(Part 8 of a Croakey series on health reform)
In a recent post, Sydney psychiatrist Professor Alan Rosen began the story of “Indiana Rudd” and the unlucky fate of mental health in his CoAG Temple of Doom. Here is the next instalment:
“Mental health reform should have been presented as a core model of what is required for the whole health system: funding the shifting of the centre of activity to the community, providing welcoming facilities to encourage prevention and offering mobile home-delivered assertive care, with acute and longterm follow-up in the community for as long as needed, and well-integrated hospital care only when absolutely necessary.
Enhancing the Headspace youth health program to ensure young people access mental health services was essential, and will be much appreciated, but is only part of the solution. Even these enhancements will only allow assessment and initial engagement of more young people in need, but leave them in the lurch with few early intervention or community mental health teams with any capacity to follow them up. We must also tackle, resource properly and reform gaps in mental health services for all other phases of care and phases of life.
The “health reforms” Mr Rudd signed off with most of the premiers will make uncapped clinical activity or hospital based procedures, not outcomes, the main game in town. This will cause currently depleted community health and evidence-based mobile community mental health services, which may well not be beneficiaries or only minor recipients of the new Commonwealth funding streams, to wither even further or just disappear into hospitals.
Against all expert advice, they are already being retracted onto hospital sites, dismantled and replaced by gestural, sedentary, traditional hospital outpatient services (are we going back to the 60’s? ), which will not be able to provide viable community alternatives to hospital admissions.
The states have insisted on and won a re-shunting of the new central pool of federal health and their forgone GST funds, back through their health bureaucracies, before being distributed to the Local Hospital Networks. So much for Mr. Rudd’s principles of “funding federally, delivering locally”, and “ending the blame game”. It will be just that much harder to disentangle the levels of responsibility and blame. As far as who can best run health services, we are between the devil and the deep blue sea.
The Commonwealth Department of Health & Ageing may be able to write a chook raffle policy, but it has few employees with much experience of running health services, and too many decision-making generic career bureaucrats without any clinical background. It has also presided over the serial down-grading of the national mental health strategy and standards, so not to embarrass any health bureaucracy or minister by committing to any real reform. It seems that even specifying practical goals, targets and timelines for improvement would be seen as far too “aspirational”.
The states have much more experience at running health services, though they have done so incredibly poorly in some jurisdictions. However, most states and hospitals have forfeited the right to administer mental health services, as they have siphoned off their resources, often allowing them to shrivel and rot.
Yet Mr Rudd has left the fate of these services in the same hands. He also chose to exclude community mental health teams working with individuals with significant mental illnesses from co-location with primary health centres, in the centres of their communities, where they should be for easier access and mobility. At the same time he has channelled the funding for their complementary support services (eg the CoAG Personal Helpers & Mentors program) to primary care via the GP networks. This will cause further fragmentation and cause these support services to move up-market, or their staff to turnover due to lack of immediate clinical back-up by expert mental health teams.
Mental health services will get some access (yet to be specified) to the new $400 million p.a. national investment for 1300 sub-acute beds. This is welcomed. However, the bulk of this funding is likely to be used up on expensive hospital beds, while in rehabilitation, and especially in mental health, most of these places need to be located and staffed in the community. Mental health is likely to be low in the pecking order for its share of this funding, as usual. Mental health alone could have used up most of this amount, just to replace the loss since the 1990’s of over 1000 sub-acute beds. Yet, it is to be spread thinly across many medical conditions.
Why disrupt mental health services further just when they so badly need better organisation? Why abandon evidence-based community mental health services when they most need rescuing and rebuilding? Can a chaotic phase really be a creative circuit-breaker? Is there a brooding hidden opportunity, lurking in the depths of all this seething primeval soup of dismantled and fragmented elements of service, that has not yet surfaced?
Is all the “doom and gloom” really that warranted? Stay tuned for the rivetting climax and conclusion of Indiana Rudd and the CoAG of Gloom…”
• Alan Rosen is Secretary, Comprehensive Area Service Psychiatrists’ Network; Clinical Associate Professor, Brain & Mind Research Institute, University of Sydney; Professorial Fellow, School of Public Health, University of Wollongong