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Australia's Fifth National Mental Health Plan required governments to report, not only on the progress of changes to mental health service delivery, but to also plan for services that should be provided. Future population demand for treatment and care is challenging to predict and one solution involves modelling the uncertain demands on the system. Modelling can help decision-makers understand likely future changes in mental health service demand and more intelligently choose appropriate responses. It can also support greater scrutiny, accountability and transparency of these processes. Australia has an emerging national capacity for systems modelling in mental health which can enhance the next phase of mental health reform. This paper introduces concepts useful for understanding mental health modelling and identifies where modelling approaches can support health service planners to make evidence-informed decisions regarding planning and investment for the Australian population. [ABSTRACT FROM AUTHOR]

Objectives: This paper compares the evolution of the psychosocial sector in two Australian regions pre and post introduction of the National Disability Insurance Scheme – a major reform to the financing, planning and provision of disability services in Australia, intended to create greater competition and efficiency in the market, and more choice for service users. Methods: We used a standardised service classification instrument based on a health ecosystems approach to assess service availability and diversity of psychosocial services provided by non-government organisations in two Primary Health Network regions. Results: We identified very different evolutionary pathways in the two regions. Service availability increased in Western Sydney but decreased in the Australian Capital Territory. The diversity of services available did not increase in either Primary Health Network 4 years after the reform. Many services were experiencing ongoing funding uncertainty. Conclusion: Assumptions of increased efficiency through organisational scaling up, and a greater diversity in range of service availability were not borne out. Implications: This study shows the urgent need for evaluation of the effects of the NDIS on the provision of psychosocial care in Australia. Four years after the implementation of the NDIS at vast expense key objectives not been met for consumers or for the system as a whole, and an environment of uncertainty has been created for providers. It demonstrates the importance of standardised service mapping to monitor the effects of major reforms on mental health care as well as the need for a focus at the local level. [ABSTRACT FROM AUTHOR]

Objective: To describe a recent process by which mental health service sector leaders identified key elements of strategic, systemic and structural mental health reform. These elements could guide an incoming Federal government. Method: The paper describes the process undertaken by the Sydney Mental Health Policy Forum between 2019 and 2022. This work generated principles, key domains and finally a set of actions. Results: Five immediate actions were identified that are cost neutral or require minimal investment. Five further actions requiring realignment of existing funds and/or new funds were also identified. Conclusions: The task of mental health reform in Australia is both large and overdue. Continued investment in fragmented or piecemeal programmes and services will not propel desired change. Reform must facilitate new regional control of planning, funding and responding to community mental health needs. The actions identified by the Forum set out a menu of opportunities to guide reform over the life of the next Parliament, starting now. [ABSTRACT FROM AUTHOR]

Objective: To explore the impact of proposed expansion of Australia's Better Access Program and alternatives. Method: Australia's Better Access Program, which costs taxpayers AUD28 million every week, is once again the focus of national political and professional scrutiny. The current Medicare Review calls for a massive expansion. This article reviews its history and context. It challenges the recommendations made by the Review. It also provides three scenarios which model the proposed expansion, with significant implications for consumers, the workforce and taxpayers. Results: The capacity for continued growth of the Program is demonstrated. At the same time. Conclusion: There has been recent evidence suggesting the impact of the programme on key mental health indicators in Australia has been negligible, while also perpetuating social, economic and geographic inequities. While advocacy for increased mental health expenditure is easy, active reform of existing patterns of service is hard. Nonetheless, this article suggests that it is timely to reconsider the structure and scale of this AUD1.5 billion annual investment, which has the potential to grow to up to AUD10 billion per year over the next decade. In our view, it is possible to make the programme fit for purpose in the 21st century. Specifically, the principal focus could be shifted to better support the interdisciplinary, team-based care that responds to the needs of people with more complex mental health problems. An increased role for incorporation of digital technologies alongside clinical services is part of the mix. The combination of changes suggested would suggest that the programme could be rebranded as 'Better Access and Quality'. This shift in the primary focus of the clinical programme away from brief interventions for those with lower needs to more sustained interventions with those with greater impairment requires new service models, as well as new regionally based health care systems. In addition, we propose specific outcomes that can be measured regionally, and collated nationally, to properly evaluate the impact of the programme and drive systemic quality improvement. [ABSTRACT FROM AUTHOR]

A doubling of Australian expenditure on mental health services over two decades, inflation-adjusted, has reduced prevalence of neither psychological distress nor mental disorders. Low rates of help-seeking, and inadequate and inequitable delivery of effective care may explain this partially, but not fully. Focusing on depressive disorders, drawing initially on ideas from the work of philosopher and socio-cultural critic Ivan Illich, we use evidence-based medicine statistics and simulation modelling approaches to develop testable hypotheses as to how iatrogenic influences on the course of depression may help explain this seeming paradox. Combined psychological treatment and antidepressant medication may be available, and beneficial, for depressed people in socioeconomically advantaged areas. But more Australians with depression live in disadvantaged areas where antidepressant medication provision without formal psychotherapy is more typical; there also are urban/non-urban disparities. Depressed people often engage in self-help strategies consistent with psychological treatments, probably often with some benefit to these people. We propose then, if people are encouraged to rely heavily on antidepressant medication only, and if they consequently reduce spontaneous self-help activity, that the benefits of the antidepressant medication may be more than offset by reductions in beneficial effects as a consequence of reduced self-help activity. While in advantaged areas, more comprehensive service delivery may result in observed prevalence lower than it would be without services, in less well-serviced areas, observed prevalence may be higher than it would otherwise be. Overall, then, we see no change. If the hypotheses receive support from the proposed research, then implications for service prioritisation and delivery could include a case for wider application of recovery-oriented practice. Critically, it would strengthen the case for action to correct inequities in the delivery of psychological treatments for depression in Australia so that combined psychological therapy and antidepressant medication, accessible and administered within an empowering framework, should be a nationally implemented standard. [ABSTRACT FROM AUTHOR]

Objective:: The objective of this study was to present an assessment of Australia's mental health system performance, within its social context, by comparison with other countries.Method:: A review of existing literature and databases from both Australia and overseas was undertaken. Systems permitting international comparison of mental health and its social context are few. The review is limited in scope.Results:: Although Australia was one of the first nations to develop and adopt a national mental health policy (in 1992), the data that are available suggest that we are not World leaders across the identified domains.Conclusions:: While international benchmarking can play an important role in fostering quality improvement, there are only limited mental health or social system performance data sources to utilise. It would be desirable for a more systematic international process to be established to review existing approaches and design a new multilateral strategy. It would be important that this new strategy reflected the full experience of mental health and its broader social context. [ABSTRACT FROM AUTHOR]

Objective: To consider the changing profile of Australia's mental health workforce and the implications, particularly for specialist psychiatry services.Method: We analyse data from a national collection that describes changes in the workforce over a decade, to 2017-2018.Results: While single practitioner-based psychological services flourish, other areas of more complex and team-based care are struggling to remain relevant. Psychiatry and mental health nursing, two areas that previously led Australia's response to complex mental illness, are under enormous pressure.Conclusion: The shifting balance of specialised mental health workforces is affecting the mental healthcare available in each region of Australia. Questions arise regarding the desired or optimal mix of professionals we wish to deploy. What roles should each professional group play and how should they work together? What does this mean for how various groups should be trained and paid? These data challenge the role specialist psychiatry wishes to play in leading reform. Current mental health reforms risk foundering should psychiatrists fail to take up the challenge of leadership. [ABSTRACT FROM AUTHOR]

Objective: In this second and final part of this series about mental health commissions, we consider the extent to which it is possible to find hard evidence that these new structures really can drive mental health reform. Four key domains of improvement are established for the purposes of this review: do commissions lead to better resources, better services, better accountability and better stakeholder engagement? A review of the evidence from both Australia and overseas is presented. The article also considers how the commissions, federal and state, will organise their relationships productively to avoid duplication and promote synergy. What of those jurisdictions without commissions? Is this genuine national reform or merely more piecemeal activity in mental health? The authors have been informed by the varying structures and functions of mental health commissions internationally and were part of the New South Wales taskforce to establish a mental health commission. They had the opportunity to visit the Western Australian and New Zealand Commissions as part of this process. Conclusion: Addressing mental illness requires a joined up approach to government and services. Commissions offer a new organisational structure designed to deliver this contiguity. There is also evidence that nascent and established commissions are delivering real reforms, including in terms of additional resources and influence. Without concerted efforts to coordinate activity, the intersection between federal and state commissions will be confused and duplications might arise. The paper calls for a new network of commissions to be established across Australia and New Zealand, to share resources and common tasks, clarify roles and build common approaches. [ABSTRACT FROM AUTHOR]

Objective: Partly in response to ongoing concerns about the state of mental health care, several jurisdictions across Australia, including the federal government, are hoping to drive change via the establishment of a mental health commission. This is the first of two articles in a series which aims to describe the background to this new trend. The commissions are being established with different powers and structures. This variety is explored and considered against a typology of commissions. Some consistent themes and goals emerge. The paper then provides a contemporary assessment of the ‘state of play’ of the nascent commissions and describes important emerging issues and differences between the models.Conclusion: There are significant differences not only in the construct of the respective commissions but also in the political circumstances in which each must work. At the same time, the problems facing mental health in Australia are ubiquitous and profound. For commissions to be successful they will require not only astute leadership but also durable, bipartisan political support and an enduring capacity to generate new resources for the mental health sector. [ABSTRACT FROM AUTHOR]

The article discusses Australia’s Better Access initiative in mental health. Enhancing affordable and equitable access to relevant psychological therapies has long been the main aim of reforming primary care-based mental health services in Australia. The Better Outcomes in Mental Health Care (BOiMHC) programme introduced in 2001 was a major breakthrough for mental health and direct support for skilled professionals, including psychologists to deliver evidence-based interventions.

Objective: This paper proposes a framework for a systematic evaluation of the Better Access Program, the largest single component of mental health reform announced under the Council of Australian Governments National Action Plan on Mental Health 2006-11. Method: The article explores the genesis of the Program and considers extant data sets and information available with which to establish the impact of the Program on consumers and service providers. Results: There are useful data available in Australia from which to derive pre- and post-implementation analysis about the impact of the Better Access Program. There is doubt as to whether these data form part of the Federal Government's current approach to evaluation of the Program. Conclusions: Anything less than a genuine and comprehensive evaluation will leave Australia unable to assess the real impact of the Better Access Program. The merit of further expenditure in the vital area of primary mental health care will be in doubt as a consequence. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "How to tackle a giant: creating a genuine evaluation of the Better Access Program," by S. Rosenberg and I. Hickie in the 2010 issue.