Organisational Change in Mental Health Services - Part 1

• Abstract
• Introduction
• Overview of Progress and Problems in Implementation
• National Policy Translated to Local Practice in Relation to "Serious Mental Illness"
• Promotion, Prevention and Early Intervention
• Mental Health and General Practice
• Organisational Change Theory and Practice

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Abstract
National Mental Health Policy in Australia is well understood and widely disseminated. Both the first and second National Mental Health Plans are explicit in what is required of the specialist Mental Health service sector. The expectations include demonstrated progress towards mainstreaming, fully integrated hospital and community-based services, well-developed partnerships with consumers and carers, with general practice and the primary care sector and with the non-government organisation (NGO) sector, a commitment to mental health promotion and prevention as well as intervention and treatment services and improvements in quality and effectiveness.

Organisational change management theory and practice describes how service unit level changes can be brought about, it describes visioning, engagement, resource investment, systematic implementation and monitoring and feedback.

The challenge is utilising change management strategies to implement local service unit level interpretations of national strategy. The levers, resources, barriers and culture carriers do not automatically line up and the leadership of service unit level change requires expertise in interpreting and linking between the two.

From past experiences of institutional change management, through to regional service developments and current role at the state level as policy driver for a major reform agenda, the author describes examples of linking national policy with local organisational change.



Introduction
The Australian National Mental Health Strategy is widely disseminated and its broad principles are understood throughout Australia. The First and the Second National Mental Health Plans articulate what is expected from both the specialist mental health service sector and other providers. These expectations include demonstrated progress towards mainstreaming (ie, the provision of mental health services within general hospital systems), fully integrated hospital and community based mental health services, well developed partnerships between providers from different sectors (health, non-government and housing) and between consumers and providers, improved quality and effectiveness of mental health services and commitment to the promotion of good mental health and the prevention of mental illness.

There are approximately 10 companion documents to the National Plans that delineate specific aspects of the national strategy. These documents also reflect the national consensus on the direction of mental health policy and are supported by the two major political parties in Australia and by real growth funding increases at State and Commonwealth levels.

The implementation of the National Mental Health Strategy provides a case study in the application of organisational change management theories to a broad policy platform and aspects of this application will be discussed in this paper.


Overview of Progress and Problems in Implementation
The annual National Mental Health Reports in Australia report progress towards the expectations and objectives of the National Mental Health Plans. This progress has been systematically analysed through national benchmarking of expenditure and activity levels.

There has been progress in the reduction of stand-alone institutional beds, which has been accompanied by an increase in the number of acute care beds for mental health clients in the mainstream health system and in community based mental health services. Significant growth has been reported in the non-governmental organisation sector, which provides a range of psychiatric disability support services. Consumer participation in all aspects of mental health policy and service development has increased and the impact of advocacy groups, such as the Mental Health Council of Australia, is widespread. These achievements demonstrate that there has been significant reform of the Australian mental health system in the past ten years.

Whilst such reform is significant, concern about the adequacy of mental health services is still widely expressed by the community and health professionals. Such inadequacy is illustrated by the level of unmet need within the population estimated at 60%.^{[ 1 ]} Furthermore, families and carers of the mentally ill are disenchanted with many aspects of services, staff recruitment and retention is difficult and the varying levels of access, safety and quality across Australia are unacceptable. Differences in mental health service utilisation are compounded by the disparate availability of State funded services, the Commonwealth’s "fee for service" funded sector and the private health insurance funded private hospital inpatient sector.

It can be argued that the overall inadequacy of resources has limited progress towards achieving the objectives of the National Strategy. The mental health sector receives approximately 6.5% of the national total gross recurrent expenditure on health services.^{[ 2 ]} This level of expenditure seems inadequate given that prevalence is 18%,^{[ 1 ]} mental health disorders comprise four of the top 10 contributors to socio-economic disease burden in Australia,^{[ 3 ]} and there are predictions that depression will be the number one contributor by 2020.^{[ 4 ]}

It is simplistic to attribute all failures of the strategy to inadequate resources. Other major issues relate to the capacity of the mainstream health and welfare systems to provide mental health care, given several decades of policy that supported marginalisation and neglect. Developing partnerships between mental health and welfare and mainstream health systems is in itself problematic because "partnership" has different meanings for different stakeholders.

In addition to the slow development of capacity within mainstream health services, a significant contribution to the limited success of the strategy has come from the ineffective and diverse interpretation of national policy at local levels despite broad acceptance of its principles. The pace and style of change implementation within different services in the mental health sector throughout various regions of Australia have also impeded the progress of reform. This paper discusses several examples of these issues.

National Policy Translated to Local Practice in Relation Mental Illnesses
National policy may be accepted in broad terms across most Australian health and welfare services, but unless it is translated adequately into the local context it will not be implemented successfully. Inadequate translation resulted in distortion of the national priority regarding services for people with "serious mental illnesses".^{[ 5 ]}

This priority was enthusiastically adopted as a means of rationing limited community based resources so they would be directed towards people most in need. Community mental health services across Australia started to change criteria in order to restrict the numbers qualifying for services, initially to people with a "diagnosable mental illness" with subsequent further narrowing to those with a "psychotic illness".

The severe and unexpected consequences of this flawed local interpretation were that early intervention was refused up until people actually exhibited overt signs of psychosis. Treatment for a wide range of high prevalence and serious illnesses, such as depression and anxiety, became unavailable outside the private sector. People with serious behavioural problems associated with personality disorder were often refused even an assessment. This was accompanied by a loss of some of the essential psychological skills necessary to manage mental illnesses through lack of utilisation, an exodus of staff from the public mental health sector, because of the narrow range of illnesses being seen, and growing public dissatisfaction. One of the most unfortunate consequences of this flawed local interpretation and its results were that the results were attributed to the National strategy itself, thus encouraging, for example, widespread criticism of de-institutionalisation.

Whilst this incorrect interpretation of the First National Mental Health Plan has since been reversed by clarification of public policy, negative effects are still obvious. This situation demonstrates the need to utilise formal organisational change theory and practice at local mental health service provider level to ensure ongoing collaboration of "fine tuning" implementation strategies and a reduced risk of further incorrect interpretation and implementation of the policy.


Promotion, Prevention and Early Intervention
A second example of a possibly flawed local interpretation occurs within the mental health promotion and prevention priority of the Second National Mental Health Plan.^{[ 6 ]} In some jurisdictions this promotion and prevention has been given precedence over mainstream specialist service provision, with school-based education and screening interventions occurring at the expense of new investments in emergency mental health services.

In other places mental health promotion is now being prioritised within the range of mainstream health promotion activities. Campaigns to improve literacy and increase awareness, and hence help-seeking behaviour and decreased discrimination, receive as much investment as campaigns promoting healthy exercise and diet. The different implications of these two local implementation strategies are profound in terms of their impact on resources available to meet urgent needs.


Mental Health and General Practice
A third example relates to engagement of General Practitioners (GPs) in better mental health service provision. The Centre for GP Integration Studies undertook a national audit of the numerous divergent approaches to this issue.^{[ 7 ]} In broad terms, initiatives taken to achieve this goal of engaging GPs have included GP training in mental health, many different shared psychiatric care models, the production and dissemination of guidelines for GPs and GP screening and early detection tools.

One of the authors of this paper (Tobin) has been involved in three different initiatives across two of these approaches – GP training and shared psychiatric care models.^{[ 8 ]} The initiatives with which the first author was involved achieved modest gains only and were not influential outside the immediate proximity of where they occurred outside these services.

Despite similar encouraging achievements at a local level across Australia, progress in improving primary care mental health services has not been uniform. In many places anecdotal accounts suggest that relationships between GPs and specialist mental health services have not greatly improved. Similar criticisms are articulated within the Australian Medical Workforce Committee report into the Psychiatric Workforce^{[ 8 ]} and the external mid-term review of the success of the Second National Mental Health Plan.^{[ 9 ]}

It can be argued that, in order to bring about more rapid and effective change in the relationship between the primary care and the specialist mental health services, systemic funding levers such as changes to the national health insurance scheme and the Medicare Benefits Schedule (MBS) would be more likely to succeed than attempting to change cultures and attitudes.

In summary, the examples cited demonstrate the negative impact for the implementation of the national policy of the flawed and/or too widely diverse interpretations at the local service level. This leads to the conclusion that there must be greater emphasis on developing skills in the leadership and management of change at the local mental health service providers level. The responsibility for this upskilling should be accepted by service providers and regional, State and national purchaser and policy levels. 

Organisational Change Theory and Practice
The organisational change literature notes that tension frequently exists between "top down" change, initiated from the leadership of a service (in this case from national policy drivers), and "bottom up" change involving staff, consumers and the community (in this case from service providers, usually State funded). This tension, if not well managed, can result in significant resistance to change.^{[ 10 ]} In the Australian situation, this may mean that staff may attempt to subvert national or State directions by refusing to be involved in processes leading to changes in local practice. Local managers may collude with these staff attitudes; in an attempt to develop consensus within their own services, they may achieve local goals at the expense of the implementation of national policy. To counteract this risk, and achieve consistent implementation of national strategy, there must be greater collaboration between the policy drivers at the national level and leaders and managers of services at the local level. This collaboration will test Commonwealth/State relations, requiring as it does alignment of the national and State funding drivers and flexibility in interpretation timing and style of change. At the same time there a need for sufficient national consistency to ensure that what is being implemented is in fact national policy and not some widely different hybrid.

Organisational change management theory describes how service level changes can be brought about. Most theories describe visioning, engagement, resource investment, systematic implementation and monitoring and feedback as steps for achieving change.

The change process must be inclusive of all employees, consumers and the community generally, and it must be manageable in terms of the time commitments required by management. Leaders of organisational change must also acknowledge that such change often poses a threat to staff at the "grass roots level"^{[ 11 ]} and realise that consequent resistance by staff has the potential to obstruct progress, preventing beneficial changes from taking place. Change leadership is required to avert tension and opposition that may be aimed towards furthering of personal agendas.

The challenge is to use these change management strategies to implement local service level changes in line with the national strategy. The relevance of national strategies is an important factor in their local adoption and interpretation. National policy needs to be sufficiently flexible to ensure its applicability to local services and to encourage "buy in" at local levels. However, if national strategies are too broadly defined and flexible, the result of implementation may be the attainment of goals that are not part of the national plan. Hence, there is an underlying tension between providing sufficient shape and direction at the same time as a reasonable level of flexibility. The greatest challenge in relation to this tension is the separation between national and service level leadership. Organisation change must be applied at a local level by leaders who were not necessarily involved in formulating the initial vision.

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