The government’s response was much anticipated and, while details have yet to emerge, there is much promise for improving the care of people experiencing mental health difficulties across the range of severity. Existing universal access to mental health care under Medicare will be augmented by a centralised telephone advice service, access to online mental health services for people with mild to moderate problems, and tailored packages to support those people with severe, chronic and complex conditions.

The Australian Government’s Response to the National Mental Health Commission’s review of mental health services holds out hope of addressing serious problems with Australian mental health care. Commonwealth involvement in integrated planning for regional service delivery with cooperation across the various levels of government, much needed, has been missing for a long time so we should warmly welcome this change.

Welcome too is commitment to addressing the unfairness of the current system where access varies greatly across Australia. The Response emphasises access in regional areas; while that’s important, access in poorer parts of the cities can be as bad or worse as in regional areas and I’d hope as things go forward that this issue also gets serious attention.  It’s also good that the response  plans for pilot schemes before introduction; introducing such measures without careful piloting can saddle us all with  flawed systems so that’s good strategy.

While we need to wait some time yet before we see the Fifth National Mental Plan this response gives us some sense of how the Commonwealth will position itself in the plan development process and so starts to fill what has been a policy vacuum for some years now. It’s very encouraging.

Previous health reforms by John Howard and Julia Gillard greatly increased access to mental health services in Australia, and the uptake was commensurate with the high need in the community. However, the mental health system has continued to suffer from a degree of inflexibility in terms of its ability to meet the needs of individuals with more or less complex conditions. Reforms that increase flexibility in the system, whereby people can more easily and equitably access the level of services they require, are important. A stepped-care approach, whereby individuals with less complex needs can easily access information and brief interventions and individuals with more complex needs can received well-coordinated, longer-term, and  multidisciplinary care, can be both cost-effective and user-friendly. Reforms that ensure services are delivered in the highest areas of need are also required. If the reforms announced today by the Health Minister meet the following criteria, outcomes for mental health consumers will almost certainly improve.

1.       Increased flexibility to provide individualised care: consumers receive the level of care they require, no more and no less

2.       Increased access to services where and when they are required, particularly in rural and remote areas

3.       Creative use of technology to address geographical constraints to accessing services

4.       Access to well-coordinated multidisciplinary care

5.       Increased ease with which consumers can navigate the health system and access the care they require

The mental health changes announced by Minister Ley represent a significant opportunity for structural reform.  They bring the Primary Health Networks (PHNs) to the forefront of planning to understand and meet the mental health needs of local populations.  The reforms also permit the mental health system to move beyond the constraints of fee-for-service, creating the opportunity for new pooled funding.  These new funding pools encourage PHNs to build multi-disciplinary teams, including mental health nurses, occupational therapists, peer workers and psycho-social support staff as well as psychologists, to provide a fuller range of services particularly to those with more complex needs.  This team-based approach is likely to be more effective than just going to see a psychologist for a set number of sessions.  More straightforward mental health problems will be referred to Australia’s world leading e-mental health online services and therapies.

The PHNs are brand new organisations.  For these changes to work, they will need considerable resources and capacity.  There will also need to be strong links to services run by the States and Territories.  It is not yet clear how this will occur.  There will also need to be strong and robust accountability across Australia demonstrating where things are working well and where improvements can be made.  This accountability must illuminate the issues which matter most to consumers and carers and relate to employment, education, housing and social inclusion. 

While more detail is needed before assessing the Federal Government’s proposed reform of the mental health system, the apparent focus on addressing service fragmentation is welcome.  Given that many service users and their families often seek help at a time of crisis and confusion, a key attribute of the system needs to be ease of access.  In order for this to be implemented, primary care givers require clarity as to service availability and access pathways.  To that end, a single mental health “hotline”, provided it is adequately resourced, is positive.

The “stepped care” model, which has developed internationally over the last decade, is based on the assumption that intervention effectiveness and efficiency are maximised by the adoption of a targeted “low-key” approach.  This involves the needs of service users being assessed and monitored in a holistic fashion, taking social, cultural and economic circumstances into consideration as key aspects of the ways in which mental health problems are experienced.

Effective reform will therefore require systems in which the lived experiences of service users are incorporated into service design and delivery.  Social Workers will play a key role here.  The Australian Association of Social Workers notes the “social context and social consequences” of mental illness as the profession’s primary domain.  Their skills and training in conducting holistic assessments and forging crucial therapeutic alliances with service users will be central in ensuring the stepped process is undertaken in a responsive, informed fashion. 

Better co-ordination of existing mental health services is a step in the right direction. A critical missing piece, however, at this early stage appears to be early intervention to help young children and their families.

We look forward to seeing how the Government intends to address this issue in its upcoming response to the National Mental Health Commission’s review into mental health services.

There is a strong economic argument, as well as the Government’s own prevalence rates of mental health problems in very young children, for the Government to respond to the Mental Health Commission’s call to directly help Australian families.

The Review called for ‘local, planned and coordinated community action on child development and wellbeing’ and said this was ‘as much about parenting and the mental health of adults as it is about children’.

While children under 12 can access Medicare-funded psychological services, their parents, strictly speaking, cannot access a medical rebate to gain parenting support, despite the fact that medical guidelines around the world routinely recommend evidence-based parenting programs such as the first step of care for conduct disorder and ADHD.

The single most important thing we as a community we can do to promote the wellbeing and development of children and to prevent mental health problems is to increase the skills, confidence and competence of parents at a whole-of-population level.

I welcome the new Mental Health Plan’s approach to meeting the needs of people with complex needs. To date the mental health care for individuals in Australia has been fragmented. There has been little coordination between different specialists, the GP and the Community Disability carers involved in a patient's treatment. There has been a silo mentality in working with the population who has complex needs.

This has resulted in unnecessary waste of resources and inappropriate care particularly for those with multiple comorbidities. These deficiencies have been emphasised in the National Review of Mental Health Programmes and Services released earlier this year by the National Mental Health Commission. At Griffith University we have recently completed a review of over 700 studies world-wide looking at Care Models and the Health Economics of Complex Need patients. It is clear that the international standard which offers the best care for the individual as well as being the most economic approach is the integrated model of care.

I am pleased to see the new Mental Health Plan has addressed this and hopefully sets out a blueprint to better assist people with complex needs. The one-size-fits-all model does not work and wastes resources.  The key, of course, will be in seeing how this is implemented and where the priorities are set.

Parents have an important role to play in prevention of mental health problems in young people. Mental health problems are common and often start to affect young people in the first 2 decades of life, when parents are still actively involved in their child’s life.

Most young people with mental health difficulties still do not seek appropriate professional treatment, and even amongst those who do, the substantial burden of these problems is not adequately averted. There is clear research evidence that prevention of such problems is possible and effective.

The most effective prevention approaches focus on reducing factors that render young people more vulnerable to developing mental health problems, and promoting factors that make them more resilient against these problems.

Many of these factors can be influenced by parents, most of whom are also inherently motivated to take preventive action and to support their child if they are experiencing difficulties; but parents do not always know how best to do this.

Evidence-based resources to support parents in this important role are urgently required. Online resources are promising in this regard because they are scalable and sustainable for population-wide dissemination. An example of such a resource is www.partnersinparenting.net.au.

The Australian Government response to the Review of Mental Health Services does not mention older Australians, which by 2030 will number over 5.7 million. In particular, the mental health needs of nursing home residents remain unaddressed.

Prior AIHW reports found over three-quarters of residents have a mental illness, more than half a diagnosis of dementia and over two-fifths of residents with dementia also had a diagnosis of a mental illness, while a quarter had a diagnosis of mental illness without a diagnosis of dementia. Furthermore, nearly half of older persons admitted for the first time to aged care had symptoms of depression, a quarter with moderate to severe symptoms.

We are very pleased the Government has acknowledged the very powerful evidence that clearly demonstrates mental health programs need to be fully integrated into day to day life.

Like any serious public health issue, mental health can’t be something we only worry about when it turns bad.

We need a whole systems approach that incorporates education, prevention, early intervention, access to quality treatment and ongoing support where required.

Research shows that many cases of mental illness, and nearly all cases of suicide, could be prevented with the appropriate systems in place.

With this plan finally completed, I hope we can now work with the government, community and health systems to significantly reduce the rates of mental illness and suicide in Australia.”

Inclusion of technology

“A key component of the stepped care mental health released by government today is to provide mild to moderate care through a digital portal - offering e therapies, helplines and self-help programs. However, how this portal will work is not at all clear.

The new focus leads itself strongly to online and digital mental health solutions to ensure care is effective, accessible and tailored to the individual. Our online programs such as myCompass are already being used by thousands of Australians.

We strongly applaud the focus on technology and the emphasis on online technology. Australia is a world-leader in this technology, all started by our development of MoodGym which is now used internationally.

However, much of the good research and development in this space has stagnated over the last 10 years, with little Government investment, direction or will.  As the government now acknowledges, the real trick is to work out how digital stepped care can be delivered well. To date the lukewarm Government response has resulted in the development of prototypes but not the roll out of the innovations into clinical care or education settings. 

The Black Dog Institute and others in the digital space wants to work with the government to advance the innovation agenda, most notably in areas where many young lives are lost (suicide) or impacted (depression). There are numerous problems that must be addressed:

1)         No financial models for developers to work with health to deliver solutions;

2)         No incentive or interest from government/industry to work with to put these models into place; and thus stifle innovation and competition

3)         No promotion of e health solutions as viable alternatives to face to face treatment;

4)         No regulation of services or e health solutions so no incentives exist to develop quality products.

We also see many potential solutions, but we require a culture where government will work with innovators and technology companies. In the short term we see the following as potential solutions: investing in infrastructure to offer a range of interventions that currently exist to go to scale; set up an organisation that regulates quality control, thus incentivising research and development; invest in the IT structure to link personal devices to link to health records; encourage the creation of new innovation technologies in this space; provide platforms for Australian companies to expand or develop products in the US and China. 

Asking the innovators in this space to wait for government or to sort this out for themselves is simply the wrong approach. We look forward to contributing to an integrated plan to put this place urgently. After all, lives are lost every day, and many can be saved by digital technologies.”

Shift towards local communities

“Mental health care will never be a “one-size-fits-all” portfolio. For this reason, we strongly support the shift towards community-focussed mental health initiatives.

In a country as diverse as Australia, it is important to acknowledge that requirements for prevention, intervention or clinical care will vary greatly across time and space.

It is important, however, to protect Australians from the fragmentation of services we have seen in the past. We look forward to more detail on how Primary Health Networks will manage this potential issue.”

Clinical Care

“The implementation of stepped care models is in line with best practice and we welcome this decision, especially the focus on the individual.

Put simply, stepped care programs enable us to deliver the most appropriate intervention for the individual, whilst ensuring their care level can be stepped up or down depending on treatment response.

Black Dog is currently working on Stepped Care programs for adolescents and adults that step patients through levels of online and face-to-face assessment and care. These will be available in 2016.”

Young people

“We welcome the incorporation of Headspace and Primary health networks as this will strongly support a broader group of young people in all parts of Australia.”

Suicide Prevention

“We strongly support the shift towards community-focussed mental health initiatives.

In a country as diverse as Australia, it is important to acknowledge that requirements for prevention, intervention or clinical care will vary greatly across time and space.

It is important, however, to protect Australians from the fragmentation of services we have seen in the past. We look forward to more detail on how Primary Health Networks will manage this potential issue.”

Clinical Care

“The implementation of stepped care models is in line with best practice and we welcome this decision, especially the focus on the individual.

Put simply, stepped care programs enable us to deliver the most appropriate intervention for the individual, whilst ensuring their care level can be stepped up or down depending on treatment response.

Black Dog is currently working on Stepped Care programs for adolescents and adults that step patients through levels of online and face-to-face assessment and care. These will be available in 2016.”

Young people

“We welcome the incorporation of Headspace and Primary health networks as this will strongly support a broader group of young people in all parts of Australia.”

Suicide Prevention

“Every day, around 7 Australians take their own lives. We are disappointed that the Government have not taken a stronger approach to this serious health issue, with considerable evidence-based programs available to be rolled out immediately.

We hope that the integration of suicide prevention programs into localised initiatives that simultaneously involve schools, health care providers, hospitals and emergency services will provide some benefit in this area.”