Response to Allison et al.,‘The National Mental Health Commission Report: Evidence based or ideologically driven?’

The National Mental Health Commission review of mental health programmes and services recommended that the Commonwealth Government continue to fund headspace and the youth early psychosis programme (YEPP) as core components of Australia’s response to mental ill-health in young people. This recommendation was consistent with the positive findings of the first headspace evaluation, the encouraging outcome data on headspace clients (Rickwood et al., 2015) and the extensive and growing national and international evidence base about the effectiveness of the early psychosis model of care that is operationalised by YEPP (e.g. Chan et al., 2014). In November 2015, the Minister for Health, Sussan Ley, confirmed the government’s support for headspace and early psychosis care and foreshadowed new arrangements for contracting these services that are at variance to the approach proposed by Allison et al. (2015).

The Commission and the Federal Government’s support for headspace and youth mental health reform is also consistent with the review’s central emphasis on investing in earlier, more holistic mental health care. Headspace centres already focus on the access, accommodation, education, employment, physical health, service satisfaction and suicide prevention outcomes that the review recommended should become national targets in mental health care. The extensive headspace database on client care and outcomes, the embedding of research partners within the governance of headspace and the significant research activity already occurring across the headspace network advance the Commission’s goal to increase mental health research capacity and impact.

It is therefore a mischaracterisation to suggest that the Commission found that the headspace model was inefficient. As highlighted elsewhere (McGorry et al., 2016), Allison and colleagues assess headspace’s effectiveness based on inappropriate comparisons to samples that differ markedly from headspace clients in complexity, diagnosis, age and socio-demographic background. National headspace data tell quite a different story, with greatly improved access especially to young people from regional Australia, indigenous and other marginalised groups, and with levels of self-harm and days out of role significantly improved. We expect that the independent evaluation of headspace will demonstrate real benefits, although it is almost impossible to find a control group of comparable complexity, ironically because access to traditional primary care and State-funded services is so poor.

Based on the Commission’s recommendations, Minister Ley announced that the contracting functions currently managed by headspace National Office would be devolved to the Primary Health Networks. The Commission emphasised that any governance arrangement for these youth mental health platforms should strongly safeguard the fidelity of the headspace and YEPP models of care. Consistent with this recommendation, Minister Ley confirmed that national oversight and some continuing core activities, which we believe must include national data collection, accreditation, research and training, would be provided by a central agency.

The Commission did not identify devolving governance of headspace and/or YEPP to State-based local health networks (LHNs) as one of its suggested options, nor is it likely that the Minister seriously considered this as an option. Instead, the Commission noted that as Commonwealth investment increased via programmes such as headspace and Better Access, State governments appear to have disinvested from mental health care, mitigating the potential impact of these programmes. Cuts to tertiary mental health care may contribute to the client mix of headspace being more severe than originally intended.

Extending control of State-funded mental health networks over youth mental health platforms, as proposed by Allison and colleagues, is inimical to the Australia Government’s reform agenda of increasingly locating mental health care within primary care and regional communities. This is a much better nexus than linkage to acute hospitals where a permanent funding crisis already puts unprotected mental health budgets at constant risk.

Headspace is a fully integrated system of enhanced primary care that already brings local services together in a regional partnership to improve local collaborations. The consortia that run headspace services include primary care providers, State-funded specialist mental health services and education, employment and housing agencies. Headspace employs community liaison staff to nurture relationships with other agencies and to reach out directly to schools and other referral points. These are features that hospital-centric State mental health services have failed comprehensively to develop.

It is true that the interface between headspace and State-funded public mental health services is often problematic. There are two contributing factors. First, State services are under-resourced, resulting in the bar for access being extremely high, even for young people with complex and severe disorders, with greater needs than headspace as a primary care service can manage. This creates barriers and tensions. Headspace welcomes initial access, the State services are forced to restrict it. Second, the structure of most State services is still the traditional child and adolescent mental health services/adult mental health services (CAMHS/AMHS) model with its dividing line at 18, which is hugely problematic for young people and families (Singh and Tuomainen, 2015) and doesn’t align well with the 12–25 approach of headspace which receives uniformly positive feedback from patients and families.

It would be an advantage for more psychiatrists to work sessionally in consultation-liaison mode within headspace centres, which does occur in a number of headspace centres. There is also a telehealth model that has been developed that provides consultant psychiatrist input to sites. The Orygen-led headspace sites have a clinical director who is a psychiatrist; however, in keeping with the primary care focus of headspace centres, clinical governance at most other sites should ideally be led by a general practitioner. Headspace has also developed a new clinical governance model to manage potential risks.

The performance of State governments and LHNs in operating community mental health services does not augur well for them becoming the appropriate custodians of Commonwealth investment in mental health service innovations. Their foray into community mental health has been eroding for years and seems unsustainable as long as governance and finance remains linked to acute general hospitals.

The failure of State governments to fund or contribute to comprehensive early psychosis programmes prompted the Federal government in 2011 to finally step into this evidence-based zone of care. Many States wanted to take the Commonwealth funds and use them to prop up existing underfunded and dysfunctional structures rather that fill the major gap that existed for early psychosis patients. Since the new resources were to be community-based, the Australian Government decided it would fund a smaller number of services on its own to ensure the money was going to be spent on what it was intended to be. The Minister has recommitted to that strategy and plans to extend the focus to other serious mental disorders. We welcome this development, although the extended focus will need to be adequately resourced and evidence-creating. The YEPP initiative was carefully designed to cover evidence-based care for up to 5 years for early psychosis cases only, and only 20% of the Australian communities needs would be covered anyway within the current funding envelope.

Mental health needs Commonwealth money because of vertical fiscal imbalance. The Commonwealth’s decision to move into service provision was visionary and has produced an emerging youth mental health system that is now the envy of many developed countries that are moving to emulate it. This success must be built on and extended across the lifespan, as the Government states it intends to do. This will require substantial new funding over time but with a potential significant return on this investment.