Organisational Change in Mental Health Services - Part 2

• Local Implementation of National Policy
• Improving Consumer Participation
• Increasing Access to Services for People from Non-English Speaking Backgrounds
• Emergency Mental Health Demand Management
• Improving Services for People with Co-existing Mental Health and Drug and Alcohol Problems
• Emergency Mental Health Demand Management
• Summary
• Discussion
• Conclusion
• References

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Local Implementation of National Policy
South East Health (SEH) is one of the largest Area Health Services in Sydney, New South Wales, Australia. It provides services to a diverse population of more than 750,000 people. The SEH mental health programme is comprised of four integrated inpatient and community mental health teams in separate geographical locations. The first author (Tobin) was Director of SEH from 1993 to 2000.

This section of the paper discusses four examples of the use of formal change management theory to implement national mental health policy within SEH. They are consumer participation, access to services for people from non-English speaking backgrounds, emergency mental health demand management and provision of services to people with co-existing mental health and drug and alcohol problems.


Improving Consumer Participation
The value of consumer involvement and the need to actively increase consumer participation in health services has been recognised both internationally and nationally within Australia. In Australia, the importance of consumer participation has been acknowledged in the National Mental Health Strategy, particularly the Second National Mental Health Plan. Across Australia multiple local level initiatives and projects have been undertaken to promote greater consumer participation.

To increase consumer participation, SEH initiated a project to evaluate the then existing level, extent and quality of consumer participation and to examine whether there were demonstrable differences between different mental health services within SEH which had made different resource commitments to achieving participation. To do this, two mental health services in the SEH region that had different histories of consumer participation activities were compared.

The methodology of this project, which is described elsewhere^{[ 12 ]} , was itself heavily weighted towards improving consumer participation. Consumers developed the evaluation strategy, collected the data and collaborated with the analysis and dissemination of the results. The project, thus, used the action research methodology of using formal evaluation to drive changes in the services being evaluated.^{[ 13 ]}

The results revealed that across the board there was low familiarity with the concept of and involvement in consumer participation. There were no differences in the results for the service which had a three- to four-year history of assertive and resource intensive consumer participation initiatives and the service which had a one- to two-year history with more focused activities centred around participation training for consumers. There was a correlation between a consumer having a good relationship with an individual clinician and higher levels of individual participation. Barriers to involvement identified by consumers included lack of motivation, fear of stigma and lack of information. These findings identify the major challenges to be overcome when attempting to increase levels of consumer participation and the lack of correlation between investments in initiatives and achievements of desired outcomes.

These findings led the two services within SEH to re-evaluate their approaches to achieving high levels of consumer participation, and to conclude that merely investing in what seemed like relevant initiatives was insufficient achieve progress with national policy implementation. This is, therefore, an example of the value of regular "fine-tuning" of measurable outcomes against effort. This project demonstrated that to achieve significant uptake of consumer participation more than a belief in what should work is required. Commitment to the concept of consumer participation must be accompanied by someone being accountable for ensuring that effective strategies are used. Given the lack of evidence to support current strategies, all initiatives in this area must be evaluated against effectiveness criteria. Simply devoting energy and resources to consumer participation initiatives to achieve what can be interpreted as a "politically correct" approach to the issue is not a worthwhile exercise.


Increasing Access to Services for People from Non-English Speaking Backgrounds
Research has shown that people in Australia who speak a language other than English tend to underutilise mental health services generally but when they do, they are more likely to be experiencing acute stages of illness and have poor rates of treatment completion.^{[ 14-17 ]} Participation in community-based programmes and voluntary inpatient admissions are consistently lower for non-English speaking psychiatry patients.^{[ 18-19 ]} It is possible that such underutilisation reflects lack of knowledge of availability of services, inability to seek help or reluctance by non-English speaking persons to use services that are perceived to be culturally inappropriate.

Underutilisation of mental health services by people from non-English speaking backgrounds, as well as an attempt to improve cultural sensitivity, were tackled in SEH using a quality improvement methodology and through partnership between mental health and multicultural services.^{[ 20 ]}

Analysis of data from clinical files, self-report questionnaires completed by mental health staff, workshops attended by mental health and multi-cultural staff and feedback from clients and carers obtained through focus groups revealed three main areas for service change. These were policy and procedure modifications, a comprehensive staff development programme and a revision of the role and function of the bilingual counsellors.

Policy and procedure changes and a comprehensive staff development program were implemented by management. The revision of the role and function of bilingual counsellors was undertaken using Action Research.^{[ 13 ]} The counsellors participated via group meetings between themselves and other staff and through and workshops. Input from consumers, carers and mental health professionals was fed into the process and a gradual change in priorities and approaches became accepted.

The results of this exercise, a revised bilingual counsellor job description and the cultural and attitudinal changes achieved through the process, provides an example of the use of qualitative data to identify and address organisational issues.^{[ 21 ]}

By undergoing this change process, members of the bilingual counsellor group were able to provide leadership for change, rather than having it imposed upon them. This subsequently enabled the counsellors to represent themselves and their client group more adequately at senior levels within the parent organisation.


Improving Services for People with Co-existing Mental Health and Drug and Alcohol Problems
SEH’s Alcohol and Other Drugs (AOD) programme consists of five operational units providing methadone maintenance, needle and syringe exchange, outpatient detoxification, counselling and education. There are six inpatient beds available across the units for AOD service consumers requiring admission. The mental health and AOD services of SEH are independent from one another, receive separate funding and have varying administrative and programme mandates.

SEH’s Mental Health and AOD units jointly implemented a two-year organisational development project. The aim was to improve services for people with co-existing mental health and substance use disorders.^{[ 22 ]} This was achieved using quality improvement methods to engage both mental health and AOD clinicians in the design, implementation and evaluation of a model of care for people with co-existing problems that could be sustained within existing resources. The project was an example of local implementation of a national policy directive that mental health and AOD treatment services should demonstrate greater partnership with each other to achieve better health outcomes for consumers.

Discussions, consultation and review led to improved service agreements between mental health and AOD services, the collaborative development and implementation of policies and procedures for staff and the introduction of practice guidelines. Newly developed clinical pathway flow charts and screening and assessment tools were successfully introduced within both services and resulted in a shared approach to care. An agreed language of "co-existing problems" replaced the much-debated "primary responsibility" label. Joint training programmes were developed, allowing each service to learn from the other, rather than trying to solve problems by affixing blame. Additional resources involved in the project were used only for facilitation of change not for new service delivery. This resulted in the staff working smarter as a result of the changed processes they were able to use. This led to positive organisational changes being sustainable beyond the life of the project.

This project demonstrated that it is possible to implement, at a local level, the national policy guidelines about shared care for people with co-morbid AOD and mental health problems. However, the quality improvement approach used required a significant commitment of time and energy from the leaders of both the mental health service and of the AOD service. Whilst improved services for consumers and improved relationships between providers could be demonstrated, it required prioritisation by management for significant staff development time and repeated emphases within management committees of both services.

Consideration of the national applicability of such a project raises such questions as whether such commitment could be achieved at broader levels and how the opportunity costs of such resource intensive initiatives could be measured.

Emergency Mental Health Demand Management
Mainstreaming mental health services has seen Emergency Departments (EDs) of general hospitals become an important access point for people with mental health problems. While convenient and efficient from a structural point of view, hospitals, health services and State governments have increasingly recognised that persons presenting to EDs with mental health problems pose particular challenges and have specific needs that require attention.

The National Triage Scale (NTS) was developed in Australia in 1993 to standardise ED triaging on the basis of clinical urgency. ^{[ 23 ]} The five-point scale was developed for use with injury and illness and did not take into consideration acuity of mental illness. As a consequence, patients presenting to EDs with mental health issues are usually triaged on the basis of physical severity and are, therefore, generally placed in lower triage categories indicating less urgently in need of medical assistance and with anticipated longer waiting times.

The absence of ED guidelines for the triage of patients with mental health problems, inadequate staff skills and knowledge of how to deal with people with mental illnesses and the less than optimal co-ordination of care between a majority of emergency settings and specialist mental health services have resulted in inefficient and inappropriate service provision and care.

To address these issues, some hospitals in Australia have devised guidelines specifically for use in their EDs when people present with mental health problems.^{[ 24 ]} SEH was the first Area Health Service to design, implement and evaluate collaboratively between mental health and ED staff across five hospitals a comprehensive set of mental health triage guidelines and an accompanying training package for standardised use.^{[ 24 ]}

The introduction of these guidelines within SEH has brought identifiable improvements to the treatment of patients with mental health problems within EDs and to the relationship between mental health service and ED staff in these five hospitals. Involving all stakeholders in the steering committee, working collaboratively to develop the guidelines and the training manual, empowerment of key clinical drivers at each site and ensuring local ownership were the fundamental elements of the successful implementation.

Improved communication and integration between the mental health service and EDs was one of the significant outcomes of introducing the guidelines. Other benefits included increased staff awareness of mental health issues beyond just the members of the steering committee. For example, once the guidelines were in operation, discussions developed within services at each site regarding the guidelines’ effectiveness in the ED care of patients with mental health emergencies beyond the initial triage decision. The guidelines thus had a "ripple effect", in terms of improved collaboration across sites and between clinical leaders from different disciplines. This was influential in achieving consensus about prioritising mental health issues in EDs.

Thus SEH was able to demonstrate that the initial negative impact of National Mental Health policy on the mainstream health services can be used as a driver of reform in that sector to the ultimate benefit of consumers. However, increasing the capacity of the SEH EDs to manage complex issues had additional benefits, as this provided their staff with greater confidence in assessing and managing people with complex and challenging behaviours across a range of illness groups.

Summary
These examples illustrate that significant organisational change can occur provided appropriate change management strategies are utilised, but that such strategies are resource intensive and challenging to local leaders who must demonstrate appropriate skills at linking national priorities with local imperatives. One important aspect of such leadership is how national policy is interpreted at local levels.

It is essential that such investments are directed at the most focused local interpretations of the strategy, and constantly evaluated against the nationally agreed descriptions, which will ensure that whole services do not again fail the Australian public by taking a policy direction which is in fact not the one that appeared to be agreed.


Discussion
There are two underlying issues in any discussion of Australian mental health reform. The first of these relates to apparent flaws in the national strategy itself and the second concerns the paucity of literature relevant to bridging the gap between national policy and local implementation.

It can be argued that there is a potential flaw in the national mental health strategy, illustrated by the distortion of the serious mental illness priority. This flaw is that the national strategy is too broad and visionary, thus leaving it open to a variety of interpretations. From the organisational change literature it is clear that local ownership and buy-in by a diversity of stakeholders requires prophetic qualities to inspire local adaptation. Hence, the dilemma is to develop a national plan/policy that allows for local interpretation yet has sufficient inherent robustness to avoid gross misinterpretation. It is not clear whether the Second National Mental Health Plan does better that the First in this regard, but the confusion over promotion and prevention priorities would suggest it does not.

The solution to this dilemma can be found by examining the organisational change literature. The main element of effective change management is that it is not a linear process, it is holistic with structure and culture change occurring simultaneously.^{[ 25 ]} Setting of the vision occurs from the top and it is necessary to achieve participation of key middle managers and other stakeholders to establish ownership. All of these elements can be readily applied to the local implementation of national policy. However, the important element, which appeared to be missing with respect to the serious mental illness priority, was the continuous evaluation and communication that leads to shifts in direction in a continuous interactive way. The non-linear aspect of change means that projects often change direction as they progress and new issues may arise that were not initially considered. It is only by building innate flexible management of change that difficulties arising from these unexpected directions can be overcome.

The cited example of service improvement for people with co-morbid conditions reflected this process. Whilst the general directions were agreed, each local pair of AOD and mental health services needed to take its own first steps and achieve objectives appropriate to its context. This is illustrated by the fact that some services developed service agreements, others joint policies and others shared care. This reflected their different stages of maturation as organisations. However, the central objectives of improved services to the group remained clear, and each service learned from the initiatives undertaken by the other.

The second important lesson that was learned from the SEH projects was that change must be holistic in order to be sustainable. Change in mental health services (eg, mainstreaming of emergency mental health care) can only be successful if it is accompanied by congruent changes in general hospital EDs.

The SEH experience illustrates that national policy architects require the involvement of the significant State and Territory service providers. The SEH organisation was sufficiently large and robust to implement successful emergency mental health care involving middle and senior level managers as well as front line clinicians. Similar success, however, has not been achieved universally. South Australia, for example, has been reliant instead on patterns of emergency mental health care involving excessive use of security and restraint and is only now addressing the issue in a systemic way.^{[ 26 ]}

The lesson of continuous evaluation at the national level and communication of disquiet in a way that leads to a change in direction is still being learned in Australia. The Mid Term Review of the Second National Mental Health Plan pointed out that there are still significant problems associated with access to psychiatrist specialist assessment and advice and inadequate linkages between general practice and specialist mental health services.^{[ 10 ]} These views confirm the findings of the Australian Medical Workforce Advisory Committee (AMWAC) regarding the specialist psychiatrist workforce in Australia which have been known for some time.^{[ 8 ]} Unfortunately, they cannot be addressed solely at the national or local level. This is one of the reasons why full implementation of the Second National Mental Health Plan will remain elusive. The inability of either Commonwealth policy and funding levers or the local implementation of change in service models to address unmet needs in high prevalence disorders is widely recognised. However, this issue has not yet been clearly articulated in terms of public policy debate.

The Commonwealth funded fee-for-service medical practitioner system and the State funded and run public sector mental health services, are still so widely separated that neither side can be held responsible or accountable for the outcome.

Without continuous evaluation and public scrutiny this issue will remain an obstacle to full achievement of the goals of the Second National Mental Health Plan.


Conclusion
Australia’s national mental health strategy, as articulated in the First and Second National Mental Health Plans and companion documents, has engendered some significant improvements to mental health services for the population.

Unfortunately, there have been, and continue to be, obstacles in the way of complete implementation of what are widely accepted goals. These include:

1. Inconsistent interpretation of visionary policy leading to unanticipated negative outcomes;
2. Failure of some State and Territory run mental health services to invest in appropriate organisational change strategies, leading to incomplete or failed implementation; and
3. Failure to undertake the necessary continuous evaluation and critique which will shape important national problem solving.

As a result of these failures, Australia has not achieved as much success in implementing its national mental health strategy as was theoretically possible. Nonetheless, there are important lessons to be learned from evaluating the examples of successful implementation at local levels using organisational change theories such as action research and total quality improvement. The application of these theories to national policy implementation, whilst arguably necessary to improve access across the community for a whole range of conditions, has not been tried. Significant behavioural and attitudinal changes within large systems are necessary to successfully implement better integration between Commonwealth and State funded mental health services. Determining how such changes can be brought about will test the flexibility of the Australian health care system and the value of traditional organisational change theories.

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