Leviathans reprised: Adult Mental Health Centres

‘Both jaws, like enormous shears, bit the craft completely in twain’.

–Herman Melville, Moby Dick

We raise concerns about, and offer alternatives to, the Commonwealth Government announcement of AUD$114.5 million in the 2019–2020 budget for a trial of eight Adult Mental Health Centres (AMHCs) situated within primary healthcare networks (PHNs) in all state/territory jurisdictions (Department_of_Health, 2020a). AMHCs were inspired by the Headspace model and will provide care to adults who are too old for youth-focused services (over 25 years old). The AMHCs ostensibly are ‘… intended to complement, not replace or duplicate, mental health services already provided in the community’.(Department_of_Health, 2020a). Like Headspace, AMHCs will be run by non-governmental organisations (NGOs) and will operate in parallel to the extensive Commonwealth-funded network of general practices, public and private mental health services (MHS).

AMHCs are designed to cater for the patients in the ‘missing middle’ who fall in the gaps between the Commonwealth-funded system and State/Territory MHS (Productivity_Commission, 2020). These are patients with complex mental health problems who do not require inpatient care but are unable to access adequate levels of mental healthcare because of costs in the private system or the unavailability of community services in the public sector. This includes people experiencing a crisis, or in significant distress, and those at heightened risk of suicide, with the aim that the AMHCs ‘may reduce the need for emergency department attendance’ (Department_of_Health, 2020b).

We previously criticised the Commonwealth Government’s policy of creating NGO-based entities that operate in parallel to GPs, private and public MHS, describing them as Leviathans due to their considerable size, scope and national influence (Looi et al., 2019b). We caution that AMHCs may similarly duplicate and divert resources from existing services, thereby increasing fragmentation in an already poorly integrated national mental health system (Looi et al., 2019b). Funding for AMHCs would be more effectively spent to improve existing acute public MHS in community mental health centres and emergency departments and to enhance care pathways between GPs, public and private MHS, and private psychiatrists.

In view of the rapid closure of the AMHC consultation process after only one month, we therefore highlight four specific concerns about the existing proposals.

Unclear mandate and model of care

The proposal gives unclear, and sometimes contradictory, descriptions of the people who might use the service. In some places, it says the AMHCs would treat adults experiencing distress, crises and mental ill health, as well as people with addiction and those at heightened risk of suicide (Department_of_Health, 2020b). Yet elsewhere, it says AMHC staff should identify and refer individuals whose needs cannot be met appropriately such as people with alcohol/substance use disorders and those who are at risk of harm to themselves or others. Long-term care is also excluded, but it is unclear to whom these individuals would be referred, since AMHCs are predicated on these services being unavailable or unaffordable.

The duplication of other services and unclear co-ordination of care

The model proposes that the services of mental health professionals such as GPs, psychiatrists and psychologists are either commissioned or provided in-house to address moderate-severe level mental illness (Department_of_Health, 2020b). However, these professional groups already provide primary care for many of these patients, supported by albeit under-resourced community MHS. The needs of the ‘missing middle’ might therefore be better addressed through further funding of the current system rather than duplication with another. This is especially important given the expected increase in demand as a consequence of the COVID-19 pandemic. Furthermore, centres are likely to be located in metropolitan areas, thereby exacerbating inequities in service delivery for regional, rural and remote Australia. These are the regions that should receive the immediate priority for additional funding rather than a further parallel service in the major centres. There is also the danger that without further funding of existing services, stand-alone AMHCs may identify more people with a mental illness, and of a greater severity, than such centres can treat. Accordingly, people with a mental illness will then require handover to acute public MHS, which may be impossible given current health service resources. Even if feasible, additional handovers could lead to confusion, increased clinical risk and system inefficiency. The recommended reliance on My Health Record to facilitate communication and coordination is also concerning, given its piecemeal uptake. Worryingly, the proposal is particularly unclear on arrangements for people who need transfer to an Emergency Department or hospital, including the use of mental health legislation. The need for in-reach from acute MHS is mentioned without consideration of the additional burden of already stretched resources. Efforts might better be directed towards improving links between primary care and enhanced MHS in both the public and the private sectors.

Unclear governance

Funding for AMHCs will be directed through PHNs, which would be responsible for commissioning the exact range of services. However, it is unclear whether PHNs have the necessary expertise, capacity and capability in needs assessment, risk profiling and service planning. Furthermore, PHNs have varying degrees of engagement and liaison with general practitioners (GPs), psychiatrists and allied health practitioners, as well as public and private MHS. The model is also inconsistent with recommendations from the Productivity Commission that the Department of Health cease directing PHNs to fund Headspace centres or other specific service providers (Productivity_Commission, 2020). We argue AMHCs would be better if they were redesigned, situated and funded within State/Territory public MHS with established systems for clinical governance, as opposed to a parallel NGO framework. This would enable better vertical integration of acute care so that people with a moderate-severe mental illness can be directly transferred to more intensive services within the same organisation. Such improvements might be achieved through establishing for-mal intergovernmental (Federal-State/Territory) collaboration for coordinated clinician- and consumer-directed mental health service planning (Looi et al., 2019a), informed via independent medical-professional organisations, e.g., RANZCP/AMA.

Lack of any independent evaluation or pilot site

The AMHCs will be established from 2020 to 2021, with service delivery to commence in 2021–2022. The rapid implementation and lack of a pilot site mean that there is no opportunity for Centres to learn from the experiences of others. Of particular concern, given that these are ostensibly trial sites, is the lack of mention of any independent evaluation, including explicit methodology and outcome measures.

Conclusion

The proposed AMHCs bear a striking likeness to the Headspace NGO healthcare service model, which we criticised previously as creating parallel, resource-intensive and siloed services of unclear efficacy (Looi et al., 2019b). The budget has been allocated. The advisor places have been set. The bids from NGOs or other organisations for sites will come. The money and other resources will be spent without independent evaluation of outcomes.

Such stand-alone AMHCs may cleave in twain effective primary care for adults with complex mental health disorders and further divide their care from public sector services. By contrast, an effective mental healthcare programme that assists the ‘missing middle’, and thereby reduces emergency department demand, would be located within State/Territory public MHS. Programmes should be co-designed by individuals with a mental illness and practising clinicians, building on the existing skills and resources of the public sector in close partnership with private mental health practitioners and services. Currently, the mental health consequences of the COVID-19 pandemic require greater resources and an integrated response from existing services, not a parallel structure with its attendant bureaucracy.