Federal and state cooperation necessary but not sufficient for effective regional mental health systems: insights from systems modelling and simulation

Abstract

For more than a decade, suicide rates in Australia have shown no improvement despite significant investment in reforms to support regionally driven initiatives. Further recommended reforms by the Productivity Commission call for Federal and State and Territory Government funding for mental health to be pooled and new Regional Commissioning Authorities established to take responsibility for efficient and effective allocation of ‘taxpayer money.’ This study explores the sufficiency of this recommendation in preventing ongoing policy resistance. A system dynamics model of pathways between psychological distress, the mental health care system, suicidal behaviour and their drivers was developed, tested, and validated for a large, geographically diverse region of New South Wales; the Hunter New England and Central Coast Primary Health Network (PHN). Multi-objective optimisation was used to explore potential discordance in the best-performing programs and initiatives (simulated from 2021 to 2031) across mental health outcomes between the two state-governed Local Health Districts (LHDs) and the federally governed PHN. Impacts on suicide deaths, mental health-related emergency department presentations, and service disengagement were explored. A combination of family psychoeducation, post-attempt aftercare, and safety planning, and social connectedness programs minimises the number of suicides across the PHN and in the Hunter New England LHD (13.5% reduction; 95% interval, 12.3–14.9%), and performs well in the Central Coast LHD (14.8% reduction, 13.5–16.3%), suggesting that aligned strategic decision making between the PHN and LHDs would deliver substantial impacts on suicide. Results also highlighted a marked trade-off between minimising suicide deaths versus minimising service disengagement. This is explained in part by the additional demand placed on services of intensive suicide prevention programs leading to increases in service disengagement as wait times for specialist community based mental health services and dissatisfaction with quality of care increases. Competing priorities between the PHN and LHDs (each seeking to optimise the different outcomes they are responsible for) can undermine the optimal impact of investments for suicide prevention. Systems modelling provides essential regional decision analysis infrastructure to facilitate coordinated federal and state investments for optimal impacts.

Sound Decision Making in Uncertain Times: Can Systems Modelling Be Useful for Informing Policy and Planning for Suicide Prevention?

“…Perth South PHN is a metropolitan region of Western Australia, covering 5069 square kilometres with an estimated resident population of 973,769 [21,22]. The system dynamics model developed was based on a similar model reported elsewhere [20] that was reviewed, re-parameterised, and verified in partnership with Perth South PHN collaborators to ensure that the model structure and assumptions were valid for the Perth South context. Briefly, the model includes: (1) a population component, capturing changes over time in population size resulting from births, migration, and mortality; (2) a psychological distress component that models flows of people to and from states of low or no psychological distress (Kessler 10 [K10 scores below 15), and moderate to very high psychological distress (K10 score 16−50); (3) a mental health services component that models the movement of psychologically distressed people through possible service pathways across the primary to tertiary service continuum involving (potentially) general practitioners (GPs), psychiatrists and allied mental health professionals (including psychologists, mental health nurses, social workers, etc.…”

“…The model used for the current analysis was originally developed using a broad and inclusive participatory process involving stakeholders from state governments, health and social policy agencies, local councils, non-government organisations, the education sector, emergency services, research institutions, community groups, primary care providers, multidisciplinary researchers, indigenous representatives, and people with lived experience of suicide [20]. The model was further verified during the re-parameterisation processes with Perth South PHN collaborators.…”

“…Evidence from systems modelling applications to answer questions related to mental health systems strengthening, system reform, and investments in the social determinants of mental health have elucidated a range of important insights. These insights include, (i) that more is not necessarily better, i.e., investing in programs and initiatives beyond the best performing combination can deliver little additional benefit [13]; (ii) that even evidence based interventions can fail to deliver impact or can potentially result in unintended consequences [14]; (iii) that health systems exhibit non-linear behaviour and threshold effects that have implications for system investment [15,16]; (iv) that some intervention combinations and system reforms have the potential to deliver synergistic effects, i.e., where the impact of key strategies combined is greater than the sum of their impact if implemented in isolation [14,17]; (v) that some social determinants of mental health can be more important than others [18]; (vi) that regional variation in population and health system characteristics modifies the impact of suicide prevention measures on local suicide rates [19]; and (vii) that there can be marked trade-offs between minimising different population mental health outcomes, which have significant implications for crossagency planning when there are competing priorities [20]. This growing evidence suggests that the comprehensive, 'evidence-based' approach long promoted by the population health research community and embraced by public health planners lacks nuance, focus, and strategic sophistication.…”

Which Social, Economic, and Health Sector Strategies Will Deliver the Greatest Impacts for Youth Mental Health and Suicide Prevention? Protocol for an Advanced, Systems Modelling Approach

“…Model building will draw on foundational work undertaken over the past 5 years applying systems modelling to mental health service planning and suicide prevention (35,(50)(51)(52)(53). Based on this existing body of work, the current protocol (along with Additional File 1) provides a comprehensive and detailed operational roadmap for researchers and decision makers to leverage when developing systems models in other contexts.…”

Participatory Methods for Systems Modeling of Youth Mental Health: Implementation Protocol

“…This challenge has traditionally resulted in investment in a comprehensive and all-encompassing package of interventions in which individual programs are often not sufficiently scaled and resourced to deliver impacts [ 7 ]. More effective decision support methods are needed to ensure that investment is well-targeted, coordinated, and implemented at a sufficient scale to deliver real impacts [ 7 , 8 ].…”