Preparing the ground for mental health reform: key challenges in translating new resources into better care

Careful planning is required to ensure new resources for mental health lead to better consumer care

Both the Productivity Commission into Mental Health1 and the Royal Commission into Victoria’s Mental Health System (RCVMHS)2 acknowledge that mental health services have been in the grip of a protracted resourcing drought.

The RCVMHS identified that, until recently, Victoria’s public mental health services have fared particularly badly,3 with the 2015–2016 per capita funding to public mental health services being the lowest of any state. The impacts of chronic under‐resourcing, including a predominant focus on managing risk, underutilisation of evidence‐based therapies, and a lack of individualised care, were all reported by service users in testimonies highlighted in the RCVMHS interim report.2

After years of stagnation, in 2020 Victorian mental health services experienced some funding growth.4 These resources have allowed our team to strengthen existing services; bring on new staff, including expanding our lived experience workforce; and initiate new programs, including the Hospital Outreach Post‐Suicidal Engagement (HOPE) initiative, intensive community packages of care, the pre‐hospital response of mental health and paramedic team (PROMPT), and a mental health, alcohol and other drugs hub in our emergency department. In addition, our service is currently planning new mental health beds and rolling out an innovative hospital‐in‐the‐home program stemming from the recommendations of the RCVMHS interim report. We anticipate the final recommendations, due in February 2021, will bring even more new resources.

Like sudden heavy rain on degraded soils after drought, such an inundation is welcome, but not without its own risks and challenges. Our recent implementation efforts have highlighted several challenges in managing rapid funding growth, including issues with human resources, leadership capacity, change management competency and stakeholder engagement, which will need consideration across the system to ensure services can translate funding into better consumer care.

Human resources

Delivering care requires staff who are difficult to find. There are insufficient mental health nurses5 and psychiatrists6 to fill current roles, particularly in regional and rural areas, and with an ageing workforce,7 problems with staffing are predicted to worsen.6 While international recruitment may assist, these processes come with lengthy delays and high administrative burdens. As a consequence, program implementation may be delayed due to recruitment challenges, or may adversely affect the operations of other service areas when clinicians shift between roles.

Significant investment in training and recruitment pathways are required to prevent workforce shortages becoming a barrier to the pace of reform. Diversification of disciplines, grades and programs that encourage qualified staff to enter mental health care will all be required.1

Leadership capacity and competency in change management

The presence of effective leadership and competency in change management principles are critical for successful health reform.8,9

Rapid growth can stretch existing leadership capacity. Health leaders already face significant challenges at system (eg, demographic changes, increasing demands, advancing technology), organisational (eg, human resources, changes to organisational structures and processes, intensification of frontline and middle management roles) and individual levels (eg, lack of role clarity, lack of training in managerial and leadership capabilities).10

For leaders already managing the challenge of daily operations, additional responsibilities to enact significant reform quickly carries a risk of overload. A key potential outcome of overload is loss of focus on the consumer.11 Therefore, as the pace of desired reform increases, a focus on developing current and future mental health leaders should be prioritised.2,12

Engaging stakeholders meaningfully

Meaningful stakeholder engagement is crucial to successful change.9 As outlined by the RCVMHS, the “necessary changes to the mental health system cannot … be achieved by government alone”.2

The implementation of new programs requires engagement with diverse stakeholders including consumers, carers, staff, hospital executives, government and industrial bodies. Such stakeholders often have different interests, and forging and maintaining alignment is critical to progress. Meaningful engagement is vital to achieving this and subsequent success,9 but it is also resource intensive.

Enacting multiple reforms quickly carries the risk that meaningful stakeholder engagement may be sacrificed. For this reason, timelines for delivery need to balance urgency with getting things right.

The appropriate urgency for implementation articulated in the initial recommendations from the RCVMHS (eg, operation of an additional 170 acute mental health beds by mid‐2022) will only be achieved if those leading the change are supported and those affected by the change are included.

Harnessing a generational opportunity for reform

The RCVMHS calls for transformational change2 to our mental health system. The pace of this change and the other challenges involved must be managed carefully by system leaders to ensure that the intended reform occurs and results in provision of better care to the community.