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Five views of the Roadmap for National Mental Health Reform

The roadmap was released after the COAG meeting on Friday December 7, 2012. AAP/Alan Porritt

Patrick McGorry, Professor of Psychiatry at University of Melbourne

Last year at COAG, Mental Health Council of Australia CEO Frank Quinlan, social inclusion advocate David Cappo and I discussed a blueprint for mental health reform for over an hour with the prime minister and premiers. It was agreed that a ten-year road map would be created to ensure that, by 2020 all Australians would have the same access to quality mental health care as they already have to physical health care.

Since then, even though the National Health and Hospital Reform Commission and the mental health sector had agreed upon a clear sequence of best buys to achieve this goal, federal and state governments have totally failed to produce a credible road map, instead diluting recommendations down into empty rhetoric. Once again, our governments have manifested attention deficit disorder when it comes to mental health reform.

Other policy issues have pushed aside the needs of the four million Australians with mental ill health and their families. Even the $2.2bn over four years – a modest start – announced by the federal government last year has been delayed or stymied. Clearly, we need a new process that doesn’t require the lowest common denominator of COAG. And the federal government needs to assume leadership and control of community-based mental health care.

Louise Newman, Professor of Developmental Psychiatry, Monash University

The ten-year road map is a combination of vision, values and wishful thinking. It’s an ambitious exercise and also one that poses some risk if the vision is not realised.

It’s difficult to argue with the vision as outlined and the desire to improve the mental health and the social and emotional well-being of all Australians, and many of the broad goals. There’s a clear need for reform of mental health services and approaches, as well as a need to focus on the social inclusion and support of individuals and families affected by mental illness.

What’s not so clear, however, is how we are to achieve this and whether the road map is more than a re-statement of the points made by mental health advocates for many years. Driving change is more than just stating the need for change and requires leadership and will.

The need to look in a serious way at the prevention of mental illness is key, but this receives limited attention in the plan and is not detailed. While there’s mention of the significance of trauma and abuse as risk factors for mental disorder, there’s no mention of the need for a comprehensive strategy for both prevention of child abuse or for treatment and intervention for survivors.

This is a noble vision but light on details of achievable reforms, time lines and how the process will be driven.

Professor Ian Hickie, Executive Director of the Brain and Mind Research Institute

In the last few weeks, we have seen the release of two major documents that are critical to the future of mental health reform in Australia. The first, the 2012 Report Card of the National Mental Health Commission (NMHC), documents the major failings in our disorganised systems of health care, social services and community support for those individuals and families affected by mental illness.

It continues a long tradition of such independent reports dating back to the Burdekin enquiry in 1993. Along with all the others, it stands in contrast to the ways in which governments have continued to report substantive progress.

Sadly, after more than 20 years of national focus on coordinating improvements in state and federal services, all too frequently those in the greatest need – young people, those without the capacity to pay for better services, and those who live outside the major urban centres – struggle to access the basic help that they would receive if they had a major heart condition, or cancer or other chronic illness.

As a result, the lives of our fellow citizens are left impoverished and the nation pays a high price in terms of lost productivity and unnecessary social dislocation.

The second, the Roadmap for National Mental Health Reform, is the response of our collective governments to the challenge put to them by Prime Minister Gillard following her investment of $2.2bn in new and redirected funds in the 2011 budget. As such, one would have hoped for a document that clearly defined the destination, set a timetable for reaching landmarks along the road to that destination, defined the key measures by which substantive change could be assessed, set real targets that were consistent with our national aspirations and modelled the size of investment that would be necessary to achieve real change (as has been done for the National Disability Insurance Scheme).

Unfortunately, what we’ve been offered instead is another worthy policy and planning document that continues the long tradition of such tomes dating back to the 1992 national mental health strategy. It picks up themes left dormant since the last major COAG agreement in 2006 – and once again tries to narrow the field of key indicators for success. And it proposes yet another collaborative and protracted dialogue with the states, which may or may not result in setting actual targets for success.

Frankly, for those who have waited patiently for substantive improvements in access to real health and social services, employment and education opportunities, stable housing and respect for their basic human dignity – it’s just not good enough. It won’t be sufficient to prevent a major campaign leading up to the 2013 federal election – just as we saw before the 2010 election when the Labor party was forced belatedly into a series of ad hoc and poorly conceived policy options.

Currently, specialised services are largely clustered around acute care hospitals, homelessness shelters or gaols. The available community-based mental and general health services are still focused largely on those with chronic and persisting illness. We have not set about any serious response to the appalling physical ill health and premature mortality experienced by those with enduring mental disorders.

To date, we have not instituted the nation-wide system of early intervention services that was such a focus of community support during the tenure of 2010 Australian of the year, Pat McGorry. Worse still, that key commitment to ensure an appropriate balance of early intervention and continuing care services – through sizeable new investments in novel pathways to care - is noticeably weakened by the current discourse.

Once again the dysfunctional political process that derails any serious national reform agenda in this country is hard at work. In health, this is very frustrating as good health underpins our capacity to achieve a “contributing life” – a notion central to our national values and social contract. While Australia has a proud tradition of responding actively to real health emergencies, such as the arrival of HIV/AIDS in this country 30 years ago, we have a much poorer record of responding to ongoing inequality. Just look at the state of dental care, indigenous health, chronic disease management and mental health as key measures.

The message is clear enough. If reform is left to a bureaucratic committee – convened by both the states and the commonwealth - then expect no real change. Instead, we will witness more buck-passing and endless finger pointing. Of course, what’s also obvious from our history is that national leadership – meaning the actions of a determined prime minister and federal government – can make a real difference.

The Keating government put real money behind the first major step away from specialised mental hospitals to community-based care in the early 1990s. The Howard government led the response to suicide prevention in the late 1990s, the provision of psychological services under Medicare-type funding from 2001 onwards and the establishment of the national network of youth services that are now incorporated under the Headspace brand in 2005.

Cooperative premiers can respond to the national agenda. This was obvious in mental health with Jeff Kennett in Victoria in the 1990s and Morris Iemma in New South Wales in 2006. It has recently been re-emphasised by Barry O’Farrell’s commitment to fully implement the NDIS in New South Wales.

Sadly, the new roadmap doesn’t build on the successful model for national leadership. Rather, what’s proposed is more of the same joint federal-state red tape and “shared responsibility”. We’ve had that for 20 years – and as the 2012 NMHC report so clearly indicates - it just doesn’t work!

Helen Berry, Professorial Research Fellow in Psychiatric Epidemiology, The University of Canberra

The Council of Australian Government has just released its Roadmap for National Mental Health Reform for the next 20 years, focusing initially on the next decade and building on significant new investment in mental health services in recent years. New, more consultative administrative arrangements are part of overseeing implementation of the plan and these may prove effective.

There’s also something of a shift from conceptualising mental health as an issue the health system has to address, to a greater awareness of the need to promote good mental health and the best quality of life possible for those with mental illness. This is welcome, as is a life-course approach (understanding that, as people go through life, their needs change) and the inclusion of families, carers and communities as key partners in promoting mental health.

Yet there’s still, in my view, too little focus on people as primarily social beings. Implicit in the roadmap is an acknowledgement that there remains a desperate lack of appropriate, affordable, accessible mental health services. Of course, we must continue to address this. But this is not the main game.

Most mental health problems arise directly from, are triggered by or are significantly worsened by isolation, exclusion, stigmatisation and injustice. These are defining features of marginalisation – multiple, complex, persistent, and usually intergenerational disadvantage. It’s no surprise at all that elevated rates of mental illness are found among Aboriginal people. Why would they not be? If we are to make really big improvements in mental health among those most in need, we have to confront the social structures of our society that marginalise people.

It’s easy to nitpick and find fault. I don’t want to do that because this plan is a step in the right direction. It’s just that, like climate change, if we are to avert disaster as a society, we need to go all the way – and quickly.

Jen Smith-Merry, Senior Lecturer in the Faculty of Health Sciences at the University of Sydney

The long-awaited Roadmap for National Mental Health Reform 2012-2022 has finally been released by COAG.

It emphasises important areas for reform, prioritising the promotion of person-centred approaches, improvement of the mental health and social and emotional wellbeing of all Australians, prevention, early intervention and detection, access to high quality services and support, and an improvement in the social and economic participation of those experiencing mental ill-health.

The roadmap commendably takes a wide approach to mental health, including that often forgotten other half of the mental health picture, health prevention. And, to address this takes a whole of government approach that “sets priorities that include and go beyond the health system.” It also has a stated commitment to person-centred approaches. This is difficult to implement but a key part of the recovery framework – and a stated value in state, territory and national policies.

The roadmap calls for “collective responsibility” for mental health. In a collective, ideally everyone takes responsibility, but a common problem with collective responsibility is that no one takes responsibility. So while it’s reassuring to see a list of indicators around which to measure roadmap achievements, an important factor missing from this list is the allocation of responsibility. Indicators are also far more powerful if they are linked to targets and time lines, but only a few of these have been identified.

But this is a “vision” document guiding governments to the resolution of this vision. Much of the implementation rests on the successful operation of an intergovernmental working group. To them I say, good luck. It’s a big task and the road which this map leads us down is littered with discarded and poorly implemented plans, policies and lists of priorities.

One of the criticisms of the roadmap development process has been a lack of broad consultation with the mental health sector. To avoid similar potholes to those that have confounded previous visions, it’s important that this situation is rectified and that the working group is genuine in seeking advice from the sector.

Successful implementation of the roadmap must go beyond “whole of government” to what we need to think of as a “whole of sector” approach to mental health.

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