25 August 2011

The Proposed NSW Mental Health Commission: Opportunities for the Cunning Health Bureaucrat

Any new venture goes through the following stages: Enthusiasm; Complication; Disillusionment; Search for the guilty; Punishment of the innocent; and Decoration of the unworthy.

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The recently-elected Coalition Government in NSW came to power with a mandate to form a new Mental Health Commission by July 2012 that will ensure ‘there is quarantined and accountable funding for mental health expenditure’. Well. We’ve seen all that enthusiasm before.

To that end the NSW Minister for Mental Health, Kevin Humphries MP, has formed a Mental Health Taskforce comprising himself and a dozen other worthies, whose role is to advise the Government on how best to establish the Commission.

Although the Taskforce is still consulting and its recommendations are not yet made, early and informal advice from some members indicate that the proposed Commission will not likely hold the NSW mental health budget, but will focus on monitoring, auditing and other performance-related functions. Sounds good.

Key functions will not at this stage include enforcing agreements with Local Health Districts (LHDs). This provides an opportunity to continue the venerable NSW Health practice of mental health budget stripping. Let’s hope it stays that way.

It is essential that the NSW Government is convinced of the merits of having the Commission as an oversight body. Failure to do so could threaten the cash flow that general health services have been relying on for years to balance their books.

While not wanting to try and teach bureaucratic grandmothers how to suck financial eggs, it will be crucial to conceal evidence of dollars being diverted from mental health to other parts of the health service. To aid this complication, I have taken the liberty of preparing the handy guide below:

1. Simply take mental health dollars, spend elsewhere, and report opaquely

2. Divert mental health dollars to similar staffing (eg community health) and divert community health funds to (eg) general inpatient staffing, and report opaquely; and

3. Freeze all recruitment on basis of cost overruns in high-demand (non-mental health) areas, wait until end of financial year and redistribute unspent mental health funds to cover overruns and help balance overall budget, and report opaquely.

It is unlikely, given the experience of the last twenty years, that even ingenuous mental health managers will continue to fall for the above simple tactics, so I recommend focusing in the future on these more subtle approaches:

4. Substantially overcharge on overheads for mental health services (eg as much as 40% when benchmark is 18-20%) –fail to centrally impose compliance with a reasonable charging regime

5. Insist that mental health services meet ambitious revenue targets when overwhelming majority of psychiatric patients are on income support – failure to meet targets amounts to an effective budget cut of up to 10%; divert surplus funds to remainder of general health services

6. Impose a general levy (say 3-5%) on all program budgets – including mental health – which results in less money for clinical services (despite the usual public commitment that any savings will not affect ‘front line staff’), distribute savings to meet general health budget shortfall;

and, best of all...

7. Your cunning, new (but as yet unpublicised) scheme to continue funding general health cost overruns out of the mental health budget – please email details to me at the address below (confidentiality will of course be assured).

Let’s face it, when it comes to matters of finance, mental health folk aren’t the brightest stars in the firmament. NSW Health effectively emasculated its own Mental Health Service Agreements in 2004-05. Disillusionment reined. Quarantining has been defeated before. It can be beaten again.

The only mechanism that would have any prospect of securing mental health funds for their intended purpose is binding funding agreements made between two legally separate entities – enforceable contracts. These would severely limit the capacity for mental health funding to be diverted to the ever-hungry general health budget.

The NSW Government has just announced that the Department of Health will be replaced by a Ministry which will, it claims, ‘purchase’ services from LHDs. It is this purchaser-provider model that must be resisted at all costs in mental health. It is essential that the new Ministry mete out mental health funds to LHDs as the Department did in the past.

But please, whatever you do, don’t let on about any of this to the Minister, the Taskforce, or anyone likely to be a member of the new Commission. Maybe NSW health bureaucrats will get lucky again, and can look forward in a few years to continuing disillusionment in mental health, a search for the guilty, and punishment of the mental health innocents for their failure...while the best will be decorated for bringing in their health finances on budget.

© Enrico Brik, August 2011

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