Matthew Hercus - Department of Health Victoria -An efficient and effective mental health system


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Matthew Hercus delivered the presentation at the 2014 Young People at Risk Forum.

The 2014 Young People at Risk Forum reviewed the challenges and solutions surrounding intervention programs around topics such as suicide prevention, substance abuse, mental health, education, employment and housing. Additionally, the forum focused on culturally competent care and care within Aboriginal communities.

For more information about the event, please visit:

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Matthew Hercus - Department of Health Victoria -An efficient and effective mental health system

  1. 1. 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…)
  2. 2. Overview • Decision making re resources • Measurement and monitoring • Some things that may or may not help –Considerations and discussion
  3. 3. Hang on – isn't this a forum about Young People at Risk?
  4. 4. 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)
  5. 5. 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 Not to mention Commonwealth activity
  6. 6. Monitoring Evaluation Policy Development Service System Design Service Design Service Specification Resource Planning Implementation Planning Commissioning Consolidation
  7. 7. 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 ServicesPublic/Private Paediatricians Specialist Children’s Services Private Psychiatrists headspace/eheadspace Early Intervention Services TERTIARYChild & 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
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. Reource allocation: Technical Approaches – Economic Evaluation •Four key characteristics •Costs and Benefits Have you ever found yourself in a discussion re cost- effectiveness?
  12. 12. Technical Economic Evaluation within the MH system – use and limitations • Less frequent than other sectors • Limitations • Data availability • Measurement • Costs • Outcomes
  13. 13. 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?
  14. 14. 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
  15. 15. Potential - Pragmatic (PBMA) economic approaches within the MH system •Breadth of application •More responsive – enhanced practicality •Judgement, equity, justice issues
  16. 16. 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…
  17. 17. 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?
  18. 18. 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
  19. 19. 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
  20. 20. Efficient Service Performance – Mental Health • Mental health system – largely within the health system • “input” funded • Commenced monitoring • Performance meetings • Consider and begin expanding TARGETS
  21. 21. 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) • nchor
  22. 22. 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
  23. 23. 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
  24. 24. Using targets as a lever for change Two quick examples…
  25. 25. 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%
  26. 26. 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
  27. 27. 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
  28. 28. 0 200 400 600 800 1,000 1,200 1,400 1,600 Seclusions Adult Metro Adult Rural Aged Metro Aged Rural CAMHS Statewide Trend (Statewide) Seclusions by setting/location
  29. 29. 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
  30. 30. Post discharge follow up within 7 days - statewide 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100% Statewide Post Discharge KPI Target
  31. 31. Measuring and monitoring: Some challenges and next steps • Taking targets seriously • Evolving and developing • Engaging seriously and deeply with providers • Not over-doing it
  32. 32. 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
  33. 33. 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