways of commissioning and contracting [to] also be used to encourage more integrated service delivery for people living with mental illness”. Outcome-based commissioning and value-based contracting methodologies are crucial tools to be considered in incentivising and driving the system-wide reforms that are required to improve the health outcomes of Australians. Strong leadership and robust collaboration both within organisations and across sectors are imperative in realising these integrated structures and complimentary processes, that are necessary for ensuring equitable distribution and access to a high quality health system by all individuals and communities.
Value-based health care requires the identification and management of the health impact on individuals across the entire patient journey. The reforms proposed in the Royal Commission’s report call for this to be undertaken at prenatal, infant, child, adolescent and older patient levels. Many of these recommended reforms reflect areas of greatest need and/or areas where substantial service gaps exist – a rationale underpinned by evidence and patients’ experiences that show a limited focus on mental wellbeing in the early years of a person’s life and a predicted increase in the number of older Victorians living with mental illness.
According to an analysis conducted by the Department of Environment, Land, Water and Planning, during the next three decades, the number of Victorians aged 65 years and over is estimated to double, rising from 1.05 million (as of 30 June 2020) to 2.13 million by 30 June 2051.
Targeting the allocation of resources and investing in the provision of care specifically to population segments and/or disease conditions is the first step towards achieving a truly value-driven health care system. In order to achieve patient-oriented outcomes that are of benefit for all players of the health care system, identification and focus on the needs and activities needed to achieve the outcomes must be the first and foremost focus in the transition plan towards meaningful reforms.
Unexpected contextual factors also play a key role in identifying the priorities for resource allocation based on need. This was demonstrated by the 2020–21 federal Budget, where the promise of a $5.7 billion investment in mental health services took into consideration the added pressures on the mental health system resulting from the 2019–20 bushfires and the COVID-19 pandemic.
A notable recommendation from the Royal Commission’s Final Report that further resonates the value imperative is the proposal for reforming the multitude of access and navigational challenges within the current system. The Royal Commission calls for establishing innovative structures for achieving better transparency and building appropriate scalability in balancing increasing service demand against capacity.
Data sharing and transparency are key enablers to both driving and incentivising systemic change. Successfully engaging stakeholders, particularly health professionals, in codesigning the care and service delivery models needed in achieving these objectives is also driven largely with access to the right data and relevant analysis. Care coordination and navigation both within and across health sectors in Australia are important challenges to be overcome if we are to progress a value agenda.
Overcoming these challenges is in fact realistic and within reach. We only have to look as far as the adoption and utilisation of telehealth in the past 12 months. Prompted by a pandemic, and propelled by the rapid removal of funding, coding and regulation barriers, access equity and patient-centred service delivery via telehealth has now become widely accepted, not just in Australia but across the world.
On careful consideration, the Royal Commission’s recommendations for the Victorian mental health system are therefore extremely timely, seem very closely aligned to value-based health care principles, and are to be genuinely applauded.
Dr Sidney Chandrasiri is Group Director (Academic and Medical Services) and Deputy Chief Medical Officer at Epworth HealthCare.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.