Keywords

Developing Highly Specialist Services for Small Target Populations

In NSW, Local Health Districts (LHDs) and Specialty Networks (SNs) have responsibility for planning of health services to meet local or defined population needs in consultation and jointly with the Ministry of Health and involving their local community (Health Services Act 1997 No 154). The Ministry of Health sets policy and strategic directions for the overall state health system and coordinates the planning and purchasing of system-wide services, including services across LHDs. In particular, the Ministry has a strong role in planning for highly specialised and low volume services that require a very specialised workforce for effective delivery. The Walker Unit is an example of a service that requires planning at the level of the population of the State because of the highly specialised nature of extended inpatient clinical mental health rehabilitation for adolescents and projected low volume.

The Ministry of Health planning process requires evidence of need and demand in a population for new services and evidence of effectiveness of interventions. An important development in Australia that leads this approach to mental health planning is the National Mental Health Services Planning Framework which was a commitment by the Australian Commonwealth Government under the Fourth National Mental Health Plan 2009–2014. This planning tool provides an ‘internationally unprecedented, evidence-based framework providing national average benchmarks for optimal service delivery across the full spectrum of mental health services in Australia’ (The University of Queensland, 2019). The Technical Appendices detail the complexity of development of the model in the face of available evidence and matching service elements to populations (The University of Queensland, 2016). Relevant insights are provided in the comments: ‘The most critical data for estimating the impact of interventions are rarely available at all, let alone in a form useable for modelling’ (page 16) and ‘levels of demand may … be invisible until a new service becomes available’ (page 15). Hence, expert working groups were essential to establishing various elements of the model. This is demonstrated in a statement found in the section dealing with acute inpatient bed requirements for the 0–17 year old age group in the Service Element and Activity Descriptions (The University of Queensland, 2016). The section notes that ‘Experts advised that beds may be arranged to provide collocated specialist sub-acute services for small numbers of adolescents who may require extended stays’ (page 62; my emphasis). To plan specialist clinical rehabilitation inpatient services with extended stays for adolescents, one must look to the contemporary knowledge of specialists in the field.

The period 1996 onwards saw the expansion of acute child and adolescent mental health beds in NSW to the point of nine acute inpatient units networked across the state meeting the then population planning estimates to 2021. The planning for the Walker Unit was based on observations of small numbers of adolescents with severe complex and persistent mental illness for whom ‘everything else’ had been tried and who were ‘stuck’ in adult or adolescent acute beds. The general view was the care needs of this group overwhelmed the resources of specialist tertiary units, the stepdown from tertiary acute inpatient care to community care was too steep and the extended care needs of the group were ill-met in acute inpatient settings. Further, extended stays in child and adolescent acute mental health inpatient units were contributing to access block for acutely unwell adolescents and extended stays in adult inpatient units were developmentally inappropriate. The Walker Unit was planned as a supra-LHD service provided on behalf of the State to the population of NSW and the Australian Capital Territory at a time when no prototype for such highly specialised care existed in Australia.

Impact of the Walker Unit on Policy Development

The Walker Unit is an example of how innovation in health is more often driven by service design than the traditional public policy model of policy cycles. Innovation is demonstrated in the way in which a customised solution was developed by experts for a significant problem impacting young people and their families and their illness trajectories leading to the proposal for a novel inclusion in the spectrum of child and adolescent mental health resources in NSW that would add value to the care provided for consumers and their families and the broader child and adolescent mental health service system.

At the time of the development of the Unit, the proposal that there would be value to the system was untested. It was a new idea that challenged assumptions that intensive community-based and acute inpatient care is ‘enough’ to meet the needs of this particular group of young people and the proposal involved considerable financial risk taking both in terms of capital and recurrent funding.

The Unit provides a specific and highly specialised inpatient rehabilitation service to NSW and Australian Capital Territory (ACT) for young people who are aged 12–18 years, have severe mental illness, have not benefited from care at a tertiary level and who are assessed as having potential to benefit from the extended secure care available at the Walker Unit. The provision of this level of child and adolescent mental health care would usually be associated with a Level 6 facility (the highest level in the NSW Role Delineation of Clinical Services 2019; note other elements of this classification level are not part of the facility from which the Walker Unit operates) and meets the NSW Health definition of a quaternary service in its meaning as an extension of tertiary care when the care is highly specialised and not widely accessed. The provision of such highly specialised services requires concentrated expertise and sufficient volume—meaning that there can realistically only be a small number or even one unit for a state, creating potential issues in access, continuity of care and vertical integration of specialised services and local specialist and primary care services.

This relates to another novel aspect to the Walker model—the Unit provides a discrete episode of care whilst actively working to maintain integration with local health and other service systems. One of the often-cited problems with a highly specialised child and adolescent mental health inpatient service is geographical dislocation for consumers and their families. This means that there are particular risks that can be anticipated and require mitigation, such as separation of young people from family and community supports; interrupted education, development and peer relationships; and, poor relational continuity of care that impacts on transitions to other forms of care. These risks are mitigated in the Walker model by several strategies. Firstly, the careful, comprehensive and collaborative assessment process that educates consumers, families/carers and referring agencies about what to expect. Secondly, the model ensures various ways, including but not limited to family therapy, of maintaining contact between the consumer and their family and ensuring that the parental role is not relinquished. Transitional planning is often complex and there may be many uncertainties during admission related to follow-up and stable accommodation in the community. Hence the model optimises available options including mobilising the support of the statutory child protection and education authorities to ensure maximum support and stability in follow-up.

Governance and Policies

Whilst the Ministry of Health has the role of coordinating the development and purchasing of supra-LHD services, the Local Health District from which the service is provided is responsible for service level monitoring consistent with local policies and procedures for Clinical Governance. This includes clinical care, adverse events and patient outcomes.

The Australian Commission on Safety and Quality in Health Care states ‘Patient safety and quality systems are in place within governance processes to allow organisations to advance the safety and quality of patients’ care’ (Australian Commission on Safety and Quality in Health Care, 2017). The purpose of policies is to communicate values, philosophy and culture. Procedures on the other hand provide the process steps to follow and assign roles and responsibilities. The importance of these documents lies in promoting clear expectations, consistency, clarity and accountability and laying the groundwork for benchmarking, quality improvement, research and evaluation and generating evidence regarding best practice. This extends beyond, say, policies to deal with complaints to creative ways of engaging consumers and carers to bring their lived experience of care to influence all the various processes of care, challenging historical norms in practice and redesigning care towards what is valued highly by consumers and their families. The available evidence at this stage positively supports such consumer engagement to be important in outcomes of mental health care and successful transitional care.

In the case of the Walker Unit, the governance is within the context of a population-based mental health programme and ultimately within the context of an LHD, which is a statutory corporation, and the Board of the LHD. Formal structures and processes for reporting and policies and procedures provide a framework that supports a high level of decentralisation in clinical decision-making and policy implementation at the Unit level. Hence, the actual management of access of the population of NSW to the service is undertaken by the multidisciplinary team which allows for optimal processes of assessment, consent and engagement by consumers and families/carers and referring agents. Alternative methods such as centralised access management or collaborative governance with referring agents to manage access would be cumbersome and would not support this approach.

The philosophy of care integrates an understanding of the developmental stage of the adolescent and the stage of shared decision-making between the adolescent and their family/carers in addition to the severity and phase of illness. The model of care is strongly based in milieu therapies and psychosocial interventions in addition to family therapies, specialised psychological interventions and medical treatments. Physical health is a programme imperative and education is optimised. It is a complex model of care and the multiple components are tightly coupled. This is a strength of the model and supports the multidisciplinary team in being able to manage the ambiguity and complexity involved in the care of young people admitted to the Unit, including being able to manage issues like complex ethical dilemmas, including issues associated with use of the NSW Mental Health Act (2007) for involuntary care and child protection matters through multidisciplinary team processes. It also requires the team to critically review the model from time to time to ensure that it remains contemporary, best practice and evidence-based and continues to provide value to consumers and the system. The Unit has been subject to external peer review, participates in state-wide benchmarking and reports on its work and outcomes, such as in this publication. These clinical governance activities are all critical in demonstrating the value of the service.

However, the value approach to health care places emphasis on outcomes achieved against cost. To deliver value, a discrete episode of care is generally supported by optimal care pathways. To demonstrate value, evidence against the care pathways is required usually across the domains of outcomes, effectiveness and experience (of giving and receiving care). Such evidence is usually lacking in mental health yet is critical to the long-term sustainability of low volume highly specialised services. This publication positions the Unit well for the future by extending the work in the domain of value based health care, albeit a very complex undertaking.

Conclusion

The Walker Unit emerged over a decade ago as a novel idea developed by experts in response to a complex and significant gap in the care for young people with severe and persistent mental illness in NSW. A decade or more on and the leaders of the service are demonstrating the significant value of this service to a group of young people who are vulnerable to poor clinical outcomes with broad impact on their lives, their families and the community. The innovation established new policy and new perspectives on care for this group of consumers—the challenge now is to stay at the forefront of value by demonstrating outcomes against cost. This is challenging in the field of mental health. This book demonstrates how Walker programme is again innovating to meet this challenge.