Leviathans: Headspace-like behemoths swallow resources

‘For by art is created that great Leviathan called a commonwealth, or state … which is but an artificial man … and in which the sovereignty is an artificial soul, as giving life and motion to the whole body …’

Thomas Hobbes, Leviathan

Leviathans

The Australian Commonwealth government is funding a unique type of non-government organisation (NGO) that raises challenges for provision of mental healthcare in Australia. We define such NGOs as organisations that seek to combine advocacy and media strategies with policy development, research and provision of mental healthcare, and describe them as Leviathans due to their vast scope of activities and budgets. Headspace and Beyond Blue are prominent examples. We focus here on the Headspace National Youth Mental Health Foundation, a charity which receives both Commonwealth government funding and public donations. Headspace operates as a national franchise with the foundation offering assistance and support for the Commonwealth-funded Headspace centres that are run by lead agencies, including many NGOs (Headspace, 2018). This branding and franchise model, shared with Beyond Blue, is quite unique: directly state-funded public mental health services (acute hospitals and the community sector) are not competing in this space, and suffer as a result.

Problems arise from the divide between Federal/Commonwealth and state government planning and funding of mental healthcare. The Leviathans are overarching Commonwealth programmes, while the states remain responsible for acute hospital and community mental health services. However, instead of assisting the states with additional funding to meet rising demand for essential mental healthcare, the Commonwealth government seems to prefer to receive the credit for setting up branded programmes such as Headspace. Thus, local regions end up with state-funded child, adolescent and adult mental health services that run in parallel with overlapping Commonwealth-funded Headspace services, which we term duplicated/looking-glass programmes.

Thus described, Leviathans may be: at best, seeking to address shortfalls in existing state services; and at worst, either interfering with or potentially draining resources from public mental health services. The Commonwealth budget for the provision of mental healthcare already faces considerable challenges, and funding for the Leviathans diminishes the finite pool of funds available for state mental health services. In addition, the new NGO mental health services are either insufficiently coordinated with state services and/or may offload patients who present with complex and chronic conditions not seen as being within their remit, potentially increasing workloads for state mental health services. Leviathans have multiple roles of advocacy, policy, research and service delivery, but we argue that limited evaluation of their effectiveness raises concerns. Finally, there needs to be consideration of the lifespan and legacy of such NGOs, in that such initiatives may be of finite duration, and at their passing, there are consequences arising from the vacation of the spaces in which they work, as has happened with some disability NGOs with the introduction of the National Disability Insurance Scheme (NDIS).

Leviathan appetites

The Commonwealth funding for Leviathans is substantial, and in fact our primary reasoning for usage of the term. The Annual Report for Headspace 2017–2018 (Headspace, 2018) details revenue of $34,890,602 with an operating loss of $23,589,525 and net assets of $15,296,905. The above figures do not include the Commonwealth April Budget 2019–2020 announcements, such as $263 million over 7 years for additional Headspace services and $109.7 million for 2 years for Early Psychosis as compared to $229.9 million over 7 years for other largely Commonwealth government and some NGO services. The figures for Headspace do not include the Medicare billing that is conducted for service delivery. By way of comparison, the projected budget for public mental health services in the ACT 2018–2019 is $646 million over 4 years (ACT Government, 2018), while NSW is $2.1 billion for 2018–2019 (NSW Government, 2019). Therefore, Headspace is a substantial programme, when compared to public mental health service budgets. For example, $263 million dollars could potentially fund 800-plus publicly employed psychiatrists or 2600-plus nurses for a year!

Looking-glass services

We argue that the funding of Leviathans by the Commonwealth government has led to a haphazard parallel provision of mental health services, akin to images in a looking-glass. The haphazard nature of the mental healthcare promulgated can be illustrated as follows. Headspace itself has established over a hundred separate stand-alone clinics staffed by groups of medical practitioners, nursing and allied health professionals, which assess, triage, treat and refer in a parallel manner to public mental health services. However, not all Headspace centres have medical staff, which will necessarily require referral to GPs and psychiatrists if specialist care is needed, and it is not clear that there is specific coordination with public mental health services. Consequently, in practice, it appears that many Headspace services need to refer onwards to public child, adolescent and adult mental health services, which may duplicate assessments as well as impact on workloads and resourcing in the public sector. The National Mental Health Commission (NMHC; 2014) 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 (vol. 2, p. 156). The NMHC Report also concluded that headspace centres were created without adequate consultation, and this led to the ‘duplication of, and competition with, other community, private and state government services’ (vol. 1, p. 82). The actual effectiveness of the Headspace model has been questioned, noting: ‘that this expansion has occurred in the absence of any evidence that headspace services are actually effective in improving youth mental health’, (Jorm, 2015). Part of the solution is to seek to evaluate the effectiveness of activities/services of the Leviathans at least as rigorously as in state-funded mental healthcare. If Leviathan looking-glass services provide uncertain levels of expertise/care, are they in fact unnecessarily reduplicative publicly funded mental health services?

The fate of Ahab and his Leviathan

Ultimately, the effective provision of mental healthcare in Australia requires adequate Commonwealth funding of both the public and private sectors. Given the shallow governmental pool of mental health funding–as the Commonwealth disburses to the states–Leviathans could devour limited resources, disadvantaging state mental health services. To evaluate effectiveness of care, it is essential to compare the outcomes from state-funded public and private mental health services with Leviathans; this will require robust outcome evaluations from Leviathans that have not been forthcoming to date. Public mental health services are essential for patients with severe and chronic mental illness, yet they are struggling in terms of funding, resources, workforce and state government support. State-funded public mental health services may be the best existing base upon which to build joined-up services that connect with NGO and other community services. If the Commonwealth government seeks to improve mental healthcare in Australia, then funding Leviathans is as futile as Captain Ahab’s infernal obsession with that most famous Leviathan, Moby Dick. It would be better for the Commonwealth government to dedicate additional funding to revitalising state mental health services, rather than chase the great white whale of large NGO programmes like Headspace, and avoid being swallowed by Leviathans.