Insight We need to raise the bar on safety and quality

We need to raise the bar on safety and quality in mental health care. Here’s how we can do it.

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Policy makers have long agreed that Australians need mental health care that is safe and high quality – but we have struggled to achieve it.

Previous attempts to achieve quality and safety (driven at a national level through initiatives like the National Standards for Mental Health Services in 2010 and the Fifth National Mental Health and Suicide Prevention Plan in 2017) have not been able to achieve the consistency many had hoped for.

Now Australia’s mental health system is on the cusp of another significant wave of reform: the new National Agreement on Mental Health and Suicide Prevention is due to be released in late 2021.

Both the Productivity Commission and a Victorian Royal Commission found that mental health safety and quality often fall short and that we need to set up an architecture for continuous quality improvement. Will policy makers use this opportunity to raise the bar in the safety and quality of Australia’s mental health system?

When we talk about safety and quality, we are referring to the avoidance or reduction of harm in health care (safety) and the degree to which health services increase the likelihood of desired outcomes (quality), in line with the definition used by the Australian Institute of Health and Welfare.

The case for higher standards is compelling. Apart from the obvious moral imperative, a focus on safety and high-quality care leads to better consumer experiences and mental health outcomes, improved workforce satisfaction and higher retention rates. It can also deliver substantial cost savings.

Right now the maturity of safety and quality varies across Australia’s mental health systems. There is almost no systematic approach to safety and quality in primary and community-managed mental health services. And there is an incident-focused approach in acute specialist mental health systems and specialist community-based services managed by states and territories.

All parts of the mental health system can seize on the reform momentum to turn talk into action. In this article we consider the ways that primary and community services, acute specialist services, and policy makers and funders can achieve a step-change improvement in safety and quality in mental health.

1. Primary and community-managed mental health services need to lay the foundations for quality and safety

Currently, there are few quality and safety structures and systems in primary mental health care in Australia. Mental health primary care is primarily delivered by registered practitioners such as General Practitioners and Psychologists funded by the Medicare Benefits Schedule (MBS) or through mental health programs funded through Primary Health Networks (PHNs) and state and territory governments.

There is no consistent or nationally agreed framework to measure, monitor or improve the quality and safety of primary and community-managed mental health care despite agreement to do so under the Fifth National Mental Health and Suicide Prevention Plan. (Action 21 requires governments to “develop a National Mental Health Safety and Quality Framework to guide delivery of the full range of health and support services required by people living with mental illness”.)

While some progress has been made, the primary and community-managed mental health sectors still lack a clear and fit-for-purpose quality and safety framework. For example, the most recent National Standards for Mental Health Services mostly focus on acute settings rather than primary and community-managed mental health services. The new National Safety and Quality Primary and Community Healthcare Standards have a broad focus and do not address many of the specific safety and quality issues that arise in the delivery of mental health care (including risks around re-traumatisation and vicarious trauma).

True collaboration between the federal government, state and territory governments, and PHNs and community-managed mental health services could lead to the development of a fit-for-purpose quality and safety architecture for primary and community-managed mental health services.

This would give primary and community-managed mental health services clarity to further develop safety and quality systems in their organisations, including embedding trauma-informed practices, establishing robust clinical governance structures and implementing a system for measuring and monitoring patient safety.

2. Acute specialist services and specialist community-based services need to move from an incident focus to systematic quality improvement

For acute specialist mental health services and specialist community-based services, the focus of quality and safety efforts is reducing the incidence of adverse patient safety events, such as suicide and deliberate self-harm, as well as harmful practices such as seclusion and restraint. But preventing harm – while itself critical – is only the foundational base for safety and quality.

Acute services and specialist community-based services need to move beyond responding to safety incidents toward a systemic approach to quality improvement. This means taking a structured approach to understanding the effectiveness of the care provided to different cohorts, and optimising models of care to maximise health outcomes in a cost-effective way.

Insights from clinical practice data and new research can feed into updates to evidence summaries and clinical practice guidelines. Structured approaches have led to continuous quality improvement in many domains of physical health (including stroke, cancer and maternity care).

Currently there are pockets of good practice, for example the NSW Clinical Excellence Commission partners with Local Health Districts and Specialty Health Networks to deliver a continuous quality improvement program for mental health patient safety. However we need to expand such efforts nationally so it is standard practice for acute specialist services and to ensure that efforts translate to broader quality improvements such as in clinical practice guidelines (rather than solely focusing on safety and harm prevention).

From our experience with health services, we have seen how structured continuous quality improvement can be delivered amid funding constraints. Success requires executives and boards to prioritise quality improvement in strategies and to support their organisations to use improvement methodologies based on data and consumer co-design. Governance structures and a learning culture need to be established so that lessons are documented in clinical practice guidelines and translated into better models of care.

3. Policy makers and funders need to establish coherent safety and quality oversight and improvement mechanisms to avoid flying blind

Bodies that fund and commission mental health services – be they federal, state or territory governments or PHNs – need effective oversight of services and quality improvement mechanisms.

Clear, consistent and low-burden data collection and monitoring frameworks are crucial. Currently the national landscape for mental health data is fragmented and at times duplicative across federal government, state and territory governments and PHNs.

Funders and policymakers could set high safety and quality expectations for service providers and establish a hierarchy of safety and quality assurance actions to address underperformance.

Beyond this, governments could encourage continuous improvement of mental health quality and safety by collecting and aggregating data and insights on effective models of care and setting up structures to translate this knowledge into better practice on the ground (such as through updated best practice care guidelines).

Internationally, governments are increasingly embarking on structured quality improvement approaches in mental health. For example, Healthcare Improvement Scotland leads mental health quality improvement, including the Scottish Patient Safety Programme in Mental Health, which seeks to reduce rates of restraint, violence, self-harm and seclusion, and improve the safety of medicines used in mental health treatment.

System design is crucial to safety and quality, as Nous Principal Tim Marney has written. To achieve this, governments can take a system design approach when designing quality and safety architecture.

Victoria’s Royal Commission noted the importance of clear delineation of roles and responsibilities between oversight and improvement bodies. The Royal Commission recommended establishing a dedicated Mental Health Improvement Unit to provide system leadership on quality and safety improvement, including working with services and producing best practice guidelines. It also proposed a Mental Health and Wellbeing Commission that will use its complaints and oversight functions to monitor, inquire into and report on system-wide quality and safety.

Australia’s health system needs a culture change that enables collaboration, integration and continuous improvement

Establishing the quality and safety architecture is not enough. Raising the bar in mental health safety and quality requires players in the mental health system working together to drive continuous improvement and learning.

It is important for federal, state and territory governments to clarify their roles and responsibilities in mental health; governance and accountabilities are currently very complex and unclear, which gets in the way of collaboration for quality improvement.

Then the system’s culture needs to shift towards collaboration, integration and continuous improvement. This will require reimaging the current siloed ways of working across jurisdictional lines and between mental and physical health.

As well as being good and cost-effective public policy, a comprehensive mental health safety and quality agenda will leave Australian consumers better off.

Governments need to work together to capitalise on the unprecedented reform appetite, making mental health care safer and better for all everyone.

If we miss this opportunity, we might be waiting a while for the next chance. How many consumers of mental health services will be let down by the system in the meantime?

Get in touch to discuss how Nous Group can support improvement to mental health safety and quality.

Connect with Ian Thompson and Jack Marozzi on LinkedIn.

This article was prepared with input from Tim Marney during this time at Nous Group.