Principles for mental health systems

December 2021

Position statement 37


Summary

This position statement outlines key principles of optimal mental health systems to inform governments and funders and achieve the best possible outcomes for consumers and the wider community.

Purpose

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has developed this position statement to affirm the importance of developing a mental health system which is person- centred and responsive to community need. This position statement outlines key principles of optimal mental health systems to inform governments and funders.

Key principles of optimal mental health systems

  • Equitable access
  • Culturally safe
  • Skilled, well-resourced workforce and clinical leadership
  • Partnering with people with a lived experience
  • Supported decision making
  • Trauma-informed practice
  • Responsive, compassionate, person-centred care
  • Integrated policies, systems, and services
  • Evidence-based systems, services, and practices
  • Consistent, coordinated data collection
  • Research, evaluation, and quality improvement
     

Introduction

Mental illness is a major cause of community distress and remains an important public health concern for both Australia and New Zealand. 1 in 5 Australians reported that they had a mental or behavioural condition over 2017-2018.[1] Nearly 1 in 4 New Zealand adults reported experiencing ‘poor mental wellbeing’ over 2018-2019.[2] The majority of conditions are treatable, and treatment may support improved health outcomes and quality of life for the community. Prevention, early intervention, and holistic care can prevent conditions from worsening; this is both supportive of human rights and cost-effective.[3, 4]

For the purposes of this document, the ‘mental health system’ refers to both public and private services which provide mental healthcare at all levels (primary, secondary, tertiary) and in all spaces (inpatient or community based), as well as the people, services and structures which intersect with mental healthcare such as funding and governance structures. This is inclusive of portfolios that encompass the social determinants of health such as justice, education and training, housing and homelessness, employment and income support, disability, family violence (FV), alcohol and other drug (AOD), and primary health service sectors.

For information regarding the role of a psychiatrist within the mental health system, please see the RANZCP Position Statement 80: The role of a psychiatrist in Australia and New Zealand. The RANZCP is committed to enabling psychiatrists to provide optimal care and psychiatric treatment. In order for this capacity to be fully realised, the mental health system must be premised upon a set of best-practice principles based on evidence, informed by lived experience, and intended to produce the best possible outcomes for consumers and the wider community.[3, 5, 6]

Equitable access

Equitable access to quality care in the mental health system is critical. There must be support structures in place that regulate system performance issues including barriers to equitable access.[4, 7] The public must have access to specialist services of the same quality, regardless of location or circumstance. Regional, rural, and remote communities must be provided with clear pathways to access services required, including specialist services.[8] Please see the Rural Psychiatry Roadmap Blueprint 2021-31: A pathway to equitable and sustainable rural mental health services for more information.

At-risk populations, including veterans, people within and exiting justice and detention systems, immigrants, refugees, and asylum seekers must be ensured access to a mental health system which provides the types of care, and is shaped to facilitate the types of access and help-seeking, required by these groups. People with disability, including intellectual and developmental disability, Autism Spectrum Disorder (ASD) and Attention-deficit/hyperactivity disorder (ADHD) have high rates of comorbid mental health conditions.[9-11] People with disability should have access, free from stigma, to sufficient, integrated services specialised in the mental health needs of these diverse and vulnerable groups.[9, 10]

Culturally and linguistically diverse populations should have access to appropriate care pathways that address eligibility, cultural, or linguistic barriers to care.[6] Mental health systems must be equipped to provide gender-sensitive care, and also recognise and address the needs of the LGBTIQ+ (a) population. For more information, please see the RANZCP Position Statement 83: Recognising and addressing the mental health needs of the LGBTIQ+ population. Children, adolescents, and young adults must also be able to access the mental health services they require, taking into account the limitations that these age groups may face in service access.[12] A holistic, age appropriate and culturally informed approach is needed to address mental illness in older people, informed by the principles of recovery, independence, dignity and quality of life. Please see RANZCP Position Statement 22: Psychiatry services for older people.

Culturally safe

Systems must be culturally safe for all peoples and, in particular, support the social and emotional wellbeing of Aboriginal and Torres Strait Islander peoples and Māori. Aboriginal and Torres Strait Islander adults have a higher prevalence of psychological distress than the general population.[13] In New Zealand, Māori have a higher burden of depression, anxiety and psychological distress.

Māori adults were about 1.5 times as likely as non- Māori adults to report a high or very high probability of having an anxiety or depressive disorder.[14, 15]

This is demonstrative of the importance of cultural safety within the mental health system, including system-wide recognition of the role of culture and community in the healing process. In New Zealand, the Whānau Ora approach is important; in Australia, the National Framework for Health Services for Aboriginal and Torres Strait Islander Children and Families may be helpful.[16, 17] For more information, please see RANZCP Position Statement 104: Whānau Ora and the RANZCP Position Statement 105: Cultural safety.

In Australia, the RANZCP supports the aspirations of the National Agreement of Closing the Gap.[18] In New Zealand, the RANZCP is committed to Te Tiriti o Waitangi (b) within the context of improving mental and physical health for Māori. Honouring Te Tiriti o Waitangi’s principles and implementing them is becoming increasingly important across all aspects of New Zealand society. Evidence suggests self-determination and supportive societal structures can be a protective factor against negative mental health outcomes.[19, 20] The right to self determination is specifically stipulated within the United Nations Declaration on the rights of Indigenous Peoples, which both Australia and New Zealand have endorsed.[21] For more information, please see the RANZCP online pages on Aboriginal and Torres Strait Islander Peoples' mental health and Māori mental health. The diversity of the mental health workforce should be reflective of the community is serves.[22] For more information, please see the RANZCP Position Statement 50: Aboriginal and Torres Strait Islander mental health workers.

Skilled, well-resourced workforce

The mental health workforce must have sufficient capacity and be equipped with the required skills at all levels.[23] It is essential to ensure the right level of staffing and access to the most appropriate professional for a particular concern.[22] Adequate investment and workforce planning is required to support adequate recruitment, training, and retention of the mental health workforce to prevent workforce shortages and instability of the workforce.[22] Please see Child and adolescent psychiatry: meeting future workforce needs.

A system-wide commitment is needed to ensure appropriate supervision and ongoing workforce professional development, enabling the workforce to deliver evidence-based treatments and care. Workforce training and professional development is required to ensure that those delivering mental health services have adequate capacity and skills to consider consumer (c) values, care for diverse community members in a way that is culturally safe, and appropriately support individuals with disability.[22]

Ensuring skilled, ethical leadership within the system is key. Psychiatrists play a key role in mental healthcare and are well-placed to partner, lead, and advise on a range of matters. Psychiatrists have an important role in the education and support of other health professionals and in leading improvements in service provision. Leveraging opportunities to lead and contribute to discussions on policy direction and better approaches to public health is also core business for psychiatry.

Partnering with people with a lived experience

Mental health systems and services should be co-designed by experts in mental health with clear governance processes; people with a lived experience of a mental health condition, clinicians and managers working in collaborative partnerships. People with a lived experience’ encompasses both consumers of mental health services and their carers and families. For more information, please see the RANZCP Position Statement 76: Partnering with carers in mental healthcare.

People with a lived experience have expertise that is vitally important to clinicians, the RANZCP, mental health service providers and policymakers.[4, 5] It is also important that people with a lived experience are included in the process of determining the structures and systems which will be used to assure safety and quality within mental health services.[4, 5]

Co-production is important in contexts where individuals or communities are involved or affected by the outcome of systems and policies, such as mental health services.[4, 5] Co-production is complementary to a recovery-oriented framework, as it validates and utilises the strengths of people with a lived experience and encourages engagement between systems and the people who access them to build better systems of care.[5, 24] For more information, please see the RANZCP Position Statement 62: Partnering with people with a lived experience and Position Statement 86: Recovery and the psychiatrist.

Supported decision making

The concept of partnerships is key within service delivery; individuals accessing mental healthcare have the right to participate in decision making about their own care.[4] Supported decision making acknowledges that every person has the right and capacity to make informed choices and autonomous decisions.[25] Clinicians and others involved in care have a key role in this process to uphold the rights of people in treatment to participate in decisions related to their treatment to the maximum extent possible, and facilitate collaborative and empowering interactions to provide better outcomes for people with mental ill health. The RANZCP promotes supported decision making as a cornerstone of psychiatry practice. For more information, please see the RANZCP Victorian Branch position paper: Enabling supported decision-making.

Trauma-informed practice

Systems and services must be designed based on evidence and delivered with trauma-informed care and supported decision-making at the heart of the system. Individuals accessing mental health services have higher rates of experiencing trauma in life, and it is especially pronounced in the year prior to their contact with services.[26, 27] Mental health systems and services need to be responsive to safety considerations including support for survivors of, and those experiencing, family, domestic, and sexual violence. For more information, please see RANZCP Position Statement 102: Family violence and mental health.

Trauma-informed practice (TIP) is an evolving concept which emphasises that trauma is a possibility in the lives of all individuals and communities. Within mental health systems there should be an awareness of the importance of TIP practice, including: the prevalence of trauma, the relationship between trauma and mental health conditions including complex psychosocial problems, and the need for respectful, sensitive care provided within secure, trustworthy and collaborative relationships.[28, 29] The needs of people who have experienced trauma must be routinely incorporated into mental health systems and processes, recruitment of staff, service funding and hospital design. For more information, please see the RANZCP Position Statement 100: Trauma-informed practice.

Responsive, compassionate, person-centred care

Community members need the right care at the right time. Timely access to appropriate treatment and support is essential.[3] An effective mental health system must be person-centred and responsive to the needs of the individual.[6] Mental health services must offer compassionate care and treatments based on both the best available evidence and consumer values and clinicians who have adequate expertise are required.[6, 30] A system which enables this must be equipped with the capacity and range of services required to meet demand.[31]

Clear treatment and referral pathways must be available where a person presenting to a mental health service is heard and matched to the intervention level which suits their needs. A working mental health system offers accessible, evidence-based treatment and support for differing levels of severity, from mild-to-moderate through to severe.[3] This may include a range of services, including: psychological therapy for mild-to-moderate anxiety, through to acute inpatient care for an episode of psychosis or mania which requires a sufficient number of available inpatient beds; and, assertive outreach in the community for individuals requiring meal support for an eating disorder.[31-34] Preventive, low-cost interventions must be provided to people in the early stages of mental illness, to prevent more serious conditions from developing and ultimately imposing higher social and economic costs on the community.[3, 4]

Social inclusion and connectedness are key to human wellbeing.[4, 35, 36] Achieving social inclusion involves a whole-community approach.[35] Quality options for community-based rather than hospital-based mental healthcare are required.[36] However, access to acute, hospital-based care will always be needed.[36] Focus on prevention and early intervention must not direct funding away from providing well-resourced secondary services, which must be available for people with enduring and serious mental health disorders.[37] People living with increasingly complex mental health and addiction issues require support and services delivered by secondary care.[37] This cohort has co-morbid presentations that make diagnosis, treatment and support challenging.[3] Mental health systems must ensure capacity to provide treatment for people with comorbid addition and mental illness.[30] The RANZCP maintains that strategies to improve the mental health system must be closely aligned with public health interventions to reduce the harms associated with substance use, and must be evidence-based.[38] Additionally, access to tertiary care for sub-specialty areas such as eating disorders, neuropsychiatry, and perinatal is required; tertiary expertise is critical in delivering safe, quality care to those who need it.

Integrated policies, systems, and services

Consumers, carers and their families must have access to integrated, multidisciplinary services.[3, 4, 39] The RANZCP maintains that many of society's complex problems impacting on health outcomes cannot be solved by the health system on its own; therefore multidisciplinary, cross- agency service approaches are essential to improve mental health outcomes and avoid fragmented care. Physical health, disability, justice, FV, employment, education and training, housing and homelessness, and AOD sectors all hold an important role in improving societal mental health and wellbeing, and connections between these sectors must be enabled.[36, 39] Coordination between clinical and non-clinical providers is essential to providing individuals with clear, coordinated care and treatment pathways.[22] This coordination includes providing holistic assessments and facilitating shared plans which determine service roles and responsibilities. Health promotion programs which emphasise the link between the social determinants of health and mental health outcomes may also be effective.[23, 30]

The RANZCP recognises that mental health and wellbeing is influenced by the prevailing social, cultural and economic environment. Mental health systems and services must be grounded within social and economic structures and policies that enhance wellbeing and minimise distress, enabling this compassionate and holistic care. Efforts to improve and connect policies, systems, and practices that impact on the mental health of the community are required.

Evidence-based systems, services, and practices

Mental health systems, services, and practice must be based on evidence and regularly evaluated; this works to establish a learning culture within a dynamic, learning system that is continuously improving and evolving based on previous practice outcomes. Evidence-based practice uses the best available research and data as a base to develop a consistent and comprehensive approach to practice.[40] This provides individuals receiving care and treatment with the best available care.[41, 42] The RANZCP provides psychiatrists with guidelines and resources for practice.

Policy has the power to lead and incentivise delivery of evidence-based practices, and therefore must drive mental health system reform, influencing services who provide practices.[41] Evidence also underpins good investment decisions, resulting in lower expenditure.[43] An understanding of the limitations of the current evidence base is also important.[44]

Research, evaluation, and quality improvement

Research and evaluation are key in building an evidence base. Opportunities for research and research translation should be prioritised as an essential element for development of mental health care and treatment.[45] Research is essential for building knowledge and an evidence-base to support systemic strategies, service design and delivery, as well as treatment.[36, 45, 46] Australia and New Zealand have their own cultural, social, legislative and economic structures that influence how health services and support are provided and used by people with mental health problems.[36, 37, 45] Using overseas data to inform our interventions does not always work; mental health systems and services must devote resources to funding clinical academic psychiatrist roles to conduct research, research translation and evaluation.

Monitoring, evaluating and improving systems are key for quality improvement.[42, 46] Evaluation is important because it can reveal strengths, weaknesses, and unintended consequences of current practices, services and policies.[22]

Data collection should be nationally consistent and coordinated, include consumer outcome measures, be used to inform system improvement, and be made publicly available for research- purposes. High quality, rapid, readily accessible data on mental health and suicides is central to improving the quality of clinical practice and community wellbeing.[40, 43] Clinical registries improve the understanding of factors which contribute to quality care, and can be used for monitoring, evaluation, continuous improvement, and in research.[43] This leads to informed change in policy and practice, resulting in improved consumer outcomes.[43]

Recommendations

The RANZCP recommends that mental health systems:

  • Ensure equitable access across services for all population groups, taking particular care to facilitate access for vulnerable groups.
     
  • Implement culturally safe principles and practices throughout all aspects of the system.
     
  • Include people with a lived experience of mental health conditions in processes of developing and evaluating mental health systems and services.
     
  • Plan and fund a sufficiently skilled and resourced workforce with the capacity to both meet community demand for services and deliver high quality care, in addition to demonstrating ethical leadership.
     
  • Prioritise supported decision making as a cornerstone of the system to uphold the rights of people receiving care.
     
  • Cultivate a compassionate, trauma-informed approach to mental healthcare.
     
  • Partner with consumers to deliver responsive, compassionate, person-centred care which is tailored to suit their needs in a way that is timely.
     
  • Provide holistic care to the community within a sufficiently integrated system which has clear clinical governance and accountability to enable clear care pathways.
     
  • Facilitate evidence-based systems, services, and practices to provide the community with the best available care.
     
  • Prioritise and fund mental health and psychiatry research in order to build the evidence base.
     
  • Monitor and evaluate all facets of the system for quality improvement purposes.
     
  • Coordinate the consistent collection of mental health data to understand gaps and opportunities.

Additional resources

Footnotes

(a) LGBTIQ+ - refers collectively to people who are lesbian, gay, bisexual, trans, intersex, ‘queer’ or ‘questioning’ (exploring their orientation and identity), as well as people with alternative sexual, orientation, or sex or gender identities who do not identify with the other terms.

(b) Te Tiriti o Waitangi or the Treaty of Waitangi is Aotearoa’s founding document outlining how Māori and the British Crown work together in partnership.

(c) The terms ‘carer’ and ‘consumer’ are used where differentiation is required for the purposes of document clarity. The RANZCP acknowledges that both carers and consumers have a lived experience and that the roles are not mutually exclusive. The RANZCP also acknowledges that ‘carer’ and ‘consumer’ may not be the preferred terms of individuals.

Responsible committee: Practice, Policy and Partnerships Committee

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Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.