Systemic change in mental health: Is it about the ingredients or how we combine them?
by Keith Bryant
As the demand for mental health support and services increases, so too does the need to build a collaborative and responsive mental health and wellbeing system that moves beyond a focus on clinicians and emergency departments.
Given the mental health crisis that we now collectively acknowledge, I wonder if we need to take a different (historical) view of the problem. How did we get here and what we can do about it?
It’s clear that our mental health systems have failed too many people for too many decades. And while for many, the eye of the problem seems to be that for forty years we have underspent on our mental health budgets, I wonder if there is a little more to it.
Looking back, we really didn’t transition towards effective and collaborative community-based support for people in distress when the doors closed on the mental health institutions in the 1980s.
Back then, people had good intentions and many of the reasons for a re-structure remain today. The intention was to replace the institutions with support for people in their community. The problem is that we didn’t have a good grasp of the implementation challenges to enable this model to take root in a way that was successful and sustainable.
So, what could community-based mental health look like in practice today?
If we limit ourselves to a definition where the spectrum of solutions only includes clinicians working in community locations through a range of services and modalities, we are missing the point.
Clinicians and emergency departments will always have a role, but in a community-based system, other organisations and community services can also play a role. So can individuals – parents, family, friends, peers and community leaders.
Our teachers, neighbours, those with lived experience, allied health and social workers can all make a huge contribution in a true community-based approach to mental health and wellbeing. This is often talked about but rarely effectively implemented.
My observation is that there is not a deep understanding amongst those who work in different the fields of mental, social and emotional health and wellbeing areas in Australia as to how to collaborate effectively. Collaboration is more than a process (for planning and design, for example). It is cultural, it is organisational, and it demands appropriate and committed local leadership.
Is the co-location of services a starting point for community-based support? Perhaps. But where co-locational arrangements are being trialled, they need to go beyond sharing office space and find a way to drive engagement and ownership with their local community.
Time pressures and activity-based deliverables force clinicians to stay in their swimming lane. Let’s be very fair to them. The current system makes it too hard to implement a collaborative way of working, especially when in a crisis.
So, in my attempt to re-define the problem – perhaps its more about how we implement a different approach from the ground up rather than fixating on finding additional funding to feed the current system.
For clinicians, staying in your lane in mental health should be recognised as no longer being a metric that will give us the outcomes we are looking for.
But how can we involve others in a true community-based solution? I have mentioned the others above, but as things currently stand they are rarely part of the story. While the media narrative around the recent resignation of approximately 200 psychiatrists in NSW has been largely focussed on the payment conditions of their employment, a bigger conversation about the ‘workforce’, paid and voluntary, needs to be had.
The latest research from APS shows that 27% of psychologists report clients waiting a month for an appointment, while 15% say the wait stretches to nearly two months.
RANZCP President, Dr Elizabeth Moore commented recently that “Australia has a critical and chronic shortage of psychiatrists.”
Compounding this, regional based Australians are missing out. 70% of Australians live in our five big cities (Sydney, Melbourne, Brisbane, Adelaide, Perth) but over 80% of registered psychiatrists and psychologists live in those five cities. Sure, some of those professionals engage in fly-in fly-out arrangements to regional locations for very short periods to meet the need.
But a clinician who lives in the community, knows the community and connects with people is surely going to have a deeper understanding of the mental health and wellbeing needs of people and their families.
To get to a coordinated whole of community response to mental health we need to do more than get the ingredients right – we need to know how to put that workforce, paid and unpaid, together to provide an approach that unlocks the true potential and capability of everyone in the community.
To do this we need new structures and frameworks that communities can co-own and drive. In summary, my view of the problem is that it’s not that we don’t have enough government funding in the mental health system, the problem is that we don’t combine the existing ingredients effectively.
Keith Bryant, CEO
