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23 Nov 2016

The Government has set out on a process of significant change to some key arrangements for providing mental health care, with a strong focus on regional integration through the core architecture of Primary Health Networks (PHNs) and Local Hospital Networks (LHNs).  Although it is early days, the AMA is concerned that this focus comes with potential risks to the provision of mental health care. 

We as AMA psychiatrists have been concerned about how PHNs will be able to provide adequate mental health care to our communities. The amount of money being provided to the PHNs seems insufficient to be able to allow them to provide a useful integrative role on a scale matched to their catchment population numbers. 

We are told that digital health technologies will be used extensively for treating people with anxiety and depression. In the United Kingdom such programs have been found to be useful to treat less severe anxiety and depression. However, people with more severe depression are likely to find the programs are not helpful, and then they often feel more of a failure and are reluctant to return to the health facility that recommended the digital program, because they feel they will be fobbed off. 

Another area of concern is that the PHNs are in some way likely to have a role in directing care to people with the most severe mental illness. The problem is: who will the people be who make the decisions about severity? 

Without clear governance arrangements in place, including clinical input, it is likely that people will be inappropriately allocated to mental illness categories. This could lead to poor care and even to more suicides. In the end, psychiatrists will probably be asked to step in and make determinations about patient severity.  

Mechanisms involving psychiatrists should be included at the beginning of the rollout of this strategy, to prevent adverse outcomes. Appeal mechanisms will be necessary unless the criteria for accessing care are relatively broad and comprehensive from an early stage. These governance issues do not seem to be the emphasis of the mental health program espoused through PHNs so far. 

AMA psychiatrists are also very concerned about a breakdown in clinical governance hierarchy within the mental health system. If there is not proper regard and respect about the scope of practice of different members of the mental health team, then adverse outcomes for patients are quite likely, and fragmentation of care may result. 

It is important that all PHNs have psychiatrist input to their overall functioning in mental health, into determining seriousness of conditions/needs as part of PHN programs, and into determining access to allied care services. One of the faults of the mental health plans developed by this Government is that psychiatrists have largely been ignored in the planning process. This seems to be a denial of the clinical governance that is expected in the community, and indeed in law courts. Such a persistent denial encompassed in government policy is likely to lead to inappropriate outcomes and legal complications. 

We would recommend that psychiatrists in public practice try to ensure that their clinical management teams are liaising closely with PHN’s, and including psychiatrists at the coal face in deliberations locally. It is also important to keep a vigilant eye on the possibility of State and territory Governments changing public mental health service delivery in an adverse way, due to the advent of PHN mental health programmes. 

Private psychiatrists would be wise to liaise with relevant local PHN’s. If you have a motivation to do so, involvement in PHN development could be valuable. You may be able to work in groups of psychiatrists, especially psychiatrists associated with private psychiatric hospitals in your area. 

The AMA also has concerns about the impact of PHN arrangements on Aboriginal and Torres Strait Islander mental health services. As part of their work on Aboriginal and Torres Strait Islander Health, the AMA's Public Health team have been meeting with a wide range of stakeholders, including Members of Parliament, and organisations involved in Aboriginal and Torres Strait Islander health provision and services. Two current areas of concern involve what is happening with funding for Aboriginal and Torres Strait Islander mental health and for suicide prevention programs. 

It is not entirely clear how the Primary Health Networks (PHNs) will be allocating funds for Aboriginal and Torres Strait Islander mental health.  There is some concern among stakeholders that the ‘pooled’ funding arrangements for PHNs may result in reduced funding and resources for Aboriginal and Torres Strait Islander mental health programs, even though suicide funding is apparently quarantined.  It is critical that there is no reduction of funding for Aboriginal and Torres Strait Islander mental health programs through pooling arrangements.  

The other concern is the Productivity Commission’s current inquiry into the increased application of competition, contestability and informed user choice to human services.  The worry here is that applying greater competition and contestability in the provision of mental health and general health services to remote Aboriginal and Torres Strait Islander communities may end up with services being delivered by ‘fly in-fly out’ providers, rather than building up the capacity of trusted on-the-ground Aboriginal Medical Services (AMS) and Aboriginal Community Controlled Health Organisations (ACCHOs). 

Published: 23 Nov 2016