Evaluation of the mental health nurse incentive program
4.3 Underlying need
Advice from the Department's mental health technical adviser involved in the original design of MHNIP was that a two step process was required to estimate the program target population in 2006.11 Using the New South Wales Mental Health Clinical Care and Prevention Model (NSW-MHCCP model) it was estimated that 3.5 % of the adult population aged 18 to 65 years had a severe mental illness, where severity was based on definitions used by the US National Advisory Mental Health Council and judged according to:
...the type of disorder the person has (diagnosis), the intensity of the symptoms they are suffering, the length of time they have experienced those symptoms, especially whether they have had them in the past 12 months, and the degree of disablement that is caused to social, personal and occupational functioning. Some diagnoses, particularly schizophrenia and other psychoses, are usually assigned to the severe category if they have been present in the previous year, but all disorders can have extreme impacts on some people for them to be classed as severe [ie the definition of severe can include anxiety disorders, mood disorders (like depression) and additional disorders like borderline personality disorder and eating disorders]12
The population with severe and persistent mental illness is a subset of this group. A statute operating in Wisconsin USA, a jurisdiction that has been a world leader in the development of services for this population, provides the most suitable definition of severe and persistent mental illness.13 This statute defines severe and persistent mental illness as:
...a mental illness which is severe in degree and persistent in duration, which causes a substantially diminished level of functioning in the primary aspects of daily living and an inability to cope with the ordinary demands of life, which may lead to an inability to maintain stable adjustment and independent functioning without long–term treatment and support and which may be of lifelong duration. Serious and persistent mental illness includes schizophrenia as well as a wide spectrum of psychotic and other severely disabling psychiatric diagnostic categories, but does not include infirmities of aging or a primary diagnosis of mental retardation or of alcohol or drug dependence.14
Expert advice provided to the evaluation team said that applying this definition meant that around 1.2 % of the adult population had severe and persistent mental illness at the time MHNIP was established.
HMA was advised this definition of the program target group is still relevant in 2012.15
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Applying this proportion to the ABS estimated resident population figures for 2012 implies that there are approximately 170,000 adults aged 18 to 64 years in 2012 who have a severe and persistent mental illness.16 While a small proportion of this group require long term hospital or residential care (estimated at around 2,000 based on the number of these types of beds reported by states and territories17), the vast majority are living in the community with a subgroup of these requiring periodic short term hospital care.
Not all people with severe and persistent mental illness living in the community require the services offered by the MHNIP program. This is because the person may be:
- primarily under the ongoing clinical care of the local state or territory mental health service rather than a GP or private psychiatrist; or
- primarily under the clinical care of a GP or private psychiatrist, but
- may have already seen a MHNIP nurse and decided not to continue treatment and support; or
- is receiving comparable support from an alternative provider such as a non government organisation; or
- has exited from the program because their condition has stabilised; or
- may not want to seek / feel unready to seek additional support for their illness, even though they may be accessing a GP or psychiatrist.
Since the introduction of the COAG Action Plan Annual Progress Report, states and territories have been reporting annually on the number of people seen by their public community mental health services. The most recent data provided to DoHA for the forthcoming COAG report, covering 2010-11, indicate that a total of 351,690 people received clinical mental health care in state and territory community mental health services in 2010-1118, a figure that has been relatively stable on a per capita basis since reporting commenced in 2006-07. Approximately 76 per cent of this group are in the adult age range 18-64 years, suggesting that about 267,000 people aged 18-64 receive clinical mental health care annually through state and territory mental health services.
Advice from the DoHA indicated that accurate data are not available to identify the proportion of the 267,000 who have severe and persistent conditions but that it would be reasonable to conservatively estimate this group as comprising one third of the state and territory adult treatment group – that is, about 88,000 people.
We have adjusted the demand model to account for this group, by reducing the 170,000 total potential target population by the estimated 88,000 receiving clinical care through the various state and territory mental health services. The resulting statistic for assessing adequacy of current and projected future service requirements is 0.6% of the adult population with severe and persistent mental illness likely to seek or receive assistance under MHNIP (around 82,000 people based on 2010-11 data).
While this number does not take account of the other factors that may lead a person to not require MHNIP (i.e. factors (b)(i), (b)(ii), (b)(iii) and (b)(iv) above), this is considered reasonable within the levels of uncertainty of the modelling. In particular, any reduction in the estimates necessary for these groups is likely to be offset by the fact that a small proportion of the MHNIP client population fall outside the 18-64 year age range. This is considered appropriate as the 18-64 year age band is used here only for modelling purposes, to identify the MHNIP core target group, rather than imply arbitrary program eligibility restrictions based on age.
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Based on activity projections supplied by DHS, HMA estimated that 49,842 patients received a service under MHNIP in the 12 months to 30 June 2012.
Key Finding 1: there is a sizeable group of people in the community with severe and persistent mental illness. Expert advice suggests this is in the order of 1.2% of the adult population aged 18 to 64 years. It is estimated that a little under half of this group is the size of the MHNIP target population - 0.6% of the adult population with severe and persistent mental illness primarily reliant on assistance from GPs and psychiatrists in the private sector.
Anecdotal information collected during the consultation process suggested that demand for MHNIP services exceeds current levels of service provision, a perspective supported by information collected during the evaluation survey of participating medical practitioners and mental health nurses. More than 62% of medical practitioners using the program considered that patient demand out-stripped the availability of MHNIP treatment capacity in their organisations (see Table 4.1).
Key Finding 2: the target group will always be bigger than realised demand under MHNIP eg some people will have exited the program because their condition has stabilised Allowing for this, there is evidence the size of the potential program target group exceeds the services currently available under MHNIP – an estimated 49,800 people in 2011-12.
Table 4.1: Patient demand - the views of participating medical practitioners
| Are all suitable patients being managed under MHNIP? | No. of responses | % |
|---|---|---|
| Yes | 52 | 27.2 |
| No | 120 | 62.8 |
| Unsure | 19 | 10.0 |
| Total | 191 | 100 |
(Source: medical practitioner survey)
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