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How system design choices can make – or break – a mental health system

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How system design choices can make – or break – a mental health system

Since the turn of the millennium, Australians have given much greater attention to mental health. Thanks to the sustained advocacy of many people, issues that were once treated with embarrassment or kept out of public view are now in the spotlight.

But while public attention has focused on mental health, government funding and support systems have lagged. In recent years, driven by the needs of their citizens, governments have begun to take notice and consider the systemic ways they can improve mental health outcomes, from prevention to treatment and support.

The issue is close to my heart. For five years until 2019 I served as Western Australia’s Mental Health Commissioner, leading a team of about 250 people that commissioned mental health services and gave policy and strategy advice to government. I have also served on the board of Beyond Blue for 11 years, including nine as Deputy Chair. I also have lived experience of mental illness as a consumer and carer.

It is pleasing to see state governments pay serious attention to mental health policy. In 2018 the Victorian Government announced a Royal Commission into Victoria’s Mental Health System. The terms of reference for the Royal Commission give it scope to consider matters including how to best prevent mental illness and suicide, how to deliver the best mental health outcomes, and how to support the needs of consumers, family members and carers.

Recently I made a submission to the Royal Commission, explaining what I believed Victoria could learn from my experiences in Western Australia, both good and bad, and with Beyond Blue over more than half of its life. A key theme of my submission is that there is a need for a ‘system design’ approach to get the right balance of services in place and for those services to be effectively integrated, and at the right cost. Here’s how a ‘system design’ approach can work.

A 10-year plan provides stability

Shortly after I joined the WA Mental Health Commission, we consulted on a 10-year strategy. We used the National Mental Health Services Planning Framework, a robust modelling tool that enabled us to estimate the optimal mix of services in our jurisdiction, including at a regional level and across service types, from hospital treatment to community-based psychosocial supports.

The modelling tool was based on epidemiology and optimal service levels established through consultation with clinicians, service providers, and consumers, carers and families. The tool helped us determine community need and guided the purchasing of services where the tool identified a gap or need.

The WA Commission used this tool to establish a blueprint for the system and guided consultations, co-design and investment. Together with the community, consumers, carers and families and clinicians, we could form a view at a whole-of-system level about the required service balance. This system blueprint was published in 2015 as the Western Australia Mental Health, Alcohol and Other Drug Services Plan 2015 - 2025 – the 10 Year Plan.

Lack of funding can limit options

The greatest challenge to achieving our vision was funding, given we were in a tight fiscal environment. This slowed our efforts in filling gaps identified by the 10 Year Plan. There is evidence that treating issues at a community level is at least three times cheaper than allowing an individual’s mental health issues to progress to the acute stage. To get a better balance in the system, the challenge is to grow community-based services quicker than hospital-based services. Lack of funding is the barrier to change

Where a state is only meeting 80 per cent of demand for acute mental health services, it is simply not possible to redirect hospital mental health funding toward early intervention services – this would exacerbate the existing shortfalls in acute services. The money must come from elsewhere – it must be ‘new’ money. If the state is funding 100 per cent or 110 per cent of hospital demand, then the money can be shifted to earlier intervention.

That was not the case in Western Australia, because hospitals and non-admitted treatment services were already experiencing demand well in excess of their capacity. Shifting money around is not the solution – adding money in the right place at the right time absolutely is the solution, which importantly also enables the services to be at the right cost.

The public hospital system in Australia has much better access to reliable growth funding – that is, funding that increases with demand under national partnership agreements – than does the rest of the healthcare and community support services.

The WA Commission can assess the needs of the population and estimate demand through the 10 Year Plan, informed by the Planning Framework. This identifies gaps and informs the WA Commission about which services are needed to fill the gaps. The 10 Year Plan articulates, for example, how many hours of community support are required in each region of Western Australia.

To help identify and address gaps, from capability building through to implementation, the WA Commission established a policy and planning area. Centralised analysis and planning encourage the system to work cohesively to implement the 10 Year Plan and, given Western Australia’s financial circumstances, to incrementally progress toward the optimal services mix.

The ‘service purchase’ model can enable progress

Using the 10 Year Plan, the WA Commission could direct investments and growth funds toward areas of need. Within the healthcare system, we knew there were gaps that needed to be addressed – including youth services, community bed-based recovery support services, specialist services for eating disorders and gender diversity specialist services.

We could chip away at major gaps in the system, relative to the optimal mix identified by the 10 Year Plan. While we could have made more progress in a more favourable fiscal environment, we still made substantial progress in reshaping some services in the system.

The WA Commission had contractual arrangements with health service providers (including in the public system) and used those agreements for targeted purchasing. We purchased an overall level of activity for the hospital-based services, and using the growth money each year, we purchased specific models of service. Incrementally we plugged gaps in the system through this targeted commissioning.

The ‘system level' commissioning approach homed in on identified gaps and translated them into services. This included translating the planning objectives into service models through co-design with consumers, carers and families, and then using procurement, contracting and performance management to establish those services and put in place quality assurance mechanisms. Ultimately, the commissioning area evaluated the effectiveness of services in terms of outcomes for individuals.

Contractual framework can give assurance on quality and safety

As well as the Planning Framework and 10 Year Plan, commissioning occurred in the context of a quality framework in the National Standards for Mental Health Services (National Minimum Standards).

The National Minimum Standards set out 10 standards agreed by all jurisdictions – for example, having a recovery focus for people with mental health issues and having culturally appropriate services for culturally diverse groups. The National Minimum Standards determine the culture and skills required from service providers, including other government departments, and drove the WA Commission’s approach to setting and monitoring quality standards in the services it purchases.

At the WA Commission, quality control and monitoring largely occurred through our contractual arrangements. For example, we met with hospital service providers quarterly to discuss their key performance indicators (KPIs). That started around 2016. Since then, shining a light on the KPIs improved their performance substantially, and we achieved co-operative improvement.

Generally, this was not achieved through sanctions or commercial levers; it was just by working together in a known and transparent contractual framework with the blueprint of the 10 Year Plan and our shared ethos. We produced dashboards of indicators for contracted services and provided those dashboards to the service providers each month for their review. If something unusual happened in some metrics, we approached the service provider and sought an explanation; if they could not explain it, there was a funding consequence.

As a purchaser of services, the WA Commission closely monitored performance metrics of the health service providers (referred to as local health districts (LHDs) or health service providers (HSPs) in WA). The performance metrics are compiled as a dashboard across admitted and non-admitted patients. Metrics include safety and quality measures and elements of the national mental health minimum data set and standards.

That dashboard is shared monthly with each HSP and Department of Health officials (if they wish to see it). If there are concerns in the monthly dashboard, they are discussed by the WA Commission and the HSP. Those two bodies also formally review the dashboard each quarter. Along with their own performance, the dashboard also showed the average performance of other HSPs and highlighted the levels of best performance. This proved an invaluable motivator for improvement in performance across all HSPs.

During the more than five years I spent as WA Mental Health Commissioner, there were some unprecedented achievements in developing the WA mental health system. And there were also plenty of lessons learned along the way!

Strong governance and accountability is needed at a whole-of-system level

The WA Commission achieved bipartisan support for the 10 Year Plan. Importantly, the plan was not used for political point-scoring and survived a change of government a few years after its release.

Developing the plan through extensive consultation and implementing it through co-design gave it veracity and impartiality that was universally respected. Nonetheless, it forms a very strong basis for accountability to the government of the day and to the parliament more broadly.

This enabled evidence-based decisions to determine the system design and mix of services and supports. It provided for universal performance monitoring by consumers, carers and families. The WA Commission is not conflicted in its governance and accountability as it is not a direct service provider. Left to their own devices, hospital-based services providers are naturally biased to invest in their own services, as opposed to investment and integration with community-based services, as that is where their accountability sits.

Having whole-of-system governance and accountability is crucial to developing a balanced and integrated system of prevention, treatment, care and support, which consumers, carers and families say is their greatest need.

While there are some differences between Western Australia and Victoria, there is a lot it can learn from the West. Other states may also benefit from following its lead.

Get in touch to discuss how we can support you to take a system design approach to mental health services.

Published 2 September 2020.