In response to some recent policy announcements and commentary on the ongoing role of headspace centres in the delivery of youth mental health services through Primary Health Networks (PHNs), Executive Director of Orygen, Prof Patrick McGorry and Senior Policy Analyst, Matthew Hamilton have prepared this response.
Summary of the independent headspace evaluation
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The independent headspace evaluation confirms that the service:
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Has greatly improved access to care for young people and their families especially to marginalised groups, notably LGTBQI and indigenous young people
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Satisfaction levels of young people and families are at an unprecedented level for a youth mental health model of care
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Although available control groups are not wholly comparable it appears that modestly better outcomes in symptoms and functioning are already being achieved even though many headspace centres are still relatively new
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Local communities highly value their headspace services having advocated for them and been appreciative of their contributions
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headspace clients are heterogeneous and one size doesn’t fit all. headspace enables stigma-free entry, engagement and assessment and some young people need a different approach usually more specialised care.
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Similarly headspace is only one component of a reformed model of care and must be complemented by more specialised expert care with longer tenure to achieve major improvements in outcome.
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The evaluation also revealed a number of ways that headspace could be strengthened and complemented. Stronger relationships with local GPs, schools and employers and with admittedly under-resourced State mental health services are highly recommended.
From 1st July, Primary Health Networks (PHNs) will begin assuming new responsibilities for the planning and commissioning of mental health services[1]. A key component of these additional responsibilities relate to promoting earlier intervention through better local service responses to the mental health needs of Australia’s young people. The best currently available evidence suggests that central to achieving this goal will be ensuring all PHNs are supported to efficiently operate headspace centres at levels of coverage appropriate to local needs.
Founded in 2006, headspace is an enhanced primary care model which provides young people with mental health problems with a range of integrated mental health, alcohol and other drugs, physical and sexual health and vocational supports. The recently released second evaluation of headspace concluded that it was a highly accessible program, with which young people and families were extremely satisfied, and which also produced modestly superior gains in symptoms and functioning than those attained by generic primary health services for young people[2]. These findings re-enforce previous evidence about the accessibility and acceptability of headspace services[3-5] and are consistent with international evidence that integrated, holistic multi-component primary care platforms achieve better mental health outcomes for children and adolescents than standard primary care approaches[6].
International guidelines also recommend that commissioning bodies commission integrated, multi-agency services which delivery effective, accessible, holistic evidence-based mental health care to young people [7]. This is exactly what headspace delivers, which when combined with headspace’s success in improving access (with notably strong reach into indigenous and LGBTI populations) and producing better outcomes, argues for all PHNs to provide headspace centres as core components of the youth mental health services they commission. It has therefore been encouraging to see new policy proposals emerge from the current election campaign that are specifically designed to safeguard the future of headspace within the new PHN commissioning landscape[8]. Such proposals are consistent the National Mental Health Commission’s recommendation that headspace centres continue as a key part of the youth mental health service system while being better integrated with local service planning approaches[9].
Despite the Commission’s endorsement and the demonstrated gains in access and outcomes, a small group of commentators have argued for restructure and even redirection of funding of headspace to other programs[10-12]. The basis for these claims is that the improvements in functioning seen in headspace clients appear to be small when compared to symptom improvements in spontaneous remitting non-helpseeking young people with mental health problems. However, as has been argued elsewhere[13, 14] great care should be taken with this line of reasoning as there are likely to be substantial differences in the helpseeking and non-helpseeking populations which make them inappropriate for direct comparisons. Similarly, as an early intervention service, headspace engages large numbers of clients for whom illness is at an early stage and anticipated to become more severe – so even amongst those groups of clients for whom symptoms do not improve, it may be wrong to conclude that the service has had no impact in arresting a downward trajectory. So even if a subgroup (4.5%) do actually worsen within headspace care, they are part of a perhaps larger subset of cases who clearly need more expert, intensive and prolonged tenure of care than headspace can provide. The problem is not that headspace has not been helpful – it has provided access and engagement which was not on offer otherwise and which shortens delay in treatment – but that this entry portal needs to be backed up by a second tier of more complex care which is in short supply. headspace clients overwhelmingly meet the severity threshold (K10 and SOFAS) for need for service and headspace provides these young people with better outcomes than other services. Additionally, headspace clients show notable improvements in suicidal ideation and rates of self-harm[2].
It should also be noted that headspace is still a relatively young program and there remains ample scope for improvement. Many of the centres evaluated had only recently commenced operations. The cost for a headspace service likely to be somewhat higher than standard generic general practice since the administrative and salaried costs of intake and assessment are included – features that mean young people face fewer barriers to access. However, the most recent evaluation of headspace highlighted wide variation in the cost per occasion of service between headspace centres.
Supporting more headspace centres to move closer to the cost per occasion of service of the most efficient headspace centres is likely to be a fruitful avenue to explore in enhancing overall program cost-effectiveness, potentially by encouraging higher volumes of activity in headspace centres as they mature. A high proportion of mental health care in Australia is not evidence based[15, 16] and within the youth mental health system clinician knowledge and beliefs have been identified as a barrier to appropriate service delivery[17, 18]. The emphasis placed on knowledge dissemination and training across the national network of headspace centres may therefore help progressively improve the proportions of young people accessing appropriate, evidence based care. Other potential areas with scope to enhance outcomes for headspace clients include better approaches to employment support (some of which are now being trialled) and strategies to improve engagement of young clients beyond the average of approximately five services per client. Finally, headspace clients are highly heterogeneous so there remains significant potential for developing more targeted and personalised approaches to care, a task that will be aided by continued commitment both to research partnerships and the maintenance and development of a high quality national minimum dataset on headspace clients.
1. Health, D.o., Australian Government Response to Contributing Lives, Thriving Communities – Review of Mental Health Programmes and Services, D.o. Health, Editor. 2016.
2. Hilferty, F., et al., Is headspace making a difference to young people’s lives? Final report of the independent evaluation of the headspace program. . 2015, Social Policy Research Centre, University of New South Wales.: Sydney.
3. Muir, K., et al., Headspace Evaluation Report Independent Evaluation of headspace: the National Youth Mental Health Foundation. 2009.
4. Rickwood, D., et al., Satisfaction with youth mental health services: further scale development and findings from headspace - Australia's National Youth Mental Health Foundation. Early Interv Psychiatry, 2015.
5. Rickwood, D.J., et al., headspace - Australia's innovation in youth mental health: who are the clients and why are they presenting? Med J Aust, 2014. 200(2): p. 108-11.
6. Asarnow, J.R., et al., Integrated Medical-Behavioral Care Compared With Usual Primary Care for Child and Adolescent Behavioral Health: A Meta-analysis. JAMA Pediatr, 2015. 169(10): p. 929-37.
7. Health, J.C.P.f.M., Guidance for commissioners of child and adolescent mental health services, in Practical Mental Health Commissioning. 2013: United Kingdom.
8. Australia, T.L.P.o., The Coalition’s plan to strengthen mental health care across Australia. 2016, The Liberal Party of Australia.
9. (NMHC), N.M.H.C., Report of the National Review of Mental Health Programs and Services. 2015.
10. Allison, S., et al., The National Mental Health Commission Report: Evidence based or ideologically driven? Aust N Z J Psychiatry, 2015. 49(11): p. 960-2.
11. Jorm, A.F., How effective are 'headspace' youth mental health services? Aust N Z J Psychiatry, 2015. 49(10): p. 861-2.
12. Jorm, A.F., Should we be protecting headspace youth mental health services?, in Online Opinion. 2016, The National Forum.
13. McGorry, P.D., et al., Response to Allison et al., 'The National Mental Health Commission Report: Evidence based or ideologically driven?'. Aust N Z J Psychiatry, 2016. 50(1): p. 11-2.
14. McGorry, P.D., et al., Response to Jorm: Headspace - A national and international innovation with lessons for redesign of mental health care in Australia. Aust N Z J Psychiatry, 2016. 50(1): p. 9-10.
15. Harris, M.G., et al., Frequency and quality of mental health treatment for affective and anxiety disorders among Australian adults. Med J Aust, 2015. 202(4): p. 185-9.
16. Runciman, W.B., et al., CareTrack: assessing the appropriateness of health care delivery in Australia. Med J Aust, 2012. 197(2): p. 100-5.
17. Hetrick, S.E., et al., What are specialist mental health clinician attitudes to guideline recommendations for the treatment of depression in young people? Aust N Z J Psychiatry, 2011. 45(11): p. 993-1001.
18. Hetrick, S.E., et al., Is there a gap between recommended and 'real world' practice in the management of depression in young people? A medical file audit of practice. BMC Health Serv Res, 2012. 12: p. 178.