Full implementation of the 4As Framework requires substantial resourcing across the health and human services sectors. Essential resources include information, infrastructure, and workforce development. However, while acknowledging the urgent need for greater resources for mental health, it must be realised that the level of need for mental health services will outweigh the ability of most communities to provide them in the foreseeable future. As a result, while we continue to advocate for increased resources, we must seek ways to improve outcomes in continuing care through more effective and innovative use of current resources.
InformationInformation relevant to the 4As Framework comes from a wide range of sources. Of primary importance is the lived experience of people with mental illness and their families and carers, but research, evaluation and clinical practice also provide valuable perspectives. All these sources of information must be recognised, resourced and used to develop the evidence base for continuing care.
There are some areas where more information is clearly needed. In relation to Awareness, better understanding of differing personal and cultural interpretations of mental health and mental illness is required, especially for Aboriginal and Torres Strait Islander peoples. The evidence base regarding the risk and protective factors for mental health and the early warning signs of illness for different population groups also needs to be developed as this will enable prevention interventions to be better targeted and more effective.
For Anticipation, information about best-practice regarding planning at all levels is needed, as well as effective ways to plan collaboratively across services and sectors and to ensure the participation of consumers and their families and carers. The evidence base to support the implementation of a wider range of service Alternatives also needs to be strengthened to enable evidence-based practice.
Finally, determining the best ways to develop infrastructure and system supports to enable and ensure Access to continuing care services is a complex task, and this requires better understanding of Australia's health care systems and the unique circumstances of each of the States and Territories. Top of page
InfrastructureAll the 4As of the Framework are based on a substantial infrastructure that supports both self-management and a wide range of service alternatives. At present, the capacity of different parts of the mental health care system varies markedly across jurisdictions. Each jurisdiction must identify its areas of strength in order to sustain these parts of the system, as well as identify system gaps to target additional resources.
Peer support deserves special mention, as it has a vital role across the entire Framework. Peer support, for both consumers and carers, is fundamental to self-management as well as to participation and empowerment at all levels. Consumer networks are well developed in many areas, and this is evident in the increasing number of roles that consumers occupy within the mental health care system. For example, consumer roles comprise: consumer support workers, consumer representatives, consumer consultants, consumer advocates, consumer coordinators/ directors and consumer liaison workers.12 Carer support networks are less well developed, but gaining momentum. Progress for both consumer and carer peer support needs to be sustained and expanded.
Disability support and psycho-social care in the community are fundamental to continuing care as these services provide the rehabilitation, accommodation, employment and other types of support that relate to many of the risk and protective factors for mental health. In States/Territories where psychiatric disability support services are well developed, continuing care is greatly enhanced. However, for most States and Territories, these services are poorly resourced and not well integrated with other parts of the mental health care system. Furthermore, psychiatric disability generally does not receive the same priority as other types of disability, and providing such support is more complex due to its variable nature. Very often rehabilitation and disability support are provided by the non-government sector, and the capacity of this sector must be substantially improved, along with ways to integrate these services as full partners in collaborative continuing care arrangements.
The capacity of primary care, and general practice in particular, to support continuing care in the community has grown rapidly. Primary care is essential across the 4As as it supports self-management as well as contributes to holistic and integrated care for people with complex care needs. Several major initiatives in primary care have been effective in this regard, particularly the National Primary Mental Health Care Initiative and Better Outcomes for Mental Health Care Initiative.13 However, these initiatives need to be expanded and sustained and it must be recognised that there are still many areas that do not have a primary care system that effectively meets their needs for continuing care.
For people with complex care needs, there is a great deal of unmet need in Australia for coordination of care. This is generally provided through a case management approach, but often those people in the workforce who are designated as case managers are not optimally effective. The principles of effective case management have been identified (see Appendix A), and should be adopted for people with complex care needs across the mental health care system.
Infrastructure within the acute and specialist mental health sectors should support the changes to practice required to implement the Framework. Resources need to be targeted toward reorienting services from their traditional acute and crisis response toward a more holistic, integrated and longer-term approach that prioritises and is responsive to changing needs, as identified by consumers and their families and carers. Of particular importance are resources related to recruitment, training and staff development, which must be used to ensure that all staff have a positive attitude toward people who have been seriously affected by mental illness and their families and carers, and are able to work with a recovery orientation and in ways that support self-management. Providing support to other services, including primary care and psycho-social community support services, and working in partnership with a wider range of services, are also continuing priorities.
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WorkforceThe Framework requires a workforce that has both the capacity and the necessary skills and knowledge for implementation. Fundamentally, the availability of the workforce must be sufficient to meet population needs. Recruitment and retention of different sectors of the workforce are major challenges in many communities, particularly rural and remote areas and communities that comprise population groups with additional or complex needs.
There are also special challenges to equipping the workforce with the necessary skills and knowledge to implement the Framework. The World Health Organization (WHO) has recently published a set of core competencies to prepare the health care workforce to meet the challenges posed by increasing need for chronic disease prevention and care in the future, and these competencies are highly relevant to mental health care.14
What is most essential is a shift in attitude and orientation so that service providers operate with a recovery focus, prioritise the participation of consumers and their families and carers, and respect and work collaboratively with other service providers.
Such shifts are achieved through good leadership, appropriate staff training and recruitment, and adequate resourcing so that staff have the capacity to reorient their practices. These processes need to be used to ensure that all staff have the following basic skills:
- a positive attitude toward people who have been seriously affected by mental illness and their families and carers;
- a recovery focus;
- a holistic approach that recognises all the risk and protective factors for mental health;
- ability to work in true partnership with consumers and their families and carers through prioritising and being responsive to their changing needs; and
- ability to work collaboratively with a wide range of other service providers from a variety of sectors.