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Mental Health: what did we find out in Estimates?

Estimates & Committees
Penny Wright 3 Mar 2015

Medicare Locals and the transition to Primary Health Networks 

Senator WRIGHT: I have some questions around Medicare locals as well, and also Partners in Recovery and how they interface. Please forgive me if I ask questions that have already been answered, because I am trying to run between two committees. If indeed this question has already been asked by Senator McLucas or someone else, you can just refer me to that, and I will look that up myself. What will be happening to the various Medicare local premises? Can you give us some information about that?

Mr Booth: The actual premises?

Senator WRIGHT: Yes.

Mr Booth: It will depend on the application process, because, as you know, some Medicare locals will apply to become PHNs and, if they are successful, then there are certain things that could happen to the premises there. So it really depends on what the different processes are that happen. I will ask to get a bit more specific advice on that and let you know, because it is in the deeds and the frequently asked questions. So I will just get a bit of clarification on that.

Senator WRIGHT: Thank you. You can come back to that, and I will keep moving through these. What about the transfer of patients' medical information?

Mr Booth: Medicare locals do not hold medical information on individual patients. That is part of general practice records, and they are owned by the general practice—that is my understanding—so the records of the patients stay with the general practice.


Mr Booth: No, we will take that one on notice. One thing that was just pointed out to me was that there are some patient records held if the Medicare local provides that service on some occasions. In that case, what we are going to be doing with that is dealing with it as part of the transition process to move from one organisation to another, and it will be dealt with within the contract to make sure that those patient records are transferred to whatever organisation is going to be running those services.


Senator WRIGHT: I might leave my colleague to follow up more about that and I will try to focus more on the mental health aspects of the transition. Again, you may have already been asked this, but how many staff are currently employed in Medicare locals across Australia?

Mr Booth: I would need to take that one on notice. I do not know if we have that information readily available. Medicare locals are private organisations—private entities. They vary quite widely in terms of size, but we will see what we can do.

Senator WRIGHT: Thank you, and could you also give a state-by-state breakdown and how many of those employees are health workers?

Mr Booth: Okay. So directly employed delivering health services?

Senator WRIGHT: Yes, that is right, and how many of the employees are likely to be made redundant, particularly in South Australia.

Mr Booth: We did have a bit of a discussion on that. We did not concentrate on South Australia, but we discussed redundancy provisions that were in there.

Senator WRIGHT: What about numbers?

Mr Booth: Basically, we had a bit of a discussion, and it really depends on what happens, because some of the Medicare locals will be bidding to become PHNs. Some of the Medicare locals are not going to do that but establish themselves as service providers. Some of the Medicare locals are going into consulting. There is a whole range of different things happening at the moment so it is quite difficult to say what is happening to South Australian Medicare locals, because—

Senator WRIGHT: Yes, because it is still happening at the moment.

Mr Booth: it really depends on where they go. So it is kind of a moving feast at the moment.

Senator WRIGHT: I imagine in the future, and when the dust has settled a bit, that we will be able to get a snapshot about what the consequences have been of the transition.

Mr Booth: You will be able to know who has formed the PHNs, and we will know whether any Medicare locals are part of those. So we will know that and we will also know if Medicare locals were not and if they are set up as independent service providers.

Senator WRIGHT: In that case we could probably do the maths and work out who is left over, in terms of redundancies.

Mr Booth: Yes. We could look at that.

Senator WRIGHT: Has there been any modelling done to predict how much redundancies will cost?

Mr Booth: This is a part of the reasonable cost determination, so basically each Medicare Local is going through a process, at the moment, of reasonable cost assessment. There is a deed of termination that has been issued to the Medicare Locals. We are working very closely with them, and they are basically in that process at the moment. Those reasonable cost estimates are not due for a while yet because it depends on everything we have just been talking about in terms of what happens to them.

Senator WRIGHT: So, again, at some point in the future we will be able to know.

Mr Booth: At some point in the future we will know where we are—but it is moving at the moment.

Senator WRIGHT: If I could come to the Partners in Recovery contracts, there has been a lack of clarity around the future of Partners in Recovery where the lead agency is a Medicare Local. Can you confirm the number of Medicare Locals in Australia which are the lead agency for Partners in Recovery, please? And, while you are at it, if you could provide a state-by-state breakdown, that would be helpful, thanks.

Mr Booth: Thirty-five Medicare Locals are lead agencies out of the 48 PIR sites. And I have just been told that apparently the state-by-state figures are on our website, so we will be able to pull those off for you.

What does the transition mean for Partners in Recovery? 

Senator WRIGHT: How many Medicare Locals have sought clarity from the department about future arrangements for the Partners in Recovery program?

Mr Booth: I would need to take that on notice, I think, because, clearly, we have been in discussions with Medicare Locals for the past nine months about a whole host of different areas in terms of what is happening with transition: what the processes are, what is going to happen—all those kinds of things. So we would need to kind of disentangle that a bit. I would suspect that that has been part of the general discussion that has been happening, as opposed to a specific query, but we can take a look at it.

Senator WRIGHT: If you could do that please, and if you could look for where there are indications that there have been specific concerns and queries raised about the future of the Partners in Recovery program, that would be helpful.

Mr Booth: I do not think that there are. Of course, Partners in Recovery is a consortia; it is a group together, and one of those partners is nominated as lead agency. In the majority of cases, as you know, that is Medicare Locals, but it is a consortia and they all work together. So we would expect that that could quite easily be accommodated.

Senator WRIGHT: During the last estimates hearing, I was asking about the future of the Partners in Recovery contracts and transition arrangements. Has there been any more progress in relation to those arrangements for the program?

Mr Booth: It is pretty similar to where we were last time, in that we are establishing the PHNs at the moment. They will, as I said before, run in shadow form for the last three months of this year. As soon as we know who the successful applicants are for the PHNs, then we can start to discuss with them in terms of lead agency responsibility for the PIR, but we need to get that process in place first before we can actually do the PIR section of it.

Senator WRIGHT: Can you provide a list of mental health services that are currently provided through Medicare Locals?

Mr Booth: The key ones will be the lead agencies for Partners in Recovery, the ATAPS services that go through Medicare Locals, and the Mental Health Services in Rural and Remote Areas, the MHSRRA program. Those of the big ones that I can think of. There will inevitably be some smaller services that may be Medicare Locals specific that I would not necessarily have access to. There are some running through the Mental Health Nurse Incentive Program as well, the MHNIP, but the big ones are ATAPS and MHSRRA.

Senator WRIGHT: When you say you would not necessarily have access to the smaller ones—

Mr Booth: We would know what they are, but I do not have information here at the moment.

Senator WRIGHT: That is what I wanted to clarify. I thought that is probably what you meant.

Mr Booth: If a Medicare Local has identified a particular need in a particular area and is running some kind of service—

Senator WRIGHT: Then the department would know.

Mr Booth: We would know about it, but—

Senator WRIGHT: Can I ask you to take that on notice, please? We want to understand the variety, the range and, I suppose, the prevalence of mental health services that are currently being provided by Medicare Locals. One of the reasons for that is that it has been raised with me on numerous occasions that, particularly in rural areas, there is a real concern about services not being able to be continued because of the state of uncertainty and the transition that has been ongoing for quite some time now. Medical Locals stopped accepting new referrals at the end of last year because they have not been able to allocate new clients to mental health practitioners because those contracts will cease to exist on 30 June and they will not be able to pay invoices. There are concerns about that uncertainty, which means they are having to turn people away, or people who have been receiving services are no longer able to receive them. Obviously there is going to be ongoing uncertainty. Are you aware of instances like these?

Mr Cormack: Earlier in evidence we talked about the current invitation to apply process and the transition process. Evidence has been given that we anticipate, in March, the announcement of the successful bidders for this process. A key element of getting up and running will be a transition process that would effectively begin from the time contracts are agreed. That will necessarily pick up many of these detailed transition issues, to the extent to which they exist in all PHNs, and in some they will not because there is a likelihood that an existing Medicare Local may possibly be a successful bidder. We are happy to take on notice the specifics of the question. We recognise that there is concern about the transition, but the implementation, that program that Mr Booth is looking after, provides a reasonable transition period of over three months to be able to manage many of those issues.

Senator WRIGHT: When you say 'a transition period' are you saying from June for the next—

Mr Cormack: No, from March.

Senator WRIGHT: From March?

Mr Cormack: We have contracts in place with Medicare Locals. As you quite correctly point out, they have arrangements in place with third-party providers in certain cases.

Senator WRIGHT: Some of them have come to an end. That is the problem.

Mr Cormack: Yes, and many of those will be finishing up in June. We will be using the period from the contracting of the new PHN providers, which we anticipate will be from March, through to June to transition all of those arrangements.

Senator WRIGHT: The problem is that on the issue that I was adverting to earlier—and concrete examples have been given to me—whereby contracts have been ceased as at the end of last year because there was a concern that those contracts would be entered into and would not be able to be honoured, we have actually had people who have had services finished and the contract has not continued from the end of last year. So we are talking about at least six months. In fact, the anecdotal evidence I have heard is that, again, particularly in country areas, there are providers who are now moving back to the city because they do not have any certainty of future contracts.

We know there is a real difficulty with workforce in the mental health sector in country areas and good people are being lost because there is such uncertainty. This transition has not been able to be done seamlessly so that those contracts have been able to continue. Have those concerns been raised with you by people in the community, practitioners or Medicare Locals?

Mr Booth: There are a couple of aspects there. One is in terms of your specific question around Medicare Locals not accepting new ATAPS referrals. Yes, we are aware of that. There were three specific Medicare Locals where we were aware of that happening. We have been in contact with those Medicare Locals and those Medicare Locals are accepting referrals through to the end of the year. So in those three areas we have spoken to them and we are aware of them.

In terms of the more general issue, as Mr Cormack has said, we are acutely aware of the need to provide certainty in terms of people's contracts and work and those kinds of things. We are just working through it as quickly as we can to try and get that transition period in place so that we can get that certainty.

Mr Bowles: It is important to point out that if the Medicare Local is funded to provide a service to 30 June 2015, they need to be providing that service. That was the issue I think Mr Booth was referring to about the ATAPS, and these three. You cannot stop something if you are funded to do it, or we will find someone else to do it. So, if something was finished at the end of June 2014, which means it is a lapsed program and it does not exist anymore, that is a completely separate issue that we would be dealing with. But Medicare Locals are funded to the end of June 2015, at which point the transition period from the end of March through to 30 June will pick up a whole lot of those transitional issues and move the funding to the PHN to continue to provide whatever level of service we are talking about going forward. And that is all to be determined through the transition period.

Senator WRIGHT: Is that a guarantee that programs that had been previously offered and provided by Medicare Locals will be continued with those contractors?

Mr Bowles: No, Senator. You cannot put words in my mouth around that.

Senator WRIGHT: I am not; I am trying to clarify—

Mr Bowles: What I am saying is that they are funded to 30 June 2015. Whatever goes forward through that transition period will be passed through to the PHN. Whether it is the exact same range of services that are there today or they are different is a matter for the next couple of months to work that through. Services do change because demographics change and all sorts of issues change in some of these areas. We will manage that through the transition period, but services in the broad will continue past 30 June. I do not want to be specific about any program because I do not have the visibility of that until we go through the transition period.

Senator WRIGHT: How many people across Australia were receiving treatment through the Partners in Recovery program?

Mr Booth: As at 12 December 2014, there were 12,234 clients in PIR services.

Senator WRIGHT: Can you provide a state-by-state breakdown of those figures?

Mr Booth: Yes. We will take that on notice.

Senator WRIGHT: Thank you. I have no further questions at this stage.


Senator WRIGHT: Finally, I have a tidy-up question about Partners in Recovery. Could I come back to the department about that. We were discussing issues arising from where Medicare Locals have been the lead agency in relation to Partners in Recovery and what would happen when Primary Health Networks replaced them. I am just trying to clarify and understand something. I understand that Partners in Recovery is a service. Is that right?

Mr Booth: Partners in Recovery is a coordination service that aims to ensure that those individuals who have severe mental health problems and have difficulty accessing services are able to access the services they need. The program, I guess, recognises that such people need services from a variety of different areas; hence, the lead agency and partnership approach of it. Some of those partners in there will provide services, but it is around coordinating the services for that individual who needs a variety of different inputs.

Senator WRIGHT: I do not want to get into semantics—I am genuinely trying to understand how it will work—but it is a service that coordinates services?

Mr Booth: It coordinates, but in some areas some of the people who are involved in there will be providing services as well, because it is a grouping.

Senator WRIGHT: I understand that Primary Health Networks, rather than actually delivering services, are designed to coordinate services. Correct me if I am wrong, but that was my understanding.

Mr Booth: Designed to commission services. So, it is the purchases of services.

Senator WRIGHT: How would Partners in Recovery, as a service, work within the mandate of a Primary Health Network?

Mr Booth: The move to a commissioning and purchasing means that PHNs do not actually employ service providers. I think the example given earlier today is around allied health professionals who are currently employed by Medicare Locals. They would be market testing external agencies to actually provide that service. If there is a situation at the moment where a Medicare Local is a lead agency within a PRI organisation and is employing professional staff to work in that area then there would need to be some kind of move to contract that out, essentially. It would depend upon the role that the individual Medicare Local is taking within that area and the kinds of involvement that they have. It is something that we will have to look at on a case-by-case basis, I suspect.

Senator WRIGHT: So that would be a case, I imagine, of understanding where the Medicare Local is the lead agency in the Partners in Recovery, whereby they are employing—

Mr Booth: That is right. That is the general principle. If the Medicare Local is employing professional staff, clinical staff and allied health staff then the intent is to move to a purchasing arrangement rather than providing, so that the PHN concentrates on the commissioning approach, looking at the needs of the population, as we have discussed. The PHN would be concentrating on that area rather than on directly employing staff.

Senator WRIGHT: That is where someone else would need to be found to have their services commissioned, who would then coordinate the—

Mr Booth: Potentially, but as I think we said earlier, for the Partners in Recovery program, typically the arrangements are that there are, as you know, a number of different bodies within there. So there is flexibility within arrangements, already.

Senator WRIGHT: The review of Partners in Recovery is currently underway. You may have answered this before, but I have been in and out a bit. Can you update us as to where that is up to and when we are likely to have a result of that review.

Mr Booth: The work, as you said, is going on. We have an evaluation framework released on 13 December 2013 and projects due to be completed 30 June 2016.

Senator WRIGHT: Is there a possibility that the Partners in Recovery program will not continue into the future?

Mr Booth: That would be a decision of government.

Senator WRIGHT: So there is a possibility.

Mr Booth: As I said, that would be a decision of government.

Senator WRIGHT: It is up to government if it does or does not.

Mr Bowles: It is a decision of government. We do not make calls on those things.

Primary Health Networks and Mental Health - has there been any modelling? 

Senator WRIGHT: I have a couple of questions that go back to the interface between the primary health networks and mental health, and then I will go to questions about the commission. Has the department done any modelling to indicate the impact of the new primary health networks on access to mental health care?

Mr Cormack: No.

Senator WRIGHT: Thank you. Are you expecting the primary health networks to deliver higher rates of access to mental health care than the Medicare locals?

Mr Cormack: The intent of the primary health networks is to establish a more informed planning approach across the primary, mental health and hospital sectors. The expectation—indeed, the requirement—for each of the PHNs is to produce a comprehensive health needs analysis in the first 12 months. It is certainly the department's expectation that mental health would be one of the key areas within the needs analysis and the plan they would be working towards. So that is certainly what we are anticipating out of the new arrangements.

Senator WRIGHT: The answer you have just given is that you assume mental health needs analysis will be part of that planning process.

Mr Cormack: Yes.

Senator WRIGHT: That does not actually answer my question as to whether there is an expectation that primary health networks will better meet and provide better access to mental health services for people. Do you have a view about that?

Mr Cormack: There is an expectation that the primary health networks should be an integrating mechanism within a defined geographical space across primary health care, mental health and the acute care sector. They would have a well-informed understanding of needs and have a governance framework in place that brought to bear the expert input of clinicians and the informed input of the community and consumers. It would be our expectation that, on the basis of a comprehensive planning process that leads to targeted commissioning of services, you would see and want there to be an overall improvement in the service offering across the area concerned, including mental health.

Senator WRIGHT: How will we know that is actually the case?

Mr Cormack: Part of the primary health networks is a performance framework. That performance framework will cover off a manageable number of indicators: population health, service access and other indicators in relation to the governance of the primary health network itself. So we would expect and in fact will require all of the PHNs to adopt a similar performance framework that will give us a good indication of how they are performing in areas of priority.

Senator WRIGHT: Has there been a previous performance framework applied to, for instance, Medicare locals so that there is some benchmark against which to measure whether or not there is actually an improvement? How will we know there is an improvement?

Mr Booth: There was not a formal performance framework put against Medicare locals. Medicare locals had five strategic objectives that they needed to achieve and they had to address those in their annual reports. The National Health Performance Authority has produced some reports which show performance in tables, but on the whole it has not been on an ongoing basis. The intent here, as Mr Cormack says, is to actually put a performance framework in place which does exactly what you just asked—which looks at a time series to see what is happening all the time.

Senator WRIGHT: But there will not be, then, any way to measure an improvement as opposed to whether or not needs are being met under the new arrangement?

Mr Cormack: No, there will be a basis for measuring performance. That is the aim of the performance framework.

Senator WRIGHT: But improvement from the status quo now.

Mr Cormack: Yes, it would. The department has contracted the Australian Institute of Health and Welfare to provide comprehensive advice to us on a manageable set of indicators. One of the key characteristics of those indicators is that they are collectable; you can measure them. So we would anticipate that that will establish a base line, and then over the life of the primary health networks, as they focus on the priority needs of the community, we would expect there to be monitoring of performance. One would certainly hope for and expect improvements in key areas of population health and access within that network.

National Mental Health Commission Review 

Senator WRIGHT: Thank you. Mr Butt, I am interested in the review, as many area. Since providing the review report to government, has the commission received any further guidance or direction from the government?

Mr Butt: No we have not. As you say, it is a report to government, so the report has been provided to government and is now a matter for government.

Senator WRIGHT: Thank you. Were any draft versions of the report provided to the Department of Health or the minister's office through the process of writing the report?

Mr Butt: There were the preliminary report, the interim report and further discussions getting feedback from the department on particular aspects in relation to the review report.

Senator WRIGHT: That was after the interim report, which has not been published yet, of course. So there were further discussions.

Mr Butt: There were further discussions, yes.

Senator WRIGHT: What level of input, then, would you say the government had into the final version of the report?

Mr Butt: Basically, the departments provided us with information. That was what we were after from feedback on various things. The departments across government have been very cooperative in relation to providing us with the information we needed on certain things we were considering. But from government itself we did not other than what I mentioned earlier in relation to ensuring that we did deal with all the terms of reference which we have, which you would expect.

Senator WRIGHT: Yes. I do not want to put words in your mouth. I am trying to understand the process. Was it more of a one-way process in that you sought information and information was provided to you, or was there a process whereby government, the department or the minister's office came back with advice about aspects of the report?

Mr Butt: The department came back with advice on aspects of the report where we were seeking feedback on particular issues which we did not necessarily fully understand and where we wanted to make sure what we were doing was accurately reflecting the situation. Not from government, as I said.

Senator WRIGHT: By government you mean the executive or minister's office?

Mr Butt: Yes.

Senator WRIGHT: How many meetings were held with the government and the department in relation to the report?

Mr Butt: I would have to take that on notice.

Senator WRIGHT: I would like to come to Senator Nash and ask a few questions about the review and the consequences of not yet having the review published and then responded to by government. It has been almost a year now, and funding uncertainty is wreaking real difficulties across the sector. There was a survey by Mental Health Australia late last year showing that 40 per cent of organisations surveyed who are in receipt of Commonwealth funding had already experienced loss of staff due to lack of clarity around funding arrangements. I am going to ask both the department and the minister assisting: are you aware of the survey to which I am referring? Can we start with Senator Nash, please.

Senator Nash: I am not aware of that particular survey.

Senator WRIGHT: I guess you cannot answer on behalf of the health minister, but could you take it on notice to ascertain whether the health minister is aware of that survey.

Senator Nash: Certainly.

Senator WRIGHT: And the department: are you aware of that survey from Mental Health Australia?

Mr Booth: Mental Health Australia do a few surveys. I am not sure of the specific one that you are referring to. I would need to—

Senator WRIGHT: It was late last year. There was quite a bit of media around it. Certainly there was a media release, and there was some media reporting that 40 per cent of the organisations surveyed said they had already experienced a loss of staff. Are the department and the minister aware of this issue around staff retention?

Senator Nash: As I said, I am not aware of that particular report—

Senator WRIGHT: Not just that report. The issues—

Senator Nash: No, hang on.

Senator WRIGHT: I am sorry. I beg your pardon.

Senator Nash: I understand. There have been some views expressed around this, but the government has been very clear in saying that in terms of the report, which you specifically raised at the beginning of your commentary, we are considering that and we are working through the funding processes as quickly as possible.

Senator WRIGHT: Is the department aware of those issues being raised by organisations in terms of trying to retain staff at a time when there is great uncertainty and low morale?

Mr Bowles: Yes.

Senator WRIGHT: You are aware of that? How has the department become aware of those issues?

Mr Bowles: Stakeholders talk to us all the time

Senator WRIGHT: Can I ask what steps, if any, are being taken to ensure that mental health organisations do not continue to lose staff during this time of ongoing uncertainty and that they can maintain vital services for clients.

Mr Bowles: As the minister said, it is a decision of government and government are looking at this issue right now.

Senator WRIGHT: Will the government be consulting with the peak mental health bodies in relation to the recommendations of the National Mental Health Commission review and on how the recommendations may be implemented? Is there a plan to consult?

Mr Bowles: The advice was provided to the minister, as in Minister Ley, and it will be her decision about how she wants to take that forward.

Senator WRIGHT: I am now asking Senator Nash whether or not there is an intention to consult in relation to the review report and the implementation of any recommendations in that report.

Senator Nash: It is with Minister Ley and it will be up to her to determine that process.

Senator WRIGHT: So that is not established at this point?

Senator Nash: Do not put words in my mouth. I said it is with her under the process.

Senator WRIGHT: I am just trying to work out what that means practically.

Senator Nash: I am not aware.

Senator WRIGHT: You are not aware of what, sorry?

Senator Nash: I am not aware, in response to what you just said about what Minister Ley was going to do in relation to that particular process

Senator WRIGHT: So you do not know whether there is going to be consultation or not at this stage?

Senator Nash: That is what I said. It is with the minister and it is up to her to determine what the process will be.

Senator WRIGHT: It is difficult, because we do not have the minister here, and everyone appreciates that.

Senator Nash: That is right, but I am very happy to take things on notice.

Senator WRIGHT: That is what I am going to ask you to do.

Senator Nash: It is more difficult when it is not my portfolio area.

Senator WRIGHT: No, I appreciate that, and that is why I am trying to be really clear. Could you take on notice to ask the minister whether she is intending to consult with peak mental health organisations about the National Mental Health Commission review report and/or the implementation of the recommendations in the report.

Senator Nash: Certainly, I can do that.

Senator WRIGHT: Thank you. Since the report was handed to the government, have there been any meetings between the government and peak mental health bodies?

Senator Nash: Again, I am not aware. I would have to take that on notice for you.

Senator WRIGHT: Does the department know? Can the department give me any information about that?

Mr Bowles: I cannot respond on behalf of the minister, but we have not had any meetings from a departmental perspective.

Senator WRIGHT: No departmental meetings. Mr Butt, I want to know a little bit more about how the Mental Health Commission arrangement is working, now that it is part of the Department of Health. Can you tell—

Mr Bowles: Excuse me, Senator. It is a portfolio agency within the health portfolio. It is not part of the department as such—just to make that clear.

Senator WRIGHT: Thank you. I apologise for the sloppy language. I did not mean to mislead in that way. What are the key differences that have come about that you have noted as a result of the change to becoming an agency associated with the Department of Health?

Mr Butt: In effect there is no difference, because a lot of our backroom services were performed by Prime Minister and Cabinet; they are now performed by Health. That is basically the change. We have obviously had a transition period where we had changes in IT systems and so forth. We went from one system to another and then back again; otherwise, there is no difference. We still remain an independent agency.

Senator WRIGHT: Has there been any difference in operations, budgets or responsibilities? I am just teasing that out a bit more.

Mr Butt: No. No different, other than, as I say, we have a contractual arrangement now with the Department of Health instead of with Prime Minister and Cabinet.

Senator WRIGHT: Is there likely to be some kind of evaluation of the change?

Mr Butt: It is a decision of government in terms of machinery-of-government arrangements, so I would not expect so.

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