New best place for mental health care – at home

WHILE the federal government has just committed an additional $2.3 billion over the next 4 years to mental health, the new spend largely avoids the hard issues about how we improve the quality and reach of our more complex (and typically state-provided) mental health services.

The Budget papers on mental health are filled with statements about “further work” to be done in 2021 with the states and territories but are entirely unclear on who will provide these services, where the clinical staff will come from, what outcomes could be expected and who will be accountable for the reform process.

Whenever these serious issues about long term health reform arise in Australia, the political and public debate is soon shut down by the combined forces of those organisations that largely represent the professional groups and the urgent need to prop up our public hospitals.

For example, this occurred in 2014, effectively derailing the National Mental Health Commission’s recommendation that annual growth funding for mental health services be preferentially directed to care outside of hospitals.

As has now been dramatically highlighted by the coronavirus disease 2019 (COVID-19) crisis, those parts of the health system that were weakest before the pandemic have struggled to respond, most notably, aged care and mental health. The Productivity Commission also identified longer term issues related to the lack of active chronic disease management to prevent emergency department (ED) presentations and repeated acute hospitalisations as major stressors on the system.

An important part of the public hospital response to COVID-19 was the need for more effective infection control. Consequently, many acute care hospitals suddenly rediscovered the virtues of “hospital in the home” programs. Suddenly, we found we could deliver very high levels of clinical care in people’s own homes and, with the assistance of modern technology, a very high level of skilled monitoring of care could be achieved.

Does this now suggest a way forward for the broader political discourse?

Rather than engaging in the usual no-win debate about the relative value of very expensive “bed-based” care in hospitals versus community care (and intrinsically lower cost) options, could we simply agree that we will provide the quality of care that is normally attached to a hospital bed, accompanied by the professional staff and monitoring, no matter where that actual bed is located?

Existing funding formulae prop up the expensive and superfluous physical infrastructure of hospital-based care. From an activity-based funding perspective, we could instead agree to pay for the actual service provided, or even shift to outcomes or results-based funding.

There have been examples of where this approach can be successfully implemented and welcomed by those most affected. One case in point is palliative care. Here, various providers have accepted the funding associated with a “hospital bed” and then worked with those individuals and families affected to provide the appropriate level of medical and nursing care at home. Aged care is an obvious next big target, where there is a serious lack of real clinical care across both its current institutional and “at-home” options. The end result is frequent admission of older persons with complex medical and behavioural difficulties to acute care hospitals.

In mental health, we are up for the challenge. Hospital in the home has a strong, evidence-based history in mental health, forming part of the balanced approach to service development recommended almost 20 years ago.

Australian evidence has demonstrated that hospital in the home programs are popular with consumers and can drive down pressure on EDs. Thirty-year-old evidence from overseas confirms there are gains to be made in relation to recovery as well as cost savings. There is Australian and New Zealand evidence showing a sizeable reduction in the need for hospital inpatient accommodation if well organised, supported accommodation is available instead.

Despite this evidence, hospital in the home for mental health has not evolved to become a mainstream service option here. Australian enthusiasm for community-based care options from the 1980s onwards failed to build either the financial or clinical skill basis for delivering high quality care outside of major hospitals. The greatest growth in new funding into mental health continues to be in hospital-based services (in both the public and private sectors). While the rhetoric is all about new models of care outside traditional institutional settings, the reality is that hospitals are funded first and last.

For many families who attempt to support acute mental health care at home, the reality is that the appropriately skilled medical, nursing and other staff are remote, located primarily in our hospitals and EDs. When people do eventually present in crisis to those settings, as recent evidence has revealed in South Australia, there is very restricted access to acute hospital beds and almost no real alternative offered. This is particularly so for younger people who are still being turned away regularly as “not sick enough” and referred back to non-existent community-based pathways to ongoing care. This is despite clear evidence that this group is at high risk of a range of poor illness and functional outcomes.

The Commonwealth and states are now engaged in another 6 months of negotiations prior to the next national partnership agreement on mental health (due for signing in November 2021). These agreements will set a platform for what will be a sixth National Mental Health Plan, as the fifth lapses in 2022. As this bureaucratic work takes place now, we should give away the pretence that it will do anything more specific than continue to fund the states’ primary responsibility – that is, to provide more acute and specialised care to those 460 000 Australians who rely on them for acute care services.

If that is what is going to happen, then we should try and encourage both innovation in the provision of those services, particularly by implementing serious new versions of hospital in the home, as well as encouraging the serious engagement of private hospital providers. Beds in private hospitals are cheaper to operate than those in public hospitals (by at least $500 per day), and they too could be mobilised to provide serious at-home alternatives.

Private hospital providers are also currently delivering low value services such as psychologically oriented day programs. Under the right activity-based pricing mechanisms, the Commonwealth could create a situation where it was attractive for both public and private hospital providers to shift much of their current bed-based, day program and outpatient practices away from their hospital-based infrastructure and relocate these services in the family home. We may then see how much more efficient and humane our service delivery system could become.

Unlike other areas of specialist medicine, very few mental health interventions actually require high specialised medical, diagnostic or interventional infrastructure.

In fact, even our newer physical treatments (eg, brain stimulation techniques) and medical interventions (eg, intranasal or other parenteral medicines) do not require inpatient beds. While there will always be a need for the provision of legally sanctioned treatments within secure facilities, much high quality care can be provided more efficiently in more open environments.

In 2021, and in the post-COVID-19 world, we need to change the discourse about the centrality of hospital-based specialist mental health care. There is a real opportunity to do things very differently. As the major funder of health care in Australia, the challenge falls to the Commonwealth to recall how hospital in the home has worked in the past and kick-start a whole new way of delivering 21st century mental health care.

Professor Ian Hickie is Co-Director, Health ad Policy at the Brain and Mind Centre, University of Sydney.

Dr Sebastian Rosenberg is Senior Lecturer at the Brain and Mind Centre, University of Sydney and Fellow at the Centre for Mental Health Research, Australian National University.

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.