Independent review of the Alcohol and Other Drugs and Mental Health Community Support Services programs 17 August 2015 Background The Victorian Healthcare Association (VHA) welcomes the opportunity to contribute to the independent review (the Review) of the Alcohol and Other Drug (AOD) and Mental Health Community Support Services (MHCSS) programs. This submission has been developed from member feedback; however it does not supersede any made by individual health services and VHA members. While both the AOD and MHCSS programs are being reviewed, the VHA understands that the performance of each program differs and as such will offer separate reflections and recommendations for each. Recommissioning process The terms of reference and scope of the Review do not extend to the recommissioning process. As such, the VHA will not be offering any extended commentary on the topic, other than to note the importance of gaining a clear understanding of the strengths and weaknesses of the approach used to inform future sector reforms and recommissioning processes. The Australian Institute for Primary Care and Ageing, in conjunction with the Victorian Primary and Community Health Network (of which the VHA is a co-convener) has developed a comprehensive report 1 of the recommissioning process. Developed on the basis of interviews with stakeholders, the report provides an independent view of the recommissioning process and should be considered a valuable resource for both the sector and Victorian Government, particularly when considering how similar processes are planned for the future. AOD program The VHA is concerned that the recommissioned AOD program has resulted in a system that has isolated crucial components of the State s public drug and alcohol treatment options from other community services, including health, social services and mental health. 1 Kate Silburn (2015). Recommissioning community mental health support services and alcohol and other drugs treatment services in Victoria: Report on findings from interviews with senior personnel from both sectors. Australian Institute for Primary Care and Ageing, La Trobe University, Melbourne. Level 6, 136 Exhibition Street Melbourne Victoria 3000 T / 03 9094 7777 F / 03 9094 7788 E / vha@ VHA Submission Independent Review of AOD and MHCSS Page 1
Rural and regional Victoria Rural and regional Victoria has distinct requirements and challenges that have not been reflected in the design of the AOD program. The use of the same model across both metropolitan and rural Victoria has exacerbated a number of existing issues for rural communities and health services, including: lack of public transport options, lack of access to in-region detoxification and rehabilitation facilities, a degradation of cooperative relationships between service providers, entrenched client behavior and expectations of accessing health services, cultural values and their impact on intangible influences such as stigma, sparse and small populations, difficulties in recruitment and retention of staff and the ongoing impact of declining economies. The VHA is concerned that clients and service providers in rural Victoria have been disadvantaged by the design of the recommissioned system, with the impacts placing the long-term viability of smaller service providers and the accessibility of AOD treatment services at risk. Data collection Inconsistent data is collected across the AOD program. Service providers are reporting significant reductions in client referrals; however due to incomplete data it is difficult to accurately assess the causes. Suggestions that the tiered assessment tool has resulted in fewer clients qualifying for care may be relevant, but without accurate reporting it is not possible to attribute responsibility. Improving the consistency of data collection should be a priority action going forward. Centralised intake and assessment The centralised IA model has presented significant challenges for the system from the perspective of both service providers and clients. While some of these can be attributed to the introduction of the new model and developing relationships between the centralised IA and service providers; many are the result of the system design and should be directly addressed as such. Service providers are regularly receiving low quality or incomplete client assessments. Many examples have been reported where a client s risk and acuity have been incorrectly assessed. In one notable case, a client on Melbourne s suburban fringe was incorrectly classified as low-risk and not qualifying for treatment. In the same week, the client required urgent rotary wing transport to a major trauma service to be treated for multi-substance toxicity. One case neither condemns nor supports an entire service system; however this particular example highlights the specific risks posed by remote, phone-based and non-clinical assessments. The phone-based model has created barriers for discrete populations of need, including but not limited to culturally and linguistically diverse groups, Aboriginal and Torres Strait Islanders and people experiencing homelessness. Navigating the phone-based process requires a degree of health literacy and understanding. Those for whom English is not a first language and those without access to a phone are placed at a disadvantage when seeking assistance. Level 6, 136 Exhibition Street Melbourne Victoria 3000 T / 03 9094 7777 F / 03 9094 7788 E / vha@ VHA Submission Independent Review of AOD and MHCSS Page 2
A key weakness in the model is that it does not facilitate an immediate interaction with a client initiating the care process. VHA members have emphasised the importance of being able to respond to client-initiated requests for care, as those who do not receive a timely assessment are easily lost to the system. Community health services (CHS) provide an ideal platform for delivering AOD assessments and treatment for individuals in community settings. Their model is based on person-centred, wrap-around care that integrates allied health, medical, dental and social services and allow an individual to receive care in a manner that is connected and holistic. The centralised IA model does not support a person-centred and holistic assessment of a client s needs. While a client s drug and/or alcohol use and risk factors are assessed, opportunities for engaging the client in allied health, social service, dental or medical care are not supported. CHS providers of AOD provide a platform that not only facilitates an in-person clinical assessment, but allows individuals to be referred directly into other modules of health and social care. VHA members have made it clear that the introduction of the centralised IA model, and in particular the removal of assessment functions from service providers, has resulted in a system that is difficult for clients to enter and navigate. Barriers to assessment The VHA recognises that one potential benefit of the centralised IA process is a consistent approach to intake across a geographic region. Under this model, demand should theoretically be assessed and clients assigned to services with capacity that best fit their needs. A strict adherence to the centralised IA model, however, places at risk the ease of access that clients may have had under previous arrangements. When considering what changes might improve the functionality of the AOD IA, it is important to balance the value of consistent assessment against the barriers to care that might result from the centralised model. Suggestions to improve the function of IA include returning the assessment function to service providers and retaining the central model as an intake and referral service for clients who choose to access the system by phone. This would facilitate central access to the system, enable demand management and catchment-level understanding of service utilisation, and more importantly would allow service providers to undertake comprehensive, in-person assessments that lead to expedited treatment for clients who present in person. System design The focus of the tiered model on higher acuity clients at the expense of early intervention and health promotion opportunities for those assessed at the lower end of acuity and need is a risk. The value of early intervention cannot be overemphasised and should be actively supported in the AOD program. The focus of AOD services on higher acuity clients implies that an individual can only qualify for treatment once a certain level of acuity is reached. Without undermining the importance of providing care for these clients, it is difficult to support a treatment system that by virtue of its design fails to Level 6, 136 Exhibition Street Melbourne Victoria 3000 T / 03 9094 7777 F / 03 9094 7788 E / vha@ VHA Submission Independent Review of AOD and MHCSS Page 3
cater for clients who would benefit from early intervention and low acuity care. The VHA would suggest that neither client group low or high acuity should have their access to care restricted as a result of specific program design. The recommissioned model has resulted in a redistribution of funding and resources, often resulting in health services employing fewer staff and losing organisational experience, local contacts and reducing local capacity to deliver the AOD program. Service providers in rural towns have seen EFT reduced and redeployed, sometimes to new organisations within the same town. While individual clients can still access care locally, the end result has been a loss of experience and the ability for some health services to develop integrated solutions across AOD, health and social services. One rural Victorian health service had its AOD program funding reduced and as a result two of its staff have been employed in the criminal justice sector. Members of this community report that it is easier to access AOD treatment in prison than in community settings. While anecdotal reports should be taken with a degree of caution; that this sentiment exists indicates a lack of confidence in Victoria s public drug and alcohol treatment system. Program funding The Victorian Government has flagged its commitment to deal with problematic drug use, particularly use of methamphetamine, through the Victorian Ice Action Plan. While the elements of the Ice Action Plan supporting drug treatment services are welcome, it is essential that the AOD program is financed to provide care across the spectrum of acuity, from health promotion and early intervention to intensive residential rehabilitation and withdrawal services. There must be a commitment from the Victorian Government to ensure that gaps in the AOD program, both existing and those relating to the recommissioned system, are addressed and long-term resourcing is secured. Recommendations 1. Return the assessment function to service providers to allow in-person assessments of clients who initiate requests for care 2. Retain the central intake model as one means of distributing client referrals to assessment and treatment providers 3. Improve data collection at the level of service providers and across catchments 4. Provide early intervention programs for clients assessed as categories one and two by the screening tool. Mental Health Community Support Services (MHCSS) program While the process by which the Psychiatric Disability Support Services (PDRSS) was recommissioned into the MHCSS program shares some procedural and design similarities with the AOD program, it is operating in a different context and with a range of other influences that must be taken into account when reviewing its performance and in particular, any recommendations for change that might arise from the Review. Level 6, 136 Exhibition Street Melbourne Victoria 3000 T / 03 9094 7777 F / 03 9094 7788 E / vha@ VHA Submission Independent Review of AOD and MHCSS Page 4
Policy context While the final quantum is not clear, it is understood that the Victorian Government will transition the majority of its community mental health funding into the National Disability Insurance Scheme (NDIS) within the next three years, making further reform to existing MHCSS providers a challenging proposition. Given the differences in eligibility between the NDIS and existing MHCSS, it is essential that the Victorian Government engages the sector in planning for and developing a state-based service system for clients currently receiving care under the MHCSS but will not be eligible for NDIS packages. There is a significant risk that those who do not qualify for NDIS packages will seek support through the existing community health integrated program and its counselling function. Should this occur, currently strained resources will be stretched and access to care further diminished. The Victorian Government is currently undertaking consultations to inform the development of its 10 Year Mental Health Plan. The VHA suggests that the Review recommends that the Victorian Government use this process to co-design, with the sector, an appropriate and effective communitybased mental health solution for clients ineligible for NDIS care. Recommendations MHCSS 1. Further reform to the MHCSS program is not an immediate priority given the impending change to the NDIS 2. Utilise the Victorian Government s 10 Year Mental Health Plan to co-design an accessible community-based mental health program that cares for individuals who do not qualify for NDIS care. Further Information For further information, please contact: Tom Symondson Chief Executive Officer Victorian Healthcare Association Phone: 03 9094 7777 Chris Templin Policy Advisor Victorian Healthcare Association Phone: 03 9094 7777 Email: chris.templin@ The Victorian Healthcare Association The Victorian Healthcare Association is the peak body representing the public healthcare sector in Victoria. Our members include public hospitals, rural and regional health services, community health services, aged care facilities and Medicare Locals. Established in 1938, the VHA promotes the improvement of health outcomes for all Victorians, from the perspective of its members. Level 6, 136 Exhibition Street Melbourne Victoria 3000 T / 03 9094 7777 F / 03 9094 7788 E / vha@ VHA Submission Independent Review of AOD and MHCSS Page 5