Response to McGorry et al.’s defence of Headspace-like Leviathans swallowing resources

We appreciate (McGorry et al., 2020) acknowledgement of the importance of the debate begun by our ANZJP article on the Leviathans (Looi et al., 2019), and their defence of Headspace as a ‘trusted brand’. In our previous article, we highlighted that the Australian Government is funding a new type of non-governmental organisation (NGO) that combines advocacy and a high media profile with policy development, research and the provision of mental healthcare (Looi et al., 2019). We described these entities as Leviathans due to their size, scope and influence. These NGOs operate as brands on the national landscape, and they are often mentioned in the political discourse on mental health issues: politicians frequently turn to the Leviathans at times of crisis because they are brands.

While the Leviathan NGOs are innovative and enterprising, our main concern is that they may divert attention and resources away from hard-pressed State/Territory mental health services, and duplicate aspects of these services without adequate coordination (Looi et al., 2019). Indeed, there is an argument for better service integration and consolidation between Headspace and regional services, as occurs with the Alfred, which is the lead agency of a Headspace, and Orygen as the lead agency of four Headspaces across northwest Melbourne. These Headspaces, with which co-authors of the (McGorry et al., 2020) article are associated, provide excellent models of service integration and consolidation: we advocate for State/Territory mental health services to adopt these models and be lead agencies for Headspaces.

Despite substantive concordance on these models of integration, there remain points of debate. In their response to our paper (Looi et al., 2019, McGorry et al. (2020) raise a number or assertions, to which we respond on a point-by-point basis, characterising the validity of their arguments, with reference to accepted criteria for fallacies in argumentation (Arp et al., 2019).

Framing assertion: the Leviathans are self-serving, acquisitive and wasteful

McGorry et al. (2020) mischaracterise our arguments on this point: nowhere in our paper are the words self-serving, acquisitive or wasteful to be found. This mischaracterisation may be regarded as an example of the argumentative fallacy representing an opponent’s views in a worse or less defensible form than that expressed by the opponent, i.e. a ‘representational straw man’ argument (Arp et al., 2019).

Indeed, such mischaracterisation of our arguments might be considered to shade into the fallacy of the ‘hollow man’, wherein there is invention by the critic of a ridiculous view for the opponent to more easily refute (Arp et al., 2019). Furthermore, the rest of this assertion is an example of ‘ad hominem bias’ (Arp et al., 2019), i.e. the imputation, without justification, that we are biased against youth mental health. The reverse is true: we support youth mental health services and their full integration within State/Territory systems as indicated above.

• Assertion 1: ‘Looi et al. (2019), in common with others, believe in a zero-sum game. They fail to understand the Commonwealth-State divide. The Com-monwealth’s primary role is in funding primary health care’.

Funding of State/Territory mental health services has unfortunately been a zero-sum game. McGorry et al. (2020) correctly indicate there has been a 1.1% annual average increase in the real per capita spending on mental health-related services from 2013–2014 to 2017–2018 (AIHW [Australian Institute of Health and Welfare], 2019). However, Government expenditure on mental health–related services in 2017–2018 was estimated to be around 7.6% of total government health expenditure, which is a small decrease from 7.8% in 2013–2014 (AIHW, 2019). This represents a reduction in mental health expenditure as part of the share of total health budget.

In our previous Debate article, we noted that ‘Given the shallow pool of mental health funding – as the Commonwealth disburses to the states – Leviathans could devour limited resources, disadvantaging state mental health services’ (Looi et al., 2019). This correctly refers to the Commonwealth disbursing funding to states for mental health services and contrasts with the assertion by McGorry et al. (2020) that the Commonwealth’s role is funding primary health care.

• Assertion 2: ‘Looi et al. (2019) state that the major reason for applying the term “leviathan” was the scale of headspace investment. They have seriously exaggerated this’.

This mischaracterises our arguments and repeats the ad hominem fallacy (Arp et al., 2019). Their assertion that we have exaggerated the extent of funding does not address the substantial figures that we quoted in our paper, drawn from Headspace publicly available reports (nearly AUD$35 million funding for 2017–2018) and Commonwealth announcements of Headspace funding of AUD$263 million over 7 years from the 2019 to 2020 budget and AUD$109.7 million for early psychosis.

• Assertion 3: ‘It is certainly true that through better access for all young people with mental ill-health, headspace has helped to reveal the state of the “missing middle”. It is extraordinary to imply that headspace somehow manufactured this group and to assert that to offload them’.

We had nowhere in our paper stated that Headspace has manufactured a group of patients, let alone raised the issue of a missing middle. This constitutes the use of another hollow man argumentative fallacy by McGorry et al. (2020). While we agree that Headspace offers access to those patients in the missing middle, it remains true that ‘in practice, it appears many Headspace services need to refer onwards to public child, adolescent and adult mental health services’ (Looi et al., 2019).

• Assertion 4: ‘The final tilt at headspace is Looi et al. (2019) claim that the state-funded health system is the best base upon which to build a better system of care’.

We stand by our argument that ‘Public mental health services may be the best existing base upon which to build joined-up services which connect with NGOs and other community services’ (Looi et al., 2019) and return to the excellent model at The Alfred as an example of a Headspace that was initially supported by and integrated with a State child and youth mental health service. This desired model at The Alfred facilitates a single point of entry for youth mental health assessment and enables integration of subsequent service delivery and care coordination. We specifically propose that all current and future Headspaces be integrated and governed by State/Territory mental health services and emulate the model at The Alfred.

McGorry et al. (2020) correctly argue that State mental health services should be fully evaluated, and that State Governments are responsible to their citizens for the quality of care. They cite the example of the Victorian Royal Commission into the policy failures of the Victorian Mental Health System. We can agree that this is an excellent example of how State/Territory governments should be working: by holding themselves and State services to account in an open and transformative way, so they can indeed be ‘the best base upon which to build a better system of care’.

In conclusion, we share the (McGorry et al., 2020) aspirations to improve mental healthcare for young Australians. However, we argue that existing base of public mental health services may be further enhanced by Headspaces specifically integrated with State/Territory mental health services. We maintain that stand-alone NGO Leviathans may draw resources away from, fail to coordinate with and unnecessarily duplicate State/Territory mental health services.