Matthew Hercus

Manager, Programs and Performance, Mental Health

Department of Health Victoria

An efficient and effective mental health

system: Tips, tricks and tools (or what I did last summer…)

Overview

• Decision making re resources

• Measurement and monitoring

• Some things that may or may not help

–Considerations and discussion

Hang on

– isn't this a forum about Young People at

Risk?

Victorian MH system context – a snapshot

• 2014-15 more than $1.26 b state funding into mental

health

• $1 b+ to clinical mental health (delivered through

health/hospital services on a catchment basis).

– Acute Beds

– Non acute beds

– Community clinical care

• $120 m+ to non-clinical NGO/community managed

services to deliver a range of bed-based rehabilitation,

individual support packages. (NB Reform outcome)

Victorian Reform Context – a snapshot

Six years into a reform program

2008 - Consultation paper and forums

2009 - Reform Strategy launched

2011 - New Government - emphasis shifting but key agenda

remains

2013 - Priorities for mental health

http://health.vic.gov.au/mentalhealth/priorities/index.htm

Not to mention Commonwealth activity

Monitoring Evaluation

Policy Development

Service System Design

Service Design

Service Specification

Resource Planning

Implementation Planning

Commissioning

Consolidation

A mental health system of care for children

and young people – any likely issues re

efficiency and effectiveness?

Emergency

Services

School

Wellbeing

Team

GPs

Disability

Services

Child

Protection

Student Support

Services

School

Focussed

Youth Service

Secondary

School

Nurses

Primary Welfare

Officers

NGO

Welfare

Agencies

Koorie

Health

Services

CALD

Health

Services

Supported

Accommodation

Youth Justice

PRIMARY

Local Gov’t Child

& Family Services

Child FIRST

SECONDARY

Family Therapy

Services

Youth Justice

Adolescent Services

Private Allied

Health

Private Allied

Health

Specialist Child

Abuse Specialists

Alcohol and Drug

Services

Eating Disorder

Services Public/Private

Paediatricians

Specialist Children’s

Services

Private

Psychiatrists

headspace/eheadspace

Early Intervention

Services

TERTIARY Child & Youth Mental

Health Services

Youth Mental

Health Services

Secure

Welfare

Mother and

Baby Units

Alcohol & Drug

Intensive Withdrawal

& Treatment Services

Paediatric Inpatient

Services Psychiatric Inpatient

& Day Programs

Youth Justice

Custodial Centres

SAFEMinds aims to empower school staff to identify students experiencing emotional distress and make consistent evidence-based decisions around early intervention strategies and appropriate referrals to key youth and mental health services. The System of Care

Map depicts the breadth of the system of mental health care and support for children and young people in Victoria at a macro level. It lists services available within schools and through external providers; and is divided into four levels: primary care services, secondary

care services, specialist tertiary mental health services and emergency services.

Medicare Locals

Family Mental

Health Support

Services

Community

Health Centres

Community Youth

Engagement Programs

Local Gov’t Youth

Services

Youth Prevention and

Recovery Care Service

(Youth PARC)

Mental Health

Community

Support Services

Enhanced headspace

Acute Community

Intervention Service

Options for reforming a working system

1. Introduce new/additional programs with

„seeding‟ funding

2. Reform what we already have

3.Re-commission (re-tender)

4. Do a bit of all of the above

Decision Making re resources: seeking

efficiency and effectiveness

• Devolved governance

• Priority Setting

• The times…the need for and expectations of

efficiency and effectiveness

– GFC

– Operating environments

– The service user as a consumer

– Transparency

Resource Allocation: Purchasing efficient and

effective services

Non-economic priority setting approaches

• Historical allocation

• Historical approaches - inefficiency

• Decision-maker preferences

• Economic approaches have merit…however

Reource allocation: Technical

Approaches – Economic Evaluation

•Four key characteristics

•Costs and Benefits

Have you ever found yourself in a discussion re cost-

effectiveness?

Technical Economic Evaluation within

the MH system – use and limitations

• Less frequent than other sectors

• Limitations

• Data availability

• Measurement

• Costs

• Outcomes

Limitations - Technical Economic

Evaluation within the MH system

Equity / distributive justice

Cost of economic evaluations

Knowledge limitations

Priority setting – responsive, inclusive, explicit

Breadth of task in MH system

Other options?

Economic approaches to priority setting:

Pragmatic Approaches – e.g. PBMA, ACE, HSW

• Address limitations of technical approaches

• Advocate „due process‟ and debate

• Incorporate stakeholder judgement & opinion

• PBMA = Program Budgeting and Marginal Analysis

• ACE = Assessing Cost Effectiveness

• HSW = Health Sector Wide model

Potential - Pragmatic (PBMA) economic

approaches within the MH system

•Breadth of application

•More responsive – enhanced practicality

•Judgement, equity, justice issues

Decision making re resources – MH System

•Noting the system for Young People at Risk

•What models and how?

•Given

• Multiple players and actors

•To measurement and monitoring…

Measuring and monitoring

Benchmarking is:

the ongoing, systematic process to search for and introduce

international best practice into an organisation (Australian

Manufacturing Council, 1994).

So, who “does” measurement and monitoring? Who is best

placed?

What should the impacts be?

Building a Picture of Service and System

Performance – efficiency and effectiveness

• Compliance

– Legislation

– Standards

– Funding and Service Agreements or

Statements of Priority

• Targets and indicators

• Quality indicators

System Performance – Broader Health

System – tools and approaches

• Health Services Act 1988

• “Policy and Funding Guidelines”

• …and the Statements of Priority

• Performance is monitored and managed

• Casemix (output) funding

Efficient Service Performance – Mental

Health

• Mental health system – largely within the health system

• “input” funded

• Commenced monitoring

• Performance meetings

• Consider and begin expanding TARGETS

Recording and Reporting

• Statewide comparative data delivered quarterly

– Adult, Aged, CAMHS

– Extended treatment settings

• New reports in development (aligned with reform agendas)

– Triage response times (Access)

– Activity-Based Funding; shadowing reports (NHRA)

– The Consumer Experience of Care (MH Act)

• Publish (i.e. open and transparent) • http://performance.health.vic.gov.au/Home/Category.aspx?CategoryKey=6#A

nchor

Management vs Monitoring

• Culture that “monitors” to one that “manages” and supports

• Reporting as developmental activity

• Accountability

• Data reporting and comparison

• Levers for change

• CEOs and Boards are focused on Funding and Service

Agreements Statement of Priorities and accountability

Putting it all together – some theory on

the operating relationship

Groundwork and framework for collaboration

Services using data to understand,

benchmark and improve their work

DH utilizing data and measures to understand how services do

business and work with them to deliver, and innovate

Using targets as a lever for change

Two quick examples…

Problem

…impact of acute MH demand

• Increased focus on community care improves options in the

community BUT means that acute units are really acute

Two possible risks

1. seclusion and restraint and coercion;

2. rotating admissions and increased readmission rates

However we have seen significant reductions in seclusion

and a stable readmission rate at or below 14%

SECLUSION - Key concepts

• Organizational culture

• Leadership

• Rigorous review and audit processes

• Experience of consumers and carers

• Physical environment must be regularly assessed

• Training and supporting a workforce

• Targets, reporting, noting performance

• Efficiency

0.0

5.0

10.0

15.0

20.0

25.0

30.0

Seclusions per 1000 Occupied Bed Days - Adult

Metro

Rural

Statewide

Target

Seclusions per 1000 occupied bed days -

Adult

0

200

400

600

800

1,000

1,200

1,400

1,600

Secl

usi

on

s

Adult Metro

Adult Rural

Aged Metro

Aged Rural

CAMHS

Statewide

Trend (Statewide)

Seclusions by setting/location

POST-DISCHARGE CONTACTS

Key Concepts

• Consumer feedback

• Discharge planning is critical and a joint activity

• Local flow management – a priority for service improvement

• Targets, reporting, noting performance

• Efficiency and Effectiveness impacts

Post discharge follow up within 7 days -

statewide

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Statewide Post Discharge KPI

Target

\

Measuring and monitoring: Some

challenges and next steps

• Taking targets seriously

• Evolving and developing

• Engaging seriously and deeply with providers

• Not over-doing it

The science and the art – efficiency and

effectiveness in the real world

System context and who‟s in charge?

•Mid Staffordshire Foundation Trust - UK

•Mersey Hospital – Tasmania

•More devolved decision making?

• PBMA in practice

• Citizen Juries

Two final thoughts…on the journey to

efficient and effective services

• If we always do what we‟ve always done…

• When playing cricket, don‟t where a watch