Mental health reform work 'remains incomplete'

Sebastian Rosenberg, Professor Ian Hickie and Dr Frank Iorfino.

What does comprehensive primary mental health care reform look like? What would it mean for consumers, health professionals, service providers, planners and funders?

We have previously outlined a framework for reform. It is now possible to describe the components and pathways of a new primary mental health care ecosystem, drawing on our research into data collection, digital systems and policy reform.

This is timely. The federal government must decide how it will respond to the recent evaluation of the Better Access Program. GPs are concerned about survival, Medicare rebates, and asserting a role as expert generalists. Psychologists focus on session limits, responding to needs of people for whom the Program was never intended. People still wait too long to find the right mental health care.

The problems extend beyond Medicare, with 60 000 thousand people receiving some sort of mental health care under the National Disability Insurance Scheme, presumably aimed at their functional rather than clinical recovery, at a cost of $2 billion in 2021.

The broader task of reform

Although these narrower perspectives drive the public debate, the task of broader primary mental health care reform is undone.

Overcoming inequity and improving the quality of mental health care cannot be achieved by existing workforce and service models alone.

Funds to just grow the workforce or to increase service access for particular groups of people will not be enough. 

This comprehensive primary mental health ecosystem will require national investment and depends on the delivery of several key functions.

Reassuringly, many of these have already been evaluated as effective, though often then defunded.

Legacy of acute fragmentation

First, we must recognise and respond to the legacy of acute fragmentation which afflicts the system. 

In fact, use of the term “system” belies the fact that federal- and state-funded services are rarely planned together and regularly lack data or other connections. 

This is perfect environment for Australians who require primary mental health care to “fall through the cracks”. And these gaps have consequences.

Australians with mental illness have notably lower life expectancy, often dying of chronic illnesses that could have been managed in primary care.

Transferring more functions to Primary Health Networks

By contrast with the existing GP-based gatekeeper system, it may be desirable to transfer the essential triage function to Primary Health Networks (PHNs), proposing that regionally organised authorities are best able to coordinate the range of clinical and psychosocial services available locally and direct clients to those services.

They already develop strategic regional mental health plans (of varying quality). 

We acknowledge that few PHNs could now fulfil this new triage and monitoring role.

PHNs receive only a small fraction (< 10%) of the total federal government expenditure on mental health.

They will need additional support, particularly to implement the digital infrastructure to enable individual tracking, planning and reporting.

However, this role is critical if we are to help people find the right care quicker, not get lost, not lose hope.

A key role for the defunct Partners in Recovery Program was this kind of coordination.

Changing the experience of care

The second critical function for this ecosystem to work well and fundamentally shift the experience of care for people is a new and central role for specialist assessment, review and support to be provided by psychiatry, clinical psychology, or mental health nurses.

Repeated inquiries have determined that people still regularly struggle to have the true nature of their mental health needs understood and dealt with, leading to misdirection, disillusionment and misadventure.

This kind of specialist advice is offered in many states and territories for a very limited number of potential service users and often with a limited scope of presenting problems.

Such systems use publicly employed (and often hospital-based) specialists to assist GPs and other primary care providers with care for more acutely unwell or complex clients in the community.

However, this kind of tertiary support is often only made available for a few hours each week.

There are some examples of more elaborate or generous approaches to this kind of consultant psychiatry service, such as the Primary Care Psychiatry Liaison Service (PC-PLS) trialled at the Western Sydney PHN, drawing on concepts such as the Wellness Support Teams developed in New Zealand.

Discussions with colleagues in New Zealand indicate the effectiveness of this work in bolstering the effectiveness of primary mental health care better managing people with complex mental health problems in the community and forestalling hospital readmission.

This kind of specialist advice must now be made available not only to professionals but also directly to potential service users.

Getting the best advice as soon as possible about what to do given your mental health needs is vital and could be a key role for the new head to health hubs being established across Australia.

A national system of psychosocial support services

A third key piece of infrastructure is a national system of psychosocial support services, to operate as partners with clinical service providers.

These services, often provided by non-government organisations (NGOs), have been a peripheral element of the Australian mental health service landscape, receiving just 6% of total state and territory expenditure.

By contrast, in New Zealand, these services account for one-third of all funded mental health services, offering multiple service opportunities in the community mental health sector (including peer-run acute care) unavailable here.

The Mental Health Professional Network that was put in place to facilitate implementation of the Better Access Program should be replicated to familiarise primary care practitioners with psychosocial services, local providers, and social prescribing options available to them.

Getting the right care at the right time

All the elements described thus far are designed to enable the effective staging of the mental health service response, across both psychosocial and clinical services, so that the person gets the right level of help at the right time.

The need for better, quicker triage and assessment in mental health has already been acknowledged by the federal government, which has invested in development of a new tool (the Initial Assessment and Referral Decision Support Tool [IAR-DST]).

However, there is doubt about whether this tool can adequately differentiate the various clinical and psychosocial needs of individuals presenting to services.

For example, the IAR-DST provides little differentiation between the need for specific clinical care that requires mental health interventions delivered by mental health professionals (eg, psychologists and psychiatrists), from the need for allied medical services for comorbidities (eg, physical health, substance misuse) delivered by GPs, nurses, and drug and alcohol workers, or from other psychosocial needs requiring more social, welfare, employment, and/or housing support.

So, although the goal of more accurate assessment and treatment is acknowledged, Australia’s current mental health system lacks the scalable infrastructure to assess a person’s current and ongoing needs consistently or accurately. This is a recipe for ongoing waste and ineffectiveness.

Patient-reported outcomes measures

To increase the power of the IAR-DST, patient-reported outcomes measures (PROMs) can be used to assess a person’s needs across multiple dimensions.

They can generate more consistent ratings, more resistant to potential biases across settings.

Outcomes and needs can be tracked within the same digital infrastructure to provide a dynamic assessment of a person’s needs over time (as opposed to static, one-off assessments at point of entry or review).

The need for change

The system requires some major changes to the way people could access more specialised psychological care. It proposes removing one barrier, namely referral via a GP. It recognises that access to GPs is restricted by availability, out-of-pocket costs, and distribution of practices.

Further, it also recognises that many people would prefer to access psychological care directly and independently of their other primary health care or psychosocial needs.

Consistent with our dynamic system modelling of what would deliver optimal outcomes for service users, it maintains an essential triage function that would assist people to access the right care, first time, where they live.

It does not propose a government-funded open access to psychological or psychosocial care.

This new ecosystem seeks to augment generalist care, using those clinicians to deliver specific types of clinical care (eg, integrated medical and psychological care, prescribing of and ongoing monitoring of appropriate psychotropic medications) alone or in team-based care with other professionals or linked to other psychosocial services (including the concept of “social prescribing”). Within this model, patients who present through their own GP would still be able to enter the new ecosystem directly or via the PHN-coordinated network.

The goals must be for people enter at low (or no) personal cost, express their own specific clinical and psychosocial needs, find the right clinical or psychosocial service the first time they present, and carry relevant prior and current treatment information across relevant clinical and psychosocial service providers.

The impact of the services they receive must be assessed and monitored, with dynamic coordination so that the system responds to a person’s changing needs.

One of the distinguishing features of our current approach is the lack of systemic accountability. The tools described here offer greater connection and coordination, permitting enhanced systemic oversight to, for example, explore whether primary mental health care prevents unnecessary hospitalisation. This is currently not reported.

It should be the aim for our primary mental health system that every time someone seeks help for care, their needs are appropriately assessed and responded to in a personalised but standardised way and with equity and consistency. This is not beyond us.

Dr Sebastian Rosenberg is a Senior Lecturer at the Brain and Mind Centre at the University of Sydney.

Professor Ian Hickie is Co-Director, Health and Policy at the Brain and Mind Centre at the University of Sydney. He holds a 3.2% shareholding in Innowell Pty Ltd, which delivers digital mental health tools.

Dr Frank Iorfino is an early career researcher for the Brain and Mind Centre at the University of Sydney. 

You can read more about the authors’ work here.