Australia’s national youth mental health initiative: Is headspace underachieving?

Introduction

Headspace, the National Youth Mental Health Foundation, is Australia’s premier youth mental health programme, which is receiving AUD410 million in federal funding over the 5 years from 2013 to 2014. While acknowledging headspace as a worthy initiative that aimed to improve mental health-care for young people, the National Mental Health Commission (NMHC, 2015) Report indicated that the headspace model was inefficient with major problems in the organisation’s structure and governance.

In commenting on the central theme of the public submissions, the NMHC (2015) Report concluded that headspace had ‘under emphasised and under achieved’ its main role, which was integrating and coordinating services for young people especially in conjunction with state-based mental health services (Volume 2: page 156). Rather, the headspace centres tended to operate as silos not as part of regional networks.

Given these issues, we explore whether the headspace centres should be realigned with the states and territories, which is the level of government responsible for clinical services. Could the local health networks (LHNs) better integrate mental health-care for young people?

Structural flaws

The NMHC (2015) Report concluded that headspace’s problems arose from the federal government’s decision to move into direct service provision, which is primarily the role of state and territory governments. In the process, headspace centres were created without adequate consultation, and this led to the ‘duplication of, and competition with, other community, private and state government services’ (NMHC, 2015: Volume 1, p. 82).

Overall, headspace has increased service fragmentation rather than decreased it because each of the 100 centres has its own lead agency, often a non-government organisation (NGO). This has added further complexity to an already complex youth sector, and it has required the creation of a large central headspace administration to oversee the national programme.

In relation to clinical governance, the absence of psychiatric leadership and consultant psychiatrists is a major flaw in NGO-led clinical services. In South Australia, the Coroner has specified that a consultant psychiatrist should supervise mental health services for young people. Following an inquest into the suicide of an adolescent patient, the Coroner recommended that the South Australian child and adolescent mental health service (SA CAMHS) required consultant oversight equivalent to other specialty areas of medicine; he specified that SA CAMHS needed ‘the same level of consultant supervision as a surgical service in a public hospital’ (The South Australian Coroner, 2014: p. 51). His recommendation recognised the unique role of psychiatrists as the medical experts who are best able to integrate care across the biopsychosocial model. These findings should be carefully considered when headspace clinical services are being rolled out for adolescents in South Australia and elsewhere.

Below minimally adequate treatment

The NMHC Review sought headspace outcome data; however, there was little systematic information available either from headspace directly or through independent evaluations (NMHC, 2015). To remedy this, Rickwood et al. (2015) reported a large study of 24,000 young people who attended headspace over 2013–2014. Notwithstanding the potential strengths of the headspace model, such as lower stigma and ease of access, these initial data showed equivocal benefits at best.

Overall, headspace’s outcomes were consistent with spontaneous improvement rather than active treatment (Jorm, 2015; Rickwood et al., 2015). One reason for these disappointing results was the inadequate treatment received by many young people; almost half attended for only one or two sessions, which is well below the threshold for evidence-based treatment. Jorm (2015) has suggested recently that clinical services should focus primarily on ensuring existing patients receive ‘minimally adequate treatment’, and this is an important goal for headspace.

Only 3.1% of the eligible young people responded to follow-up, so the evaluation was unable to investigate whether headspace made a meaningful difference to the course of anxiety and depression (Rickwood et al., 2015). This is unfortunate, as early intervention is the main rationale for the programme. Comprehensive data should guide future development of the headspace model.

A new challenge

Headspace is facing a major new test of its structure, clinical governance and outcomes; nine headspace centres are currently rolling out youth early psychosis programmes (YEPPs) that are going to offer acute treatment and continuing care. These YEPPs need to be closely aligned with state and territory mental health services, but this is the weakest link for headspace (NMHC, 2015). It raises serious questions about whether the national early psychosis programme will reach its full potential.

Originally, the federal government offered the early psychosis programme to the states and territories. Following federal–state debates about funding, the policy changed, and in May 2013, the federal government announced the redirection of AUD247 million to headspace. This decision left the states and territories mid-way through a complicated youth reform process.

This process reflects the highly problematic nature of federal–state relationships in the mental health sector. The federal government overrode state and territory responsibilities, and as a consequence, complexity and duplication increased in the youth mental health sector (NMHC, 2015).

This situation has occurred through the federal government’s use of its financial power; Australia has a well-recognised fiscal imbalance where the federal government raises most of the tax revenue that the states and territories require to provide mental health services. Saunders and Crommelin (2015) have pointed out that the fiscal imbalance only becomes problematic when the federal government uses its financial power to override the states and territories as happened with YEPP. In fact, the Constitution recognised the potential for fiscal imbalance and indicated that the states were entitled to any federal government ‘surplus’ divided on a fair basis without strings attached.

There is justifiable criticism of state and territory mental health services. In a federation like Australia, however, the remedy is not the federal government acting unilaterally, but rather the states and territories being democratically responsible for their performance. This requires the federal government to provide fair resources, and to set national benchmarks with state and territory governments, which are then held accountable by parliaments and their citizens (Saunders and Crommelin, 2015).

Within the Australian federal democratic model, the state and territory LHNs should be strengthened to provide regional mental health services across the lifespan. In the present example, headspace’s clinical services should be fully integrated into the LHN continuum of care. This would clarify the organisational and clinical governance of headspace, integrate headspace with state-based CAMHS and adult mental health services and ensure the availability of consultant psychiatrists to lead strategy, clinical governance and service delivery.

Conclusion

After careful examination of the emerging data, we suggest that headspace should be aligned with regional state and territory LHNs. This would have several benefits. It would reduce the duplication of administration and clinical services, and facilitate an integrated model of care; it would counter the perception that headspace is a silo, and most importantly, it would allow standardised governance of all clinical services for young people. This realignment would mitigate weaknesses of the current headspace model, which are managing clinical risk and developing a tiered system of care.