Writing in the ABC Online magazine  The Drum, John Mendoza has described the Abbott/Turnbull Government’s recently announced mental health reform package as ”the most transformative reform package in a generation”.

Mendoza, who was previously chair of the National Advisory Council on Mental Health and CEO of the Mental Health Council of Australia, is a respected figure in the mental health sector in Australia, and someone who has argued long and hard for radical reform of Australia’s mental health systems. He is also someone personally affected by the failures of the mental health system(s).
Therefore, we must take his endorsement seriously. He recently wrote:
What was announced today responds directly and decisively to the core problems in mental health care identified in a continual 10-year public critique and published in truckloads of reports to government. Finally, we will see an end to the sort of “mental health care system” that mirrors the old Soviet automotive industry – the one car, in one colour and only available after an eternal wait!
I hope he is right.
painting courtesy of Painting by seeds with mental health recovery wishes

painting courtesy of Painting by seeds with mental health recovery wishes

The reform package was announced in late November 2015 by Prime Minister Turnbull, Health Minister, Sussan Ley, the chair of the National Mental Health Commission, Professor Allan Fels and Commissioner Ian Hickie as a response to the Review of Mental Health Programmes and Services by the National Mental Health Commission.

The key to the new model is that federal funding for reform will be directed to 31 primary health networks around Australia. The networks will use a contestability model to contract out mental health services locally. Contracting the required local mental health services will cost $365 million from July 2016-17 and rise to $370 million in 2017-18 and $385 million in 2018-19.

Some key features of the reform package include:

  • Locally planned mental health services will be commissioned through Primary Health Networks (PHNs). Under the reform, new integrated care packages would be commissioned through 31 Primary Health Networks (the rebadged Divisions of General Practice/ Medicare Locals) across Australia.
  • The newly-established PHNs will have a flexible funding pool to commission local services, including access to mental health nurses, psychological treatments, vocational services, drug and alcohol services and peer support.
  • People with severe and complex mental health needs will be offered coordinated care packages, similar to packages offered by the National Disability Insurance Scheme (NDIS).
  • A new digital mental health gateway will be established to coordinate e-health services, including a new telephone hotline to help people find the most appropriate services for their needs.
  • PHNs will coordinate a new approach to suicide prevention by focusing on activities to address local needs.
  • the existing Headspace youth mental health facilities will remain, as will the Headspace head office, but new services for young people will be allocated through the PHNs.
  • Aboriginal and Torres Strait Islander mental health and social and emotional wellbeing services will be integrated.
  • a commitment to national leadership in mental health reform.
Mendoza argues that the reform package provides ‘a new architecture’ for mental health, which draws from recommendations contained in a recent report by The National Mental Health Commission. Mendoza argues that the new package reasserts the Commonwealth’s leadership role and commits the Commonwealth Government to transform the delivery of primary care (delivered by GPs, psychologists and psychiatrists) and community care (largely delivered by non-government providers).
Painting from the blog How to juggle glass: surviving mental illness at University

Painting from the blog How to juggle glass: surviving mental illness at University

Mendoza applauds this proposed new architecture because it provides individualised and seamless support, to enable the right care at the right time from the right mix of providers to enable people to live fulfilling lives; is locally planned and integrated, and not ‘one size fits all’; is focussed on the needs of people, not providers; uses available and emerging digital technologies; emphasises clinical excellence and improved outcomes; foreshadows bundled packages of health and social care for those who have complex needs and entrenched disadvantage and has a planned, phased rollout of the reforms.

As Sebastian Rosenberg notes the reforms might have the potential to change the appalling state of Australia’s mental health systems, but ultimately they will be judged on the outcomes they deliver, rather than the rhetorical promises they make.
There are serious questions about the Federal Government’s plans.
1) The level and amount of funding looms as a major concern. Mental health services are not currently funded to a level which reflects the extent of mental illness and mental health problems within the Australian community, resulting in significant unmet need for care. 
Painting from the blog How to juggle glass: surviving mental illness at University

Painting from the blog How to juggle glass: surviving mental illness at University

Despite this, there is no new money in the reform package just a reallocation of  $350 million of existing funds to primary health networks (or PHNs) to commission — but not deliver — mental health services. 

There are doubts as to whether the intent of the reforms can be achieved within the existing budget. The National Mental Health Commission argued that more than $1 billion over 5 years was needed.
Some of the money is being redirected from hospital based services and alcohol and other drug services. The Government is hoping that money for the reforms will come from reduced utilisation of services for patients with “lesser needs”, who will be directed to less intensive resources, self-help or low intensity services. This is questionable.
2) There are legitimate questions about the capacity of newly formed PHNs  to develop and organise tailored care packages within a contestability model and concerns that the arrangements will add to administrative costs by funnelling funding through an additional layer of bureaucracy.

PHNs are newly established agencies. There are questions over their capacity to manage these responsibilities and deliver genuine client centred care. The Primary Health Networks have no history and limited experience and capability to deliver or contract mental health services.

Some health commentators see the PHNs as ideological creations of the Abbott/ Turnbull Government and question the way they were created and their ability to deliver outcomes. Economist John Thompson writes about the creation of PHNs:

Many in the health system are of the view that the whole exercise is a very expensive ideological move that, despite very substantial financial resources and lengthy disruption and dislocation, may not achieve the results that the fledgling Medicare Locals were beginning to realise.

Despite the rhetoric, the experience from contracting and contestability models suggests that it is likely that PHN will decide what package of care people can have, based on the services it has chosen to procure.
3) There are concerns about the capacity of a phone and online service to act as a single gateway for people suffering mental illness and mental health concerns, as evidenced by the major problems experienced by people trying to access Centerlink’s services through a similar model.
4) There are serious questions associated with the use of a market based contestability and competitive model to purchase mental health services at the local level. 
The reforms aim to use competition and contestability to drive efficiency and increase consumer choice. However, there is a growing evidence that the use of contestability and contracting to deliver social, health and community services has failed to deliver the desired results.
In Australia, a range of systemic problems have been identified with the contestability and contracting of services. Over 10 years, Australian academic Mark Considine and his colleagues have undertaken an extensive body of work into contracting and contestability of social and community services.
They found that contestability and contracting of employment services to not- for- profit and for- profit providers failed to achieve the desired results.  Considine and his colleagues found that contracting processes decrease service flexibility, increase the level of standardisation and routinisation, limit the scope for quality service provision and fail to promote innovative solutions for the most vulnerable. 
They found that rather than drive innovation and responsiveness to individual needs, agencies tended to mimic the behaviour of other large NFP and corporate for-profit competitors.
These findings are replicated in other areas.
 
The recent debacle of the DSS contracting funding round, documented in the Senate Report Impact on service quality, efficiency and sustainability of recent Commonwealth community service tendering processes by the Department of Social Services is a reminder of the risks and dangers of using contestability to contract human and community services.
The Senate Report found that:
  • the 2014 tendering process was poorly planned, hurriedly implemented, and resulted in a loss of services.
  • the process was not equitable and transparent, with an apparent inherent bias toward larger providers at the expense of local knowledge and expertise that smaller providers have developed in response to clients’ needs.
  • throughout the process the Department kept providers and peak bodies at a distance and the NFP sector felt the department undervalued their expertise, experience and role.
  • the process damaged relationships between providers by pitting them against each other and engendered greater mistrust.
  • the outcomes of the contestable process were poor.
5) Contestability processes will open up the mental health sector to large corporate for-profit providers who have previously had minimal involvement in mental health service delivery, but who have a significant presence in other sectors. This includes corporations active in other sectors such as Max Solutions/Maximus, Serco, G4S, BUPA, Ramsays, St John of God, Providence, Healthscope, APM, Ingeus, Virgin Care, ESH Group,  A4e, Medibank Private, Telstra, IHMS, Transfield/Broadspectrum, Health Direct, to name a few.

This agenda to introduce more for-profit corporate and business providers into health, social and community services delivery is a major priority of the Abbott/Turnbull Government’s social policy agenda, particularly in areas where there are currently few for- profit corporate providers such as disability (through the NDIS), mental health and welfare services.

In announcing the Government’s response to the Harper Competition Review, Treasurer Scott Morrison laid out the Federal Government’s agenda when he committed the Commonwealth Government to a radical process of marketization and privatisation of health, education and human services to introduce more for- profit corporate and business providers.

Given the very poor record of corporations in other sectors- employment, vocational education and training, aged care, prisons, health, child care- it is a cause for great concern that people with mental illness and mental health problems will become clients (commodities) and opportunities for corporate profit making.

6) The Government has confirmed that there will be a loss of some services as a result of them losing funding under the new model.

The loss of mental health services, particularly community based services, peer-led services, agencies with specialist expertise or those located in regional areas where there are fewer services, will have major consequences.

7) Indigenous mental health groups welcomed the announcement and the commitment of $85 million to Indigenous mental health, but called for greater detail about the reforms and urged the government to consult and collaborate with the Aboriginal community.

8) It is unclear how the Commonwealth reforms will align with State Government reforms. Current processes and structures have been ineffective in joining up mental health approaches between governments.
9) There are no indications of accountability or how progress and success will be measured. As Simon Rosenberg notes, the Commonwealth must establish a new and robust approach to accountability and invest funding in strong and consistent approaches to data collection and evaluation, that provide real information about things that matter.
 
Rosenberg writes:
Rather than reporting on bed numbers, these processes need to reveal the extent to which PHNs are actually working to help people with a mental illness stay out of hospital, recover from their illness, complete their education, resume employment, avoid homelessness and become healthy and productive members of the community. None of this information is currently available.

10) Concerns have also been raised that the reform package neglects the role of people with lived experience and peer approaches,  and an increased role for peer workers, issues now widely accepted and promoted in the mental health sector as providing a progressive social movement of informed consumers capable of driving reform.

11) Finally, and perhaps even more importantly, other social policy reforms of the Abbott/Turnbull Government are likely to undermine the intent of the reforms. 

Mental health reforms cannot be seen in isolation from the Abbott/Turnbull Government’s wider social policy agenda, which focuses on market driven approaches, austerity measures and cuts to services, more punitive treatment of vulnerable people and greater private sector involvement in the funding and delivery of services. These are having (or likely to have) disproportionate impact on people with mental illness and people who live precarious lives who are forced to bear a greater burden.
  • As part of its crackdown on the Disability Pension (DSP) the Abbott/Turnbull Government outsourced the assessment of eligibility for the DSP, resulting in 8000 young people being kicked  off  the DSP, forcing sick people deeper into poverty. This includes many people with mental health issues. In addition, the number of applicants for the DSP being rejected is the first place has risen dramatically from a third in 2008 to almost two thirds in 2016. 70,000 new applications have been rejected.
  • The Budget measures of the Abbott/Turnbull Government are  significantly increasing the financial stress experienced by many people with mental illness and creating additional cost barriers to them accessing care.
  • Tax reform proposals, particularly the proposed increase in the GST, will hit vulnerable people the hardest, including people with mental illness and mental health issues.
  • The new Family Payments Bill and cuts in payments to single parents and families will impact on families affected by mental illness or mental health problems.
  • Problems with Centrelink.
painting by Liz Kelder

painting by Liz Kelder

There is much still unknown about the proposed reforms, however given the severity of the crisis in mental health systems throughout Australia, the reforms are overdue and welcome, as John Mendoza notes, and it is hoped they make a significant difference to the lives of people affected by mental illness and mental health problems.

However, in light of the underlying concerns raised in this paper and questions about some assumptions underlying the reforms, the fear is that the reforms will go the way of many previous reforms. Well meaning and likely to deliver benefit to a proportion of people in need, but ultimately unable to address the systemic problems and extent and severity of need. We will see.