In Australia, moves are afoot to review and implement changes to the mental health services and programs on offer – including those offered to young people. Change always produces some tensions, and that will be the case again in this situation… but something had to give… change was needed to see equitable improvements, and none more obvious than for rural young people with mental health problems. So here we go  – join me on the slippery slope of mental health care reform roller coaster!

The media have labelled the staged funding reductions to early psychosis services as “Futures will be lost. Health fears as youth pychosis program dropped”  Read about it here: http://www.smh.com.au/federal-politics/political-news/futures-will-be-lost-health-fears-as-youth-psychosis-program-dropped-20160429-goi1hu.html

This begs more questions: The  future of who…? Who will be advantaged…? And, who will be disadvantaged…? How do we achieve fairer and more equitable care for all of our young people throughout Australia? There are no easy answers or solutions… to suggest there are is to reveal a flippant disregard for the complexity of meeting the mental health needs of young people today.

I’m an optimist…

I hope that the government have got this right… and that a redistribution of youth psychosis program money will benefit young rural people more equitably as a result… Of course, advocating for the equitable mental health needs of young rural people has been my long-term professional activity of mine! So, I can only hope that this new direction to send funds to the primary health networks  – will in fact work for rural and regional young people where the gaps are larger! There are some risks to note. For example, how will people be mobilised from their comfort zones to take up work in new geographical regions…? Will this be supported in the recruitment of appropriate servicing of populations? Will it really be equitable? Or just equal? Will health professionals be contracted using brokerage models as they are ‘commissioned’ for services? And, if they are, how will this new model ensure that health professionals are able to be fully employed at reasonable pay rates, in keeping with their level of expertise?  How will we mitigate the risk of under-employment of people in low population communities yet maintain equitable service levels? How will the ‘gaps be filled’?  Has this been fully considered?

 

I don’t think that the new approach to funding of youth mental health care this is such a bad thing for rural and regional young people. I have been calling for a more equitable and inclusive distribution of the mental health dollar for many years now… (eg https://www.researchgate.net/publication/275340216_Rural_nurses_A_convenient_co-location_strategy_for_rural_mental_health_care_of_young_people )

… it has not always made me popular…

The harsh reality is that rural youth often have much longer durations of untreated mental illness, poorer access to mental health services and poorer prognosis as a result… And, the largely urban-centric models of specialist youth mental health care have not met the demands for rural youth with mental health care needs. Something needs to give a little… perhaps this new funding model will be it… But – it needs to explain how it will include nursing expertise to promote mental health among young people at its core… Because, nurses are already there in all communities… and they represent a present resource that can be better engaged in primary care.

How will nurses be engaged in the primary mental health care of young rural people? The role of nursing in the models of care continues to be vaguely described at best in current strategy offerings… Only using nurses for managing chronic care (ie the Mental Health Nurse Incentive Program) is a sure-fire for short-changing the mental health of young people… becasue… young people have simply not lived long enough to have ‘achieved’ chronic mental illness status… rendering them ineligible for government supported nursing care in the main! Thus, how will this new model of funding utilise the expertise of nurses to deliver primary mental health care to young people and mitigate the early identification and intervention end of the care spectrum problems? Remembering of course that nurses make up the largest proportion of  health professionals representing and the largest proportion of human resource for mental health service delivery throughout the country? Nurses need to be a large chunk of the journey towards successful new models of care – yet they seem to be overlooked in the latest iteration of change. Why?

I am not yet convinced the the Primary Health Networks will be the solution… but I am prepared to be open-minded about the possibilities… I hope we are seeing the beginnings of something substantially more useful than reshuffling deck chairs. I think closer federal collaboration with state health, education, family and community services and police/ justice services will bring more profitable benefits. But, while a two tier government approach persists in mental health service delivery (Federal and State/s), problems in administering equitable services will also persist with bureaucratic double-ups inevitable, ultimately soaking up some of the direct clinical and research spend potentials.

I agree with McGorry, that many gains have been achieved through the concentrating of specialist expertise in a small number of specialist services, and that it would be a shame to lose this. But, having built this considerable national human resource – if it were mobilised and dispersed across the country (for example,  the experts geographically relocated) this have a benefit of authentically redistributing the talent and in doing so benefit more people over time. Is it time to mobilise the specialist population for greater good in health service delivery? A question for health geographers and health ecologists to ponder. Will redistribution of funding trigger a wider set of conditions in communities such that mental health is more effectively promoted? I think that this is possible: https://www.researchgate.net/publication/280134451_Rural_Mental_Health_Ecology_A_Framework_for_Engaging_with_Mental_Health_Social_Capital_in_Rural_Communities

It is not all bad news, a new model could bring with it ‘catch-up’ conditions to more vulnerable and harder to reach young populations who should have convenient access to local mental health support where and when they require it. The challenge is for mental health professionals to work together using digital technologies to bring us together, it is after all what we expect of our clients these days! That is, to be satisfied with e mental health/ telehealth and digital gateway (triage) delivery….

Perhaps health professionals will also need to adapt our practices in the ways that we work and collaborate with each other – building virtual centres of excellence rather than geographical catchments of excellence. In doing so, some castles will be dismantled – and new ones will emerge… shifts in the sands of time across the landscape of mental health service and evidence development and  delivery are inevitable.

It is clear that the health budget in Australia will never be able to fund sufficient levels of mental health service delivery for Australian young people – our present budgets don’t go near sufficiency. Finding ways to squeeze a few extra drops of oil out of the rag are always going to be critical… the challenge is out for mental health researchers to be prudent in devising ways in which we can continue to do more, with less, and for politicians and policy makers to take heed of evidence as it emerges… And finally, for clinicians to be ready to adapt to the changing times as they evolve. None of that is easy!

Relevant other links:

http://www.acmhn.org/news-events/mental-health-reform

http://www.health.gov.au/internet/main/publishing.nsf/Content/0DBEF2D78F7CB9E7CA257F07001ACC6D/$File/response.pdf