Response to Looi et al. – Tilting at windmills: A giant quest

Australia has a once-in-a-generation opportunity to redesign and invest in mental health care. Common purpose is crucial. Yet in the latest divisive instalment in ANZJP, Looi et al. (2019) characterise organisations like headspace as leviathans, which pose a threat to mental health care. They seek to draw a parallel with Captain Ahab’s obsession with the pursuit of the great whale in ‘Moby Dick’. However, a credible critique requires a clear perception of reality, and we argue that the classic novel ‘Don Quixote’ captures the extent of the authors’ failure to grasp the reality of Australian mental health care. Don Quixote famously mistook windmills for terrifying giants, launching an abortive attack which rebounded badly. His idealistic, yet ultimately shallow, intentions were discredited, rendered farcical by common reality.

Giant killers

Looi et al. (2019) claim that their critique is aimed at several ‘leviathans’, non-governmental organisations (NGOs) they characterise as self-serving, ac-quisitive and wasteful. However, this is rapidly revealed as merely cover for yet another provocative critique on youth mental health (YMH) reform. Their fundamental proposition is that State-funded mental health services have suffered because of the growth of headspace, which is in fact Commonwealth-funded, through several mechanisms. First, if headspace had not been funded, the Commonwealth could have allocated these resources to boost underfunded State services. Second, headspace has worsened State-funded mental health care through duplication and confusion and unlocked demand for State-funded services. Third, headspace is ineffective in contrast to State-funded services, which should be entrusted with enhancement of YMH care.

The reality of headspace: a trusted brand in primary care

headspace was created because young people with the highest need for mental health care across the lifespan had the poorest access. headspace centres are safe, trusted, stigma-free and welcoming, offering holistic, youth-friendly primary care, working in partnership with local general practitioners (GPs), agencies and communities. Following 12-month nationwide consultation, especially with young people, families and professionals, headspace began from 2006 and has attracted strong community and bipartisan political support. The system has been scaled up from an initial 10 centres, reaching a current total of 110 and will extend to 145 by 2022. The headspace centre network now includes headspace National, PHNs and lead agencies supported by independent consortia, who bring together and coordinate local community support. The centres are not ‘separate [and] stand-alone’, but form a highly connected nationwide network whose collective expertise, infrastructure, resources and partnerships deliver consistent and coordinated best practice.

The scaling up of headspace as a nationwide model with specified elements and a trusted brand is a genuine success story in Australian mental health reform. Independent evaluation confirmed that headspace provided much better access to young people, with very high levels of satisfaction and safety, and specifically improved deliberate self-harm and days out of role (Hilferty et al., 2015). headspace clients who improved had a 59% reduction in the number of days they were unable to work or study, highlighting the economic benefits of headspace (Hilferty et al., 2015). A total of 60% of young people improve significantly symptomatically, functionally or both. This increases to over 68% for those who attended five to six sessions. In total, 77% of young Australians are now aware of headspace, which has helped over 520,000 young people since its inception. Young people are voting with their feet, with growing waitlists indicating that stigma is no longer the barrier it once was. The success of headspace has inspired similar models of integrated youth health care in many other countries (Hetrick et al., 2017).

Although evaluations were carried out early in headspace’s lifespan when implementation was incomplete, and no new treatments for mental ill-health were available, modest gains in outcome were still demonstrated. When spread across hundreds of thousands of Australian young people who would not otherwise have accessed help, this represents substantial health gain. New evidence shows that both symptomatic and functional gains are sustained longer term for a subsample of almost 2000 young people (headspace National, 2019). Furthermore, outcomes for the large subset of more complex young people, the ‘missing middle’, who need more sustained and intensive expert care, and yet cannot gain access to State-funded services, obscure the benefits for those with less severe presentations. Investment in a missing tier of care for the ‘missing middle’, and stronger financial models to support headspace’s four basic streams of care, especially vocational and substance use, could produce even better outcomes.

Assertion #1: funding for headspace should have been allocated to State services

Looi et al. (2019), in common with others, believe in a zero-sum game; if funding is allocated for one purpose, it must be at the expense of another. They also fail to understand the Federal-State divide. The Commonwealth’s major current role is funding primary mental health care. headspace is a primary care platform and it would have been inconceivable for this funding to be allocated to State services. However, when the Commonwealth allocated new funding for specialised early psychosis services in 2011, it initially did try to deliver this reform via State services through a National Partnership Agreement. All States except one refused to cooperate, and the Federal government then chose to integrate these services with the headspace system. This now shapes as a better precedent for coverage of the remaining ‘missing middle’ diagnoses.

Looi et al. (2019) state that their major reason for applying the term ‘leviathan’ was the scale of headspace investment. However, they have seriously exaggerated this. Individual headspace centres are modestly funded at around AUD900,000 p.a. which needs to cover rent, administrative overheads and core salaried clinical staff. When MBS billings from fee for service providers are added, it is estimated that this cost increases by around 50% overall. The annual cost of headspace represents approximately 0.5% of the Commonwealth’s total spend on mental health and 0.002% of the total Federal Health budget (Australian Institute of Health and Welfare: www.aihw.gov.au/reports/health-welfare-expenditure/health-expenditure-australia-2017-18/contents/summary; www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/expenditure-on-mental-health-related-services). Hardly a leviathan or giant. More like a network of windmills. Like Don Quixote’s windmills, headspace is simply fulfilling a simple, trusted and useful function at low cost.

Assertion #2: beyond the looking glass

As a primary care platform and triage-free first stage in stepped-care, the assertion that headspace somehow is competing or duplicating State-funded services cannot be upheld. It is certainly true that through better access for all young people with mental ill-health, headspace has helped to reveal the extent of the ‘missing middle’. Yet it is extraordinary to imply that headspace somehow manufactured this group and to assert that headspace seeks to ‘offload’ them. headspace cannot be blamed for the fact that it is beyond the current capacity of State services to accept them and that the current headspace model cannot fully meet their complex needs. New investment to cover this group is urgently needed. We must move beyond the zero-sum mind-set, the blame game and self-defeating professional debates.

Assertion #3: State-funded services are the best bet

The final tilt at headspace is Looi et al.’s (2019) claim that the State-funded system is the best base upon which to build a better system of care. They provide no supporting evidence. The experience of State-funded care since deinstitutionalisation directly challenges it. This public policy failure has led to a Royal Commission in Victoria (McGorry and Hamilton, 2017). State services are rarely, if ever, evaluated. However, the evidence assembled by the Victorian Auditor-General on the performance of State child and YMH services casts major doubt on this assertion. Moreover, the spate of critiques in ANZJP seem determined to hold headspace to a much higher standard than the status quo and virtually unevaluated State services; the goalposts are constantly changing and there is a clear double standard being applied.

The giant quest: unity of purpose and better mental health care for all

The pursuit of headspace and related reforms through ANZJP more closely echoes Captain Ahab’s ‘infernal obsession’ than does Federal government YMH policy. Looi et al. (2019) may characterise their quest as a whale hunt, but we are concerned that it is divisive and undermines the quest for a consensus for better mental health care. The result of tilting at windmills is that you break your lance, and you and your horse are thrown. With real giants to engage, and a once-in-a-generation opportunity for progress, it is time for better informed dialogue which focuses on reality and aspires to unity.