|Implemented in this survey?|
Since the early 1990s, Australia has witnessed the de-institutionalising of mental health care. In recent years, there has been a growing recognition of the lack of community support programs, leaving many patients with inadequate levels of care and support. This failure received widespread publicity in late 2005 with the release of a scathing report of the system. This, along with other political factors, galvanised Australian governments to develop a national action plan on mental health.
The National Action Plan on Mental Health 2006-2011 is a policy document agreed to by the federal, state and territory governments which sets out the intended outcomes, indicators and five areas for action with specific policy directions. These are
The Plan outlines the roles and responsibilities for each of the nine governments and lists specific programs to receive funding under the Plan's auspices.
Overall, the objectives National Action Plan on Mental Health are to:
New funding for mental health
In 2002-03, it was estimated that Australian governments spent AUD3.2 billion on mental health services per annum. This Plan allocates AUD4 billion of new resources towards mental health over a five year period - a significant new investment.
Expansion of Medicare to improve teamwork between different health professionals
The Plan indicates that new funding will be mostly allocated to existing programs and to a limited extent to new programs such as trials in the area of mental health and drug and alcohol treatment. Possibly the biggest set of reforms will be implemented at the federal level where the existing Medicare program has been expanded to include improved access to, and better teamwork between, psychiatrists, clinical psychologists, GPs and other allied health professionals. Reforms will allow private psychiatrists to refer patients to psychologists and GPs, encourage early assessment and management of people with a mental illness by GPs, and allow GPs to refer patients to psychologists and allied health professionals. Medicare, the national fee-for-service public insurance program, has traditionally covered only services provided by medical practitioners. The set of reforms announced as part of this Plan continues a trend of expanding Medicare coverage to allied health professionals - and the consequence of this is an expansion of fee-for-service arrangements.
The Plan will also establish and fund clinical and community care coordinators to address the issue of people with mental illnesses not accessing the right care and services at the right time. These care coordinators are, in part, recognition of the complex, fractured and at times ad hoc Australian health care system, making it difficult for patients to access the right services at the right time and place.
Integration of health and social care services
Finally, this Plan also recognises the wider well-being of patients with mental illnesses, and is not restricted to health related services. Approximately $800 million (or 20% of the total package) will be spend on programs aimed at ensuring that people experiencing severe mental illness are better connected with services and supports that will allow them to live independently in the community. Programs will be directed at education and employment; enabling people with mental illness to have stable housing by linking them with other personal support services; improving referral pathways and links between clinical, accommodation, personal and vocational support programs; and expanding support for families and carers including respite care.
Patients with mental health illness, health care professionals especially psychologists
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
Degree of innovation and structural impact
Most of the initiatives contained in the National Action Plan can be described as traditional with the majority of funds going towards expanding existing services and programs. Possibly the two most innovative aspects of the Plan are (1) coverage of psychology services under Australia's Medicare program; and (2) the funding of care coordinators to guide people with a mental health illness through the health system. For this latter initiative, people within the target group will be offered a clinical provider and a community coordinator. The clinical provider, who may be a GP, a mental health nurse, a treating doctor in hospital, or where appropriate an Aboriginal Health Worker, will be responsible for the clinical management of the person. The community coordinator will be responsible for ensuring the person is connected to the non-clinical services they need, for example accommodation, employment, education, or rehabilitation.
Degree of controversy
The Plan has a fairly high level of consensus, with governments from each of the main political parties agreeing and signing up to it. The report has received support from peak organisations and academics but some concerns were expressed by the Australian Medical Association - although these were not fundamental, nor influential.
There has been widespread media attention of this policy process, mainly because of the high level profile of COAG.
It is perhaps too early to assess the transferability of this policy. Certainly, some aspects of this policy such as the care coordinators may be quite specific to health systems that are fractured and complex such as Australia. On the other hand, investment in community programs that aim to support the health needs of the mentally ill as well as their economic and community participation may be more transferable to other countries.
In mid 2005 there was a change of leadership within the NSW Government. Keen to make his mark in the electorate the new premier and former health minister, Morris Iemma, highlighted mental health as a major policy priority. Further, a the Mental Health Council of Australia, a peak, non-government organisation representing and promoting the interests of the Australian mental health sector, published a report that included a detailed account of the plight of many people living with mental illnesses. It described the last 12 years of mental health care reform as a failure and urged governments to invest in community services, early intervention and step down care. Finally, there have been some high profile cases of mental illness, with the Western Australian Premier resigning in January 2006 due to depression.
The process by which reform was achieved was through the Council of Australian Governments (COAG). This Council consists of leaders of the 8 state and territory governments and the federal government. The role of COAG is to initiate, develop and monitor the implementation of policy reforms that are of national significance and which require cooperative action by Australian governments.
|Implemented in this survey?|
The Council of Australian Governments (COAG) recognised at its February 2006 meeting that that mental health is a major problem for the Australian community This recognition by COAG follows the release of a damming report on the state of mental healthcare in Australia, high profile identities coming out in public about their battles with mental illness and a renewed political leadership in New South Wales.
COAG invited senior bureaucrats to prepare an action plan. The National Action Plan on Mental Health 2006-2011 was released in July 2006 and included substantial new resources from all governments to address mental health issues.
De-institutionalisation in mental health care - but under investment in community services
The main purpose of the policy is to redress the failure to provide adequate support for people with mental illnesses in the community. Since the early 1990's Australia has had a policy of de-institutionalisation in mental health care - but while the number and capacity of those institutions have all been diminished there has been an under investment in community services to replace some of the functions of institutional care. This, according to the Mental Health Council of Australia, has led to a situation where "any person seeking mental health care runs the serious risk that his or her basic needs will be ignored, trivialised or neglected".
The National Action Plan on Mental Health received widespread attention and support from the media, most stakeholders and community groups. The Australian Medical Association, whilst generally supportive, did criticise the extension of Medicare over the role of general practitioners - with particular reference to the Government's undervaluing of GP services (ie the Medicare rebate for GPs were lower than those for other health professionals) (SMH October 10 2006). The Mental Health Council of Australia, whilst supportive, acknowledged that the funding was a good start but was still a long way away from the amounts of funding called for in their report. Further, it criticised the Plan's five year evaluation cycle - calling for ongoing evaluation and monitoring efforts.
|Prime minister||very supportive||strongly opposed|
|Minister for Health||very supportive||strongly opposed|
|State leaders||very supportive||strongly opposed|
|Psychologists||very supportive||strongly opposed|
|AMA||very supportive||strongly opposed|
|Mental Health Council of Australia||very supportive||strongly opposed|
This policy initiative has been driven by executive government with very little input from the legislature.
|Prime minister||very strong||none|
|Minister for Health||very strong||none|
|State leaders||very strong||none|
|Mental Health Council of Australia||very strong||none|
The National Action Plan sets out a detailed individual implementation plans for each of the governments. These implementation plans list the programs and services that will receive additional resources as well as commencement dates. In addition, each of the state and territories will convene a Mental Health Group to provide a forum for oversight and collaboration on how the different initiatives from the Commonwealth and State and Territory governments will be coordinated and delivered in a seamless way. This initiative is seen as an important aspect of the plan aimed making governments work together and consulting with non-government, private as well as consumer and carer representative to ensure the plan's effective implementation.
A series of measures have been identified to track progress against the outcomes. Australian Health Ministers will report annually to COAG on implementation of the Plan, and on progress against the agreed outcomes. The draft progress measures are listed in Table 1 below.Governments have also agreed to an independent evaluation and review of the Plan after five years.
COAG has agreed to a set of aims and progress measures that are listed in Table 1 below.
Table 1: National Action Plan on Mental Health:
|Reducing the prevalence and severity of mental illness in Australia||
|Reducing the prevalence of risk factors that contribute to the onset of mental illness and prevent longer term recovery||
|Increasing the proportion of people with an emerging or established mental illness who are able to access the right health care and other relevant community services at the right time, with a particular focus on early intervention||
|Increasing the ability of people with a mental illness to participate in the community, employment, education and training, including through an increase in access to stable accommodation||
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
The National Action Plan on Mental Health is a major new investment of resources and is primarily directed at areas that, according to many experts, have been neglected over the last 12 years. The risks associated with this policy initiative are minimised through the use of existing programs and infrastructure. In this sense, this policy reflects the incremental change to a health policy approach adopted over the last two decades and does not require major structural change. As such, this policy is unlikely to meet any significant resistance and can be implemented in full. The programs to be funded under this policy appear to be based on a reasonable level of evidence and will establish some innovative new programs under trial conditions. Funding places due emphasis on creating greater access to services for people in rural and remote areas, people of Aboriginal and Torres Strait Islander descent, people with substance abuse problems and from low socio-economic status.
There are some risks associated with the Plan. First is the system's capacity to expand services within the timeframe called for. The Plan does allocate significant new funding towards workforce training but these initiatives may not produce sufficient numbers of qualified staff in time for the commencement of some of the programs. Secondly, there is some risk of inefficient resource use because of the decision to extend fee-for-service arrangements to yet another group of health professionals, psychologists. Under Australia public insurance arrangements, where professionals can determine their own fees and the Government will subsidise significant proportions of this fee, there is a risk that professional fees will increase, especially if the anticipated rise in demand for psychology services is realised. This risk is somewhat mitigated by a restriction of 12 consultations per year. Third, it is not clear whether the progress measures identified by COAG in their Plan and listed in Table 1 are all available. If not, then there is a risk that we will not be able to evaluate the policy as planned. However, as acknowledged by COAG in the Plan, the progress measures may alter through ongoing work within the Government and other entities. Finally, as indicated in the plan, COAG intends to conduct an independent evaluation of the policy after five years time. Such an evaluation will be extremely difficult to undertake without some proper planning as the policy gets implemented.
Kees van Gool