Annually, close to $9 billion dollars (AUD) is spent on mental health services in Australia — a lot of money, but still nowhere near enough to meet mental health needs. Services must be strengthened and in many cases expanded. However, simply more of the same won’t deliver the outcomes many Australians want and need.
It is widely understood that an increased sense of belonging within family and community, stronger social connections and relationships free from trauma are some of the critical elements in promoting mental health. Professionally driven and medicalised services, whilst important, cannot alone lead to the social capital and resilience required to tackle these challenges at greater scale.
A significant amount of social policy in Australia currently overlooks the value of citizens, particularly those with lived experience, in creating transformational and sustainable mental health outcomes.
Whilst many mental health plans and strategies state the need for increased community education, primary prevention and early intervention, the majority of effort remains focused on improving and/or increasing service delivery, with efforts to build citizen capacity few and fragmented. Where present, strategies are often stuck in information sharing, insufficient for deep and sustained behaviour change.
Community capacity and service efficacy are closely related, with many services relying on helpful and resilient carers, family, friends and neighbours; welcoming and supportive communities; and broader environments that support mental wellbeing (physical environments, workplaces, welcoming and safe spaces within homes and communities).
This means we need new commissioning approaches — used to procure medical and health care services — that look beyond service oriented responses alone. Typically, the commissioning cycle involves strategic planning, procuring services, monitoring, learning and evaluation.
I share three ideas for how this could work better. First, investing in peer-led and community-focused approaches. Second, robust alternatives to emergency departments. And third, commissioning in support of broader social movements.
1. Investing in peer-led and community-focused approaches
First, we need programs that build the capacity and capability of friends, families and neighbours to be better first responders — before, during and after a mental health crisis.
One aspect of that is peer-led responses — delivered by peers with lived experience of mental illness to those experiencing poor mental health. Peer-led responses can also be provided by people with lived experience of caring for someone with poor mental health to people currently playing a caring role. Formal peer work happens within and alongside traditional mental health services, differing from informal responses not associated with services.
Whilst formal peer work is not a magic bullet, it has shown good results (reduced emergency department and psychiatric hospital admissions, enhanced social inclusion, more stable mental health), in our work and other studies. They recognise several important things, that peers:
- Know things that professionals don’t
- May have the time, information and resources to invest in improving their own quality of life and into helping others
- Can work in collaborative, rather than paternalistic ways
- Have diverse capabilities and talents
To do this well, we must increase the value and legitimacy of the peer workforce. In many organisational cultures, peer work remains seen as of less value than clinical intervention.
2. Investing in robust alternatives to emergency departments
Whilst many strategies aim to reduce acute demand, we continue to make hospitals one of the few places a person can access in crisis — particularly after hours. But citizens are clear: emergency departments suck.
We need robust alternatives to emergency departments. We need safe and welcoming places for people to find shelter and diverse support options — peer, cultural and clinical. We have some hints towards what this might look like in The Living Room in the US, Haven Cafes in the UK and the Dutch Clubhouse model.
3. Commissioning in support of social movements
To see better outcomes, there are important mindsets we must move from, and to.
Some of these changes relate to creating a more inclusive Australia, whilst others relate to dismantling organisational and clinical cultures that act as significant barriers to better outcomes. Despite the quality of services, many people leave service settings and are unwelcome in their homes or communities. We need services and social movements.
Frequently appearing in our work is the need to move …
- From commissioning by health professionals to co-design and co-commissioning across health professionals, carers and people with mental health lived experience
- From a system that knows best “for” and “about” to compassionate inquiry and curiosity
- From a colonising system that acts from one dominant worldview to a multicultural system that embraces many world-views, particularly those of First Australians
- From reporting controlled by services and commissioners to greater citizen accountability measures, tipping the power back to consumers and their families to report on outcomes
- From evaluating interventions against clinical outcomes only to evaluating against clinical outcomes and outcomes defined by the people who the intervention is intended to serve