This page was first published in December 2014 and has now been archived.

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Information is power
Bricks and mortar
Putting skills to work
Money

The reform directions presented in this document represent broad principles, and aspirations for a new approach to mental health and wellbeing in NSW.

They represent a fundamental shift – to a future in which a person, family or community sits at the heart of our thinking, services, delivery systems and planning.

That in turn presents enormous challenges to government and community-sector agencies charged with delivering not only health care but also social services, education, housing and the many other services that are critical in the lives of people who experience mental illness.

To make these changes effectively, we will need to incrementally transform the structures we have in place to deliver services – our buildings, workforce, information technology and budgets – reconfiguring them over time so that they can fulfil their primary function of supporting the things that people really need.

This section presents some initial ideas about the changes that will be required to create capable, flexible and responsive infrastructure to take us forward into a new generation of mental health reform. These will evolve, as new evidence emerges to support particular programs and approaches, as new technological developments create opportunities to do things smarter and faster, and as changing national approaches remodel the NSW mental health funding landscape.

Information is power

We have barely begun to tap the potential of data collection and analysis as a means of improving our services, by giving us real-time feedback not only on the technical performance of systems of support but – crucially – on the experience of people who use them, and on whether their mental health and wellbeing improve as a consequence.

The cost of technology is falling rapidly, vastly expanding our options as we consider how to use information systems to support mental health. For example, hand-held devices that can quickly record key details at the point of contact between a service and a consumer are now becoming cheap enough to be widely deployed to mental health workers who travel to peoples’ homes. That may reduce the burden of paperwork and increase the chance that the system will hold an accurate and up-to-date record of the person’s care and concerns, leading to better quality care and treatment in future.

The continuing development of secure, internet-based technologies for data sharing and data linkage presents new possibilities for collaboration among government, the community sector, consumers, carers, families and clinicians, giving them access to information that can improve planning and help determine the best support for individuals.

Information systems can improve continuity of care between clinical care and community services and community, family and peer supports for people living with an illness in the community. With effective information sharing, there is less chance of the person living in the community inadvertently losing touch with the service system and the carers, clinician and other people in their community such as friends and relatives who can assist with recovery. 

But first, people who experience mental illness must have the assurance that their privacy will be respected, and that information about them will be available only to the people and agencies that really need to know it, because they are directly involved in supporting them.

Towards change

  • We should support the rapid deployment of information systems in community mental health services and community-managed support agencies.
  • We must always ensure people’s privacy and the integrity of the records kept about them, but we should nevertheless support information sharing among agencies and service providers when this has the potential to improve care and support and has the person’s consent.
  • We should investigate the potential of real-time feedback systems, which would improve responsiveness and accountability by allowing both consumers and clinicians to record their perspectives, and to document evidence of immediate action in accordance with people’s needs.
  • Services need to be accountable for the quality of support they offer; they should be expected to contribute to standardised data collections in which their practices and results can be compared with others and benchmarked.
  • Meaningful reports derived from routine data collections should be published regularly, where they can be viewed by people who use services and the community more generally.

Bricks and mortar

The environment in which care and support are offered is crucially important. Building design sets expectations about what will happen there; it may comfort and reassure, or it may make people feel devalued and fearful. Building location may make the difference between being able to continue work or education, and having to suspend normal life to seek care.

The evidence shows people who experience mental illness benefit from environments where families and friends feel welcomed, where they have control over their immediate environment such as lighting, and where there is artwork and windows with a view of nature. It shows also that staff experience greater job satisfaction when the built environment is more sympathetic.

We want people to be able to find support close to home, in settings that are friendly, readily accessible and that do not restrict or stigmatise them. Hospitals are and will remain essential in the most severe crisis, but the research evidence tells us we can redefine what makes a severe crisis; even when acutely unwell most people can be better supported at home or in a home-like setting.

This move from hospitals to the community requires us to rethink our current and future investment in places where we offer support. Any up-front costs will be offset in the longer term by the therapeutic benefits to people who use services.

Towards change

  • Thirty years ago the Richmond report called for the closure of long-stay psychiatric institutions. We must bring that promise to fulfilment and close the remaining psychiatric institutions in NSW, redeploying the investment to community-based services.
  • We should plan for services to acquire or rent premises in areas where people would go in the course of their ordinary lives – in town centres, close to shops or community facilities such as libraries – and accessible by public transport.
  • We should support the development of agreed design principles for mental health facilities of all sizes and scales, based on advice from people who experience mental illness, families and carers, health care architects and interior designers.
  • In more acute settings we should explore the potential of different floorplans and technologies to keep people safe without overt forms of security.

Putting skills to work

By far the most valuable resources we hold in mental health are the skills, knowledge, energy and goodwill of the hugely diverse range of peer workers and other professionals who support people who live with mental illness.

But we still face many serious structural challenges in maintaining and developing a workforce that will carry us through the next decade, providing the diversity of support we need.

The gap we already have between demand and supply for specialist mental health staff is likely to widen in the near future as the ageing workforce retires in larger numbers and fewer people enter mental health professions. The effect will be felt unevenly; rural areas are likely to be hardest hit.

Others will leave to pursue different challenges, or in frustration with their roles or the way services are organised in a sector that can be immensely personally rewarding but also exposes workers to distress, trauma and burnout. 

The avoidable loss of mental health workers is expensive in terms of recruitment, temporary replacement and training costs. Less tangible costs include reductions in morale, organisational memory and increased pressure on remaining staff. 

Our existing systems emphasise the employment of people with particular professional backgrounds in particular roles. Sometimes, for no good reason, this reduces our ability to respond to local circumstances using a wider diversity of professional skills. 

Towards change

  • Peer workers offer hope and understanding as well as knowledge and support to people who experience mental illness, and research shows they can be highly effective in supporting people’s recovery. We must develop strategies to train and support a larger number of peer workers and integrate them as respected colleagues in mental health teams.
  • Social workers, youth workers, Aboriginal mental health workers – and many others – have key roles to play as we move towards recovery-oriented mental health support and away from a strictly medical view of mental illness. We must ensure their contribution is adequately developed, rewarded and used in practice.
  • All mental health professionals, including psychiatrists, psychologists and mental health nurses, are expected to be in increasingly short supply in the decade to come. We must develop robust projections about workforce need and advocate accordingly for adequate training places.
  • We need to provide training for existing mental health workers to increase their understanding and skills in recovery-oriented practice and trauma-informed care, recognising that even highly skilled and experienced professionals may not have confidence in these domains.

Money

We know that when it comes to spending in our public health system, mental health comes a very poor second to physical health. 14% of the impact of all illnesses can be attributed to mental illness, but NSW Health spends only 8% of its budget on supporting people with mental illness. This means they  do not have the same access to the high quality of care as those with physical illness. 

We know that funds allocated for mental health care are not always spent on mental health care. 

Hospital and health system budgets operate in such a way that money intended for mental health can be diverted to support more visible, politically sensitive issues such as emergency department waiting times or elective surgery waiting lists. 

Compounding these problems, funds that are notionally allocated to community mental health may be spent in acute mental health settings, in a state which already relies too heavily on in-patient care. 

Persistent under-funding leaches away the capacity of mental health services to respond to people’s needs in a timely and appropriate way.

Additional funding comes from the Commonwealth Government, via Medicare and a range of other schemes including headspace centres and the Personal Helpers and Mentors program. But these funding sources frequently do not align well with state spending priorities, meaning a person with mental health needs can fall through the gap between the two systems.

Towards change

  • We need to introduce transparent systems within the NSW public health system for protecting and spending allocated mental health funds on mental health services and activities, with priority to services within the community.
  • As activity-based funding becomes the dominant model for financing public hospital services, we must ensure payments are structured so that they do not perversely reward local health districts for keeping people in hospital, when they could be better supported in the community.
  • As we ask community-managed service providers to take on an increasing proportion of mental health support, we need to ensure that their income is reliable enough to let them plan and develop the programs they offer, to the benefit of the consumers.
  • We must carefully monitor the effects of Commonwealth programs, including the National Disability Insurance Scheme, to ensure that if NSW residents do not meet eligibility criteria they are still supported in accordance with their needs.
  • Community-managed organisations that wish to operate in the NDIS environment will need to adapt their business model to accommodate a system in which consumers choose from a range of available services.

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Last updated: 28 June 2017