Here’s how citizen power can drive mental health reform

By Sebastian Rosenberg, The Conversation

Citizen panels and juries around the world are having their say about how health funding is prioritised and allocated.

It’s time this happened in Australia, particularly when it comes to deciding how best to carve up Australia’s limited resources for tackling mental health.

This is because constructively engaging with the community this way is fundamentally transparent and democratic. The current system, of national and state governments making decisions about mental health funding in secret, is not.

So, what has the current system achieved? And how could citizen panels help do things better?

Report after report

Some 25 years of Australian mental health reform has mainly focused on a single goal: to make it possible for people with a mental illness to live well in the community.

Despite many plans and policies at national and state level, progress is hard to see. Mental health care in Australia has triggered 32 separate statutory inquiries between 2006 and 2012 alone. These inquiries typically conclude Australia’s mental health system remains in crisis.

Yet the community is almost completely excluded from the process of responding to mental illness. This is because the process of mental health reform has become mired in closed political and bureaucratic processes run under the auspices of the Australian health ministers’ Mental Health and Drug and Alcohol Principal Committee.

These processes prioritise existing state and territory mental health services and discourage new models of care. These old state systems have demonstrated they cannot lift the rate of access to mental health care.

Perhaps in an effort to re-energise reform and engage with the community, six of Australia’s nine jurisdictions have also recently implemented variations of a mental health commission. And while the National Mental Health Commission has prioritised local planning and autonomy, this has not involved the community.

Most Australians are aware of the crisis in mental health and would not understand why governments have permitted ongoing neglect.

How would citizen panels work?

Building on experience from overseas, citizen panels have recently been used in local and state government in Australia as a way of involving a wider range of people in the democratic process.

They involve a group of randomly selected people representing the broader community. People come together for about 50 hours, experts brief them, then citizens discuss the issues before recommending a course of action to government.

Health is no stranger to the idea of citizen-led planning. The World Health Organization first proposed in 1954 to have citizens’ values drive health service decision-making.

The late Australian health economist Professor Gavin Mooney ran seven citizen jury processes in health care and concluded they were critical tools enabling Australian health planners to build effective service systems.

The disconnect in mental health is clear. Planners and funders keep providing more hospital-based services despite the clear calls from the community and mental health consumers for earlier intervention and non-hospital, community-based service alternatives.

The question for the jury would be for them to shape the key priorities for mental health reform over, say, the next decade.

Not just health

Mental health is a complex area of human behaviour and illness. So, the jury’s work would need to cover not just health (physical and mental, including the lived experience) but also issues of social engagement, employment, education and training, justice and housing. Expecting departmentalised approaches to manage this complexity is futile.

Reform of mental health should now be driven by a tiered process of structured community engagement. A national jury process would set out the priorities for overall systemic reform. These would then be considered by regional citizen juries across Australia, to tailor national priorities to local circumstances.

Opposition to citizen juries could come from some health bureaucrats who might be threatened by alternative and more inclusive deliberative discussions. But existing policy-making is so ineffective and the level of concern about mental health so great that such concerns are surmountable.

Some health professionals might also feel threatened at the thought of redesigning mental health services, though many agree the system is broken.

How might this work in practice?

Here’s a concrete example of how citizen panels might work. The National Mental Health Plan proposed just 1% of the total mental health workforce be made up of people with mental illness employed to support others (known as the peer workforce).

When presented with the evidence about the effectiveness of peer workers, a citizen jury may find this target under-ambitious. It could identify successful models worth replicating, consider and recommend new approaches and also suggest a more appropriate workforce target to guide future action.

Rather than working in secrecy, the jury approach offers an inclusive and structured method to engage a cross-section of the community in shaping the nature of the mental health system. Experts would help this process; so would people with a mental illness and their carers.

Rather than the merry-go-round of reports, policies and inquiries mental health has endured over the past 25 years, the result would be a more stable and explicit platform to guide mental health reform, policy and funding. Politicians and decision-makers would welcome this stability.

There is already expertise available in Australia that could manage this kind of deliberative process, at no cost to government. The rhetoric in mental health focuses on putting the person at the centre of care. This proposal puts the community at the centre of mental health planning.

We urgently need a new, sensible conversation about mental health that does not begin with politics and end in frightening newspaper headlines and online disputes in the comments section. It needs to begin with the problem and what needs to be done.

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