Why is integrated mental health care so hard to achieve?
First, what is integrated mental health care- it is a mental health care system that should encompass clear and seamless care pathways that match the intensity and type of care with the severity and complexity of the illness that people experience over time. For most people living with mental illness in Australia these care pathways are often difficult to find and often unaffordable.
Improving mental health care services has been a focus of the Bupa Health Foundation since its beginnings some 15 years ago. The last 2 years has seen a refocus and increased investment by the Foundation in mental health research to better understand why, despite governments increased expenditure on mental health services and programs, we are not seeing expected improvements. This is well documented in the 2018 KPMG Report for Mental Health Australia- Investing to Save.
My reflection on the Australian health system, after many years working across many parts of the system, both public and privately funded, is that those with mental ill health and the elderly are the two groups who are most disadvantaged by the lack of connection and integration. More recently, the Foundation’s research has been directed to better understand how to improve this connectedness, particularly between the hospital sector and the community and primary care sectors in mental health.
How often do we talk and write about the Australian Health System, which is not actually a ‘system’ if we use the definition of; a group of interacting or interrelated entities that form a united whole.
What has evolved in Australia and many other parts of the world, when it comes to healthcare is the ‘system’ is more accurately explained as several ineffectively connected segments or sectors. As described by the OECD, the Australian health care system is a complex mix of federal and state government funding and responsibility, interspersed with services delivered through the public and private sectors….making it difficult for patients to navigate.
In Australia the largest and most organised of these sectors is the network of publicly funded hospitals and community health services operated by the States and Territories. They probably come closest to the perception in the public’s mind of what is called Australia’s Health System. This network consumes 40% of all health funding and delivers the bulk of acute health services. The hospital doors are open 24 hours, seven days a week and are the default option for most Australians particularly as there is no charge.
The rest of the system is made up of thousands of small businesses with a few large corporates thrown in; private hospitals, diagnostics and aged care as examples. Service integration within and across the non-government sector, includes primary care, specialists and community care is at best elementary, at worst not at all. This sector delivers 70% of all health services to Australians and is funded 70% by government. This mixed public private model is well regarded internationally, particularly for the health outcomes that are achieved in areas like cancer care. However, this model and the way it is funded may not provide the best stimulus to support integrated care for people living with a mental illness.
Taking mental health services what we now have in Australia is a division of roles and responsibilities between commonwealth, state and territory governments and the non-government sector which includes the for profit and not-for profit sectors. For individuals who experience acute and severe mental ill illness, state and territory governments deliver episodes of care in public acute and psychiatric hospital settings, or in specialised community mental health care setting. However, for individuals who do not qualify for this care, but whom still experience moderate to severe mental ill health and require a high-level of support, there is no publicly funded service equivalent. If you are fortunate and suffer with a permanent and significant disability from your mental illness, you may be eligible to enter the ‘disability’ sector and receive psycho-social support.
Without access to a seamless care pathway, often the only option for people is to pay high out of pocket costs and receive one-on-one care in a community setting. For those with private health insurance the prevailing option is inpatient care. Historically, there hasn’t been any service option for this group that delivers flexible, multidisciplinary, community-based care.
From where I sit it is this division of responsibility along with the way services and care are funded that is preventing the better integration of care, particularly mental health care. To navigate through this complex fragmented system, while living with a mental illness is a well-known and documented challenge.
The Bupa Foundation recently refocussed its research approach to better understand the system barriers to better integration of mental health services and how they may be overcome. For example, did technology have a role to play in this? Two projects were funded in 2019 for a total of $1mill to be completed in a 2-year time frame. The approach was to test and learn and to share the learnings as the research progressed. The need we identified was for new and progressive mental health models of care that met the needs of the consumer, understanding the limitations of the current models and the funding levers. We want to build the evidence around the effectiveness of innovative integrated community-based models of care.
The two projects funded included the Brain and Mind Centre at Sydney University who are investigating how technology can make it easier for young people with emerging mood or psychotic disorders to navigate the mental health system. The second project is with a large regional PHN who have introduced a stepped care community model combined with a centralised intake, triage ad monitoring system. The project is to examine and assess the impact of this model on consumers, particularly young adults.
Both projects in their own way are helping us better understand how the “system” works, one using system modelling to gather a detailed understanding of how individuals and providers interact as care is delivered across multiple settings by multiple providers. The other one is gaining a better understanding of how consumers utilise mental health services across hospitals, primary care and the community sector and the impact on their emotional and physical wellbeing.
At the Bupa Foundation we want to walk together towards a world in which people with a mental illness are valued and treated as equals and can access the right care at the right time in the right place.
Annette Schmiede,
Executive Leader,
Bupa Health Foundation