Australian Health Review Australian Health Review Society
Journal of the Australian Healthcare & Hospitals Association
RESEARCH ARTICLE (Open Access)

The future of community-centred health services in Australia: lessons from the mental health sectorA

Alan Rosen A D , Roger Gurr B and Paul Fanning C
+ Author Affiliations
- Author Affiliations

A Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia.

B Faculty of Medicine, University of Western Sydney, Penrith South DC, NSW 1797, Australia.

C Centre for Rural and Remote Mental Health, School of Medicine and Public Health, University of Newcastle, Orange, NSW 2800, Australia.

D Corresponding author. Present address: PO Box 110, Balmain, NSW 2041, Australia. Email: alanrosen@med.usyd.edu.au

Australian Health Review 34(1) 106-115 https://doi.org/10.1071/AH09741
Submitted: 28 January 2009  Accepted: 21 October 2009   Published: 25 March 2010

Abstract

• It is apparent that hospital-dominated health care produces limited health outcomes and is an unsustainable health care system strategy.

• Community-centred health care has been demonstrated to be a more cost-efficient and cost-effective alternative to hospital-centred care, particularly for prevention and care of persistent, long-term or recurrent conditions. Nevertheless, hospital-centred services continue to dominate health care services in Australia, and some state governments have presided over a retreat from, or even dismantling of, community health services.

• The reasons for these trends are explored.

• The future of community health services in Australia is uncertain, and in some states under serious threat. We consider lessons from the partial dismantling of Australian community mental health services, despite a growing body of Australian and international studies finding in their favour.

• Community-centred health services should be reconceptualised and resourced as the centre of gravity of local, effective and affordable health care services for Australia. A growing international expert consensus suggests that such community-centred health services should be placed in the centre of their communities, closely linked or collocated where possible with primary health care, and functionally integrated with their respective hospital-based services.

What is known about the topic? Community-centred health care has been widely demonstrated to be a more cost-efficient and cost-effective alternative to hospital-centred care, particularly for prevention and care of persistent, long-term or recurrent conditions, e.g. in mental health service systems. A growing international expert consensus suggests that such community-centred health services should be placed in the centre of their communities, closely linked or collocated where possible with primary health care, and functionally integrated with their respective hospital-based services.

What does this paper add? Despite this global consensus, hospital-centred services continue to dominate health care services in Australia, and some state governments have presided over a retreat from, or even dismantling of, community health services. The reasons for these trends and possible solutions are explored.

What are the implications for practitioners? Unless this trend is reversed, the loss of convenient public access to community health services at shopping and transport hubs and the consequent compromising of intensive home-based clinical care, will lead to a deterioration of preventative interventions and the health care of long-term conditions, contrary to international studies and reviews.


Acknowledgements

We thank Richard Nafa, Anne Streeter, Julie McGarrity, Zacha Rosen and Vivienne Miller for assistance with preparing this paper, and Prue Power, Dr William Barclay, Professors Kathy Eagar and David Richmond for most helpful comments on the text.


References


[1] Owen A , Thompson C , Samsa P , Grootmaat P , Fildes D , Eagar K . Community Health: the evidence base. A report for the NSW Community Health Review. Wollongong: University of Wollongong, Centre for Health Service Development, 2008.

[2] New South Wales Health. Integrated Primary and Community Health Policy 2007–2012. NSW Department of Health: Sydney, 2006.

[3] Duckett SJ. The Australian health care system: reform, repair or replace? Aust Health Rev 2008; 32(2): 322–9.
PubMed |

[4] Rix M,  Owen A,  Eagar K. (Re) form with substance? Restructuring and governance in the Australian health system 2004/05. Aust N Z Health Policy 2005; 2(19): 1–8.
CrossRef |

[5] Purdy S,  Griffin T. Reducing hospital admissions. Guidance should be evidence based and take a holistic view of patient care. BMJ 2008; 336 4–5.
CrossRef | PubMed |

[6] Collignon P . We have 38% fewer hospital beds than in 1981: it’s a scandal. 20 July 2009. Available at www.crikey.com.au [verified 1 March 2010].

[7] Roxon N. ‘A case for change’ in the Australian Health System. Canberra: National Press Club. 13 August 2008.

[8] Victoria’s Hospital in the Home Program. Melbourne: Department of Human Services, 2003. Available at www.health.vic.gov.au/archive2003 [verified 1 March 2010].

[9] Wilson SF,  Shorten B,  Marks R. Costing the ambulatory episode: implications of total or partial substitution of hospital care. Aust Health Rev 2005; 29(3): 360–5.
PubMed | |  CAS |

[10] Government of Western Australia, Department of Health. Healthy@Home: Hospital in the home, chronic disease service. Available at http://www.health.wa.gov.au/healthyathome/hith/index.cfm [verified 1 March 2010].

[11] Caplan G,  Ward J,  Brennan N,  Board N,  Coconis J,  Brown A. Hospital in the home: a randomised controlled trial. Med J Aust 1999; 170 156–60.
PubMed | |  CAS |

[12] Caplan GA,  Coconis J,  Sayers A,  Board N. Does home treatment affect delirium? A randomised controlled trial of rehabilitation of elderly and care at home or usual treatment (The REACH OUT Trial). Age Ageing 2006; 35 53–60.
CrossRef | PubMed |

[13] Caplan GA. Does Hospital in the Home treatment prevent delirium? Ageing Health 2008; 4(1): 69–74.
CrossRef |

[14] Leff B,  Burton L,  Mader S,  Naughton B,  Burl J,  Inouye SK, et al. Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med 2005; 143 798–808.
PubMed |

[15] Garling P . Final Report of the Special Commission of Inquiry: Acute Care Services in NSW Public Hospitals. Sydney: NSW Government, 2008.

[16] Board N,  Brennan N,  Caplan G. A randomised controlled trial of the costs of hospital as compared with hospital in the home for acute medical patients. Aust N Z J Public Health 2000; 24 305–11.
CrossRef | PubMed | CAS |

[17] Tran A,  Taylor D. Medical model for hospital in the home: effects on patient management Aust Health Rev 2009; 33(3): 494–501.
PubMed |

[18] Stein LI,  Test MA. Training in community psychiatry: one year evaluation. Am J Psychiatry 1976; 133 917–8.


[19] Hoult J,  Rosen A,  Reynolds I. Community oriented treatment compared with psychiatric hospital orientated treatment. Soc Sci Med 1984; 18(11): 1005–10.
CrossRef | PubMed | CAS |

[20] Rosen A,  Mueser KT,  Teeson M. Assertive community treatment – issues from scientific and clinical literature with implications for practice. J Rehabil Res Dev 2007; 44(6): 813–25.
CrossRef | PubMed |

[21] Dykes S,  Patton M,  Tinling P. Community treatment: an alternative to hospitalization. Commun Mental Health N Z 1990; 5(2): 64–76.


[22] Gómez-Batiste X,  Tuca A,  Corrales E,  Porta-Sales J,  Amor M,  Espinosa J, et al. Resource consumption and costs of palliative care services in Spain: a multicenter prospective study. J Pain Symptom Manage 2006; 31(6): 522–32.
CrossRef | PubMed |

[23] Leff B,  Burton L,  Guido S,  Greenough WB,  Steinwachs D,  Burton JR. Home Hospital Program: a pilot study. J Am Geriatr Soc 1999; 47(6): 697–702.
PubMed | |  CAS |

[24] Harris R,  Ashton T,  Broad J,  Connolly G,  Richmond D. The effectiveness, acceptability and costs of a hospital-at-home service compared with acute hospital care: a randomized controlled trial. J Health Serv Res Policy 2005; 10(3): 158–66.
CrossRef | PubMed |

[25] Larsen T,  Olsen TS,  Sorensen J. Early home-supported discharge of stroke patients. A health technology assessment. Int J Technol Assess Health Care 2006; 22(3): 313–20.
CrossRef | PubMed |

[26] Thompson JR,  Horton C,  Flores C. Advancing diabetes self-management in the Mexican American population: a community health worker model in a primary care setting. Diabetes Educ 2007; 33 159S–65S.
CrossRef | PubMed |

[27] Liebman J,  Heffernan D,  Sarvela P. Establishing diabetes self-management in a community health center serving low-income Latinos. Diabetes Educ 2007; 33(Suppl. 6): 132S–8S.
CrossRef | PubMed |

[28] Jilcott SB,  Keyserling TC,  Samuel-Hodge CD,  Rosamond W,  Garcia B,  Will JC,  Farris RP,  Ammerman AS. Linking clinical care to community resources for cardiovascular disease prevention: The North Carolina Enhanced WISEWOMAN project. J Womens Health 2006; 15(5): 569–83.
CrossRef |

[29] Chatterjee N,  Blakely DE,  Barton C. Perspectives on obesity and barriers to control from workers at a community centre serving low-income Hispanic children and families. J Community Health Nurs 2005; 22(1): 23–36.
CrossRef | PubMed |

[30] Pbert L,  Ockene JK,  Zapka J,  Ma Y,  Goins K,  Oncken C. A community health center smoking-cessation intervention for pregnant and postpartum women. Am J Prev Med 2004; 26(5): 377–85.
CrossRef | PubMed |

[31] Walker EA,  Engel SS,  Zybert PA. Dissemination of diabetes care guidelines: lessons learned from community health centers. Diabetes Educ 2001; 27(1): 101–10.
CrossRef | PubMed | CAS |

[32] Rosen A,  Callaly T. Interdisciplinary teamwork and leadership. Australas Psychiatry 2005; 13(3): 234–40.
PubMed |

[33] Rosen A. Destigmatizing day-to-day practices: what developed countries can learn from developing countries. World Psychiatry 2006; 5(1): 21–4.
PubMed |

[34] Rosen A. The community psychiatrist of the future. Curr Opin Psychiatry 2006; 19(4): 380–8.
CrossRef | PubMed |

[35] Twomey A , Withers G . Australia’s federal future: delivering growth and prosperity. Federal Paper 1. Canberra: The Council for the Australian Federation, 2007.

[36] Epstein T , Lynch A. Selective centralism no answer to federal problems. Sydney Morning Herald, 3 August 2007; 15.

[37] Hartcher P. Fiddling at the margins – and more to come. Sydney Morning Herald, 4–5 August 2007; 25.

[38] New South Wales Department of Health. Health Administration Act, Clause 2 (1), Schedule 3.

[39] Darzi A. Future framework for healthcare for London. London Strategic Health Authority and the National Health Service UK, July 2007.

[40] Darzi A . High quality care for all, and our vision for primary and community care. Department of Health and National Health Service, UK, August 2008. Available at www.dh.gov.uk/en/Healthcare/OurNHSourfuture/index.htm [verified 1 March 2010].

[41] Menadue J. Obstacles to health reform. Sydney: Centre for Policy Development, 31 July 2007. Available at http:/cpd.org.au/article/obstacles-to-health-reform [verified 1 March 2010].

[42] Coultan M. Politicians must change ‘cheaper sandwiches’ attitude. Sydney Morning Herald, 5 March 2008.

[43] National Health Service (NHS) Modernization Agency. 10 high impact changes for service improvement and delivery: a guide for NHS leaders. Leicester: National Health Service, 2004.

[44] Scottish Government Executive & Royal College of Psychiatrists in Scotland. New ways of working for psychiatrists: Scottish Report. Edinburgh: 2007.

[45] McKee M . Reducing hospital beds: what are the lessons to be learned? European Observatory on Health Systems and Policies, Policy Brief No. 6. Copenhagen: WHO Regional Office for Europe, 2004.

[46] Lancet Global Mental Health Group Scale up services for mental disorders: a call for action. Global Mental Health Series 6. Lancet 2007; 370 1241–52.
CrossRef | PubMed |

[47] United Nations General Assembly. Principles for the protection of persons with mental illness and for the improvement of mental health care. New York: United Nations Organization, Resolution 119, 46th session, Meeting 75, Report: A/46/721. 17 December 1991.

[48] Stein LI,  Test MA. Alternative to mental hospital treatment: 1 Conceptual model, treatment program and clinical evaluation. Arch Gen Psychiatry 1980; 37 392–7.
PubMed | |  CAS |

[49] Geller J,  Fisher W,  McDermit M. A national survey of mobile crisis services and their evaluation. J Psychiatr Serv 1995; 46(9): 893–7.
CAS |

[50] Rosen A,  Newton L,  Barfoot K. Evidence-based community alternatives to institutional psychiatric care. Med Today 2003; 4(9): 90–5.


[51] Gurr R . Drugs and Australasian Government policies have created a crisis in public mental health services. Canberra: Senate Select Committee on Mental Health, Proceedings, 2005; 893–7. [Submission representing Comprehensive Area Service Psychiatrists’ (CASP) Network]. Available at http://www.aph.gov.au/Senate/committee/mentalhealth_ctte/submissions/sub108_attach1.pdf [verified 4 March 2010].

[52] Andrews G. The crisis in mental health: the chariot needs one horseman Med J Aust 2005; 182 372–3.
PubMed |

[53] Rosen A,  Teesson M. Does case management work? The evidence and the abuse of evidence-based medicine. Aust N Z J Psychiatry 2001; 35 731–46.
CrossRef | PubMed | CAS |

[54] Mental Health Council of Australia. Brain & Mind Institute, University of Sydney, & Human Rights & Equal Opportunity Commission. ‘Not for Service’: experiences of injustice & despair in mental health care in Australia. Canberra: Mental Health Council of Australia, 2005.

[55] Department of the Senate. Parliament of Australia. Senate Select Committee on Mental Health Inquiry. Interim Report 30 March. Final Report 28 April. Canberra: Commonwealth of Australia, 2006.

[56] Murray G,  Judd F,  Jackson H. Rurality and mental health: the role of accessibility. Aust N Z J Psychiatry 2004; 38 629–34.
PubMed |

[57] Kent S,  Fogarty M,  Yellowlees P. A review of heavy users of psychiatric services. Psychiatr Serv 1995; 46(12): 1247–53.
PubMed | |  CAS |

[58] Hugo M,  Smout M,  Bannister J. A comparison in hospitalization rates between a community-based emergency service and a hospital-based emergency service. Aust N Z J Psychiatry 2002; 36(4): 504–8.
CrossRef | PubMed |

[59] Mellsop GW. The effect of distance in determining hospital admission rates. Med J Aust 1969; 2 814–7.
PubMed | |  CAS |

[60] Rosen A. Australia’s national mental health strategy in historical perspective: beyond the frontier. International Psychiatry 2006; 3(4): 19–21.


[61] Hickie IB,  McGorry PD. Increased access to evidence-based primary mental health care: will the implementation match the rhetoric? Med J Aust 2007; 187 100–3.
PubMed |

[62] Senate Standing Committee on Community Affairs. Mental health services in Australia. Canberra: Department of the Senate, Parliament of Australia, Commonwealth of Australia, June 2008.

[63] Keleher H. Why primary health care offers a more comprehensive approach to tackling health inequities than primary care. Aust J Primary Health 2001; 7(2): 57–61.
CrossRef |

[64] Rudd K , Roxon N . New directions for Australia’s health. Delivering GP Super Clinics to local communities. Canberra: ACP, Policy Document, 26 August 2007.

[65] Department of Health and Ageing. GP Super Clinics program. Australian Government, 2008. Available at www.health.gov.au/internet/main/publishing.nsf/Content/portal-gpsuperclinics [verified 1 March 2010].

[66] South Australian Department of Health. GP plus: a new model for GP Plus Health Networks. Report, January 2008. Available at www.health.sa.gov.au [verified 1 March 2010].

[67] Burgess T , Beilby J . Integrated primary health care and community care in South Australia. Final report. University of Adelaide, Department of General Practice, 2003.

[68] New South Wales Health. Health in our communities: HealthFirst: Primary health care in NSW 2010–2015. Sydney: NSW Department of Health, 2009.

[69] New South Wales Department of Health. HealthOne NSW Framework, Sydney, 2008. Available at http://www.health.nsw.gov.au/initiatives/HealthOneNSW/framework/index.asp [verified 5 March 2010].

[70] Katekar L . Editorial. The Echo, Bulletin of the Top End Division of General Practice 2008; 3: 1. Available at www.tedgp.org.au [verified July 2008].

[71] McGorry P,  Tanti C,  Stokes R,  Hickie IB,  Carnell K,  Littlefield L. Headspace: Australia’s National Youth Mental Health Foundation-where young minds come first. Med J Aust 2007; 187(7 Suppl.): S68–70.
PubMed |

[72] Headspace: National Youth Mental Health Foundation. Establishment report. Melbourne: Australian Government Promoting Better Mental Health – Youth Mental Health Initiative, 2007. Available at www.headspace.org.au [verified 1 March 2010].

[73] Headspace: Australian Youth Mental Health Network. 2008. Available at www.headspace.org.au [verified 1 March 2010].

[74] Kastrup M,  Dupont A,  Bille M,  Nielsen JA,  Nielsen J. A comparative study of psychiatric outpatient treatment in two geographically defined populations. Compr Psychiatry 1978; 19(2): 103–8.
CrossRef | PubMed | CAS |

[75] National Health and Hospitals Reform Commission. Beyond the blame game; accountability and performance benchmarks for the next Australian Health Care Agreements. Canberra, April 2008.

[76] National Health and Hospitals Reform Commission. A healthier future for all Australians. Final Report. Australian Government Department of Health & Ageing, July 2009. Available at www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/content/nhhrc-report-toc [verified 1 March 2010].

[77] Australian Healthcare and Hospitals Association. The Mental Health Services conference of Australia & New Zealand, Inc. Mental Health Funding Methodologies and Governance, National Roundtable discussion paper. Sydney: PriceWaterhouseCoopers, 2008. Available at http://www.aushealthcare.com.au/publications/publication_details.asp?sr=0&pid=169 [verified 1 March 2010].

[78] National Health and Hospitals Reform Commission. A healthier future for all Australians. Interim Report. December 2008. Available at www.health,gov.au/nhhrc/publishing.nsf/content/interim-report-december-2008 [verified 1 March 2010].

[79] Heald D,  Dowdall A. Capital charging as a VFM tool in public services. Financial Accountability & Management 1999; 15(3–4): 209–28.
CrossRef |

[80] Pollock AM,  Chaoul J,  Vickers N. Private finance and ‘value for money’ in NHS hospitals; a policy of a rationale. BMJ 2002; 324 1205–9.
CrossRef | PubMed |




A A more detailed version of this paper was invited by Professor David Richmond, AO, then NSW Coordinator General of Infrastructure Development, NSW Department of Premier and Cabinet, and member of the Health Infrastructure Board, to stimulate discussion around the themes of integration and balance between hospital and community healthcare, as these issues confront all Australian states and Federal Government and other comparable international jurisdictions. He is currently Consultant on Infrastructure and Public Policy to NSW Department of Premier and Cabinet.

B Capital charging: the essence of capital charging is that the costs of capital facilities should be rendered explicit. This transparency is intended to introduce new discipline to decisions about the acquisition, use and disposal of publicly financed assets.79,80 In an environment of contestability between public and private services, there should be equitable accounting for the capital used in providing services and the cost of servicing that capital. This provides a driver for making efficiencies in the use of land, buildings, and equipment, which leads to selling off properties which may be designated as surplus to needs. In health administrations which assume the centrality of hospitals to the delivery of health care, this results in the financially penalising of area and local health services for operating from multiple sites, and forcing consolidation to fewer (and inevitably hospital) sites.

C Case example. A recently approved emasculated version of a ‘HealthOne’ integrated primary health care community health clinic at Chatswood in urban NSW, invited GP’s to co-locate in a few rooms of a small community ‘spoke’ or ‘outpost’ centre which can be booked for sessions interchangeably by visiting community health workers. They are to be otherwise firmly based at a ‘hub’ which comprises a 9 storey ‘community precinct’, some kilometres away on a major general hospital site, 13 minutes walking distance from access to their community health cars. It appears unlikely to provide comprehensive service coverage, nor a critical mass of staff to sustain a viable community health service, nor a viable referral base for GPs. The Local GP Network rejected this diluted version of what otherwise could have been a sound primary and community healthcare delivery model, but only if most aspects of community health had continued to be squarely based at the Chatswood community site. This outpost centre, now being built, may be only being placed in Chatswood gesturally to ‘end community speculation’ (according to the Ministerial press release) concerning the shifting of a formerly large community health centre from this major shopping area onto the more distant hospital site. This will then enable NSW Health to sell most of this valuable community site to contribute to the rebuilding of the hospital. The new centre is likely to become a white elephant. The devolved community health polyclinics, proposed by Darzi for the NHS in London, in high streets near the main shops and transport interchanges, with substantial and stable staffing, or similar integrated primary and community health centres in Portugal, would be much more likely to attract a critical mass of GPs in shared or adjacent premises.

Full Text PDF (161 KB) Export Citation Cited By (14)

View Altmetrics