Abstract
While the aims of the Second Plan have been an appropriate guide to change, what has been lacking is effective implementation. The failures have not been due to lack of clear and appropriate directions, but rather to failures in investment and commitment.
Executive summary, Evaluation of the Second National Mental Health Plan. 1
All Australian governments have recently committed to yet another 5 year plan (2003-2008) under our National Mental Health Strategy (NMHS). 2 The new plan introduces four new ‘priority themes’ to the NMHS: promoting mental health and preventing mental health problems and mental illness; increased service responsiveness; strengthening quality; and fostering research, innovation and sustainability. It proposes 34 desirable outcomes. Remarkably, none of these outcomes deals specifically with the theme of research, innovation and sustainability.
In our recent Australia-wide review of people's experiences of mental health care (Out of Hospital, Out of Mind!), 3 we highlighted the gap between the commitment to community-based mental health reform described in 1993, 4 and again reaffirmed in 1998, 5 and our collective failure to invest in such systems of care. In that review, we relied on systematically collected consumer and carer experiences of care as well as the perspectives of local providers of care. There was a general perception that our mental health systems rarely deliver on basic issues of access, quality or continuity of care. 3 The government's own evaluation processes came to similar conclusions. 1
In a world of increasing demand for services, legitimate community desires for improved access to better quality and sustained mental health services, and the realities of limited national health funding, we asked both providers and users of mental health services to rate their top priorities for immediate reform. 3 The top five priorities for immediate action are shown in Table 1. We had hoped that such community-based priority setting may influence the development of the most recent plan. Unfortunately, the current plan does not commit governments to any priorities. While all strategies are again possible, no government is required to deliver on any specific items in the plan within any given timeframe!
Importantly, in terms of future planning, we not only derived priorities but also explored community views as to possible immediate actions. It was the views of the community that informed the four proposed key actions presented in Table 2. The preferred mechanism for increased accountability identified by 67% of respondents was the development, in one form or another, of an independent national commission. Other important actions outlined in the report included development of national data sets to track service provision and greater resourcing and use of non-government organizations and consumer and carer evaluation.
Since the release of Out of Hospital, Out of Mind!, 3 there has been little enthusiasm among our governments for establishment of any independent or ongoing external review mechanism. The potential benefits of such a review mechanism have been recognized in other countries, notably New Zealand. While the lack of enthusiasm for such a process in Australia has been attributed to the difficulty of establishing such a mechanism within our Federated system, in our view more basic motives are easily discernible. What we proposed was a yearly reporting system that examined monies spent, access and quality of services and human rights issues (Table 3). Another clear failing of our NMHS has been the inability to establish any credible, informative, longitudinal data sources, particularly with regard to experiences of care. The major source of reporting under the NMHS has been the biannual national mental health reports. Analysis of these reports clearly shows that government notions of ‘accountability’ remain limited to process issues such as delayed reporting of inputs rather than the more critical notions of quality of care or clinical outcomes. Critical incident reporting remains nonsystematic or hopelessly inadequate – as recently demonstrated by the New South Wales report ‘Tracking Tragedy’. 6
Various levels of community and stakeholder support for the national priorities
Actions required
Four questions for each head of State/Territory government
Clearly, we need to implement systems where those who provide or use services can report systematically and longitudinally on quality of care and the status of mental health reform in Australia. In the absence of any credible systems of accountability, the Mental Health Council of Australia, as the peak independent advisory group to the Federal Minister, has decided to take on this audit role. It currently does so with-out the support of the governments. Fortunately, new technologies, notably web-based information systems, make this financially and logistically feasible but only with the goodwill and voluntary work of Council partners, such as the Brain and Mind Research Institute at the University of Sydney (http://www.bmri.med.usyd.edu.au), who need to engage with the data in order to draw out its most significant messages. The first of these surveys, which asks providers to rate their perceptions of the local and state impacts of mental health reform, is included with this issue of Australasian Psychiatry. At this time, and to be repeated annually, we are asking all provider groups, including psychiatrists, to rate their perceptions as to the degree to which the key community priorities for reform (i.e. those derived during the ‘Out of Hospital, Out of Mind!’ consultation process) have been implemented. The survey can also be completed online at www.mhca.com.au Our goal is to build a national picture of the progress of reform annually, as well as develop a State-by-State perspective. Given sufficient responses, we will also be able to look at important rural and regional differences.
This particular survey is the first in a series. The second, which is also available online through the Council (http://www.mhca.com.au), is not directed at providers. Instead, it uses well-established international quality parameters for rating consumer and carer experiences of health care. 7 We encourage all psychiatrists to direct their patients, or their carers and families, to complete that survey. Until we develop a national system for ongoing reporting of actual care experiences by both providers and users of care to complement the established but limited government systems, we are unlikely to know whether we are making any real progress along the road to genuine mental health reform in Australia.