Child and Youth Mental Health

Tabled: 5 June 2019

Audit overview

There are many different terms used for children and young people in different contexts. In this report:

  • 'infants' are 0–4 years of age
  • 'children' are 4–12 years of age
  • 'adolescents' are 13–18 years
  • 'youth', 'young people' or 'young persons' are 13–24 years, ending on the individual's 25th birthday.

'Children and young people' is used in this report as a generic term that has no specific age grouping or may refer to several different groupings that are later specified.

Mental health problems are the most common health issues facing young people worldwide, according to the Global Burden of Disease Study 2017. Mental health problems encompass mild and short-term problems to severe, lifelong and debilitating, or life-threatening problems.

Three-quarters of all mental health problems manifest in people under the age of 25. One in 50 Australian children and adolescents has a severe mental health problem. Severe mental health problems include acute psychiatric disorders, such as schizophrenia, that are persistent and make daily tasks difficult. Some severe mental health problems can be triggered by trauma such as abuse or neglect, or by developmental disorders or physical trauma that leads to disability.

The likelihood of mental health problems increases exponentially where there are other indicators of vulnerability such as unstable housing and poverty, neglect and abuse, intergenerational trauma or developmental disabilities.

Intervention early in life, and early in mental illness, can reduce the duration and impact. Early intervention is especially important for children and young people because many mental health problems can affect psychosocial growth and development, which can lead to difficulties later in life.

Victoria's public mental health services focus on the treatment of more severe mental health problems and support infants, children, and young people through a mix of community, outreach, and inpatient hospital services. They also provide education, upskilling and leadership on managing mental health problems to the services and agencies that involve children and young people, which include schools, child protection, and disability services.

There has never been an independent review of clinical mental health services for children and young people in Victoria, despite significant changes in the service system with the introduction of the National Disability Insurance Scheme (NDIS) and headspace centres (youth-specific community mental health services).

This audit assessed the effectiveness of public child and youth mental health services (CYMHS) in one regional and four metropolitan health services. After our planning process identified the most significant risks for CYMHS, we focused on whether the services have been designed appropriately, and whether the Department of Health and Human Services (DHHS) is administering them effectively. The audit did not investigate the clinical effectiveness of individual patient care.

Conclusion

Not all Victorian children and young people with dangerous and debilitating mental health problems receive the services that they and their families need. This can lead to ongoing health problems, increasing the risk that children and young people will disengage from education and employment and be more likely to be involved with human services and the justice system.

Specialist child, adolescent and youth mental health services do improve many of their clients' outcomes, but they do not meet service demand or operate as a coordinated system. This can lead to significant deterioration in the health and wellbeing of some of Victoria's most vulnerable citizens.

DHHS has neither established strategic directions for CYMHS nor set expected outcomes for most of its CYMHS funding. This key issue inhibits service and program managers from realising efficiencies and improvements to service delivery such as working to a common purpose, sharing lessons or benchmarking progress.

Problems with the CYMHS performance monitoring system create oversight gaps for DHHS, which leaves it unable to address significant issues that require a system-level response. These issues include clinically unnecessary stays in inpatient mental health wards, and the admission of children and young people to adult mental health beds.

Health services express that due to DHHS's limited engagement with them, and monitoring systems that do not accurately reflect services' performance, DHHS does not sufficiently understand the CYMHS system and the challenges it faces. DHHS's lack of understanding contributes to a climate of uncertainty and distrust, which inhibits systemic improvement and creates significant variability and inequity in the care that children and young people receive.

DHHS has predominantly taken a one-size-fits-all approach to the mental health system's design and monitoring, which does not adequately identify and respond to the unique needs of children and young people.

Findings

Design of child and youth mental health services

There is no strategic framework to guide and coordinate DHHS or health services that are responsible for CYMHS, which is evident in a range of issues with the CYMHS design:

  • DHHS lacks a rationale for the programs and services it funds and there has been a lack of transparency in how some programs and services have been funded.
  • Some health services receive funding for programs that technically have ceased, and health services that provide similar activities receive different funding.
  • DHHS does not set expectations for service delivery for most funded programs and does not monitor what programs and activities health services deliver.
  • DHHS has not adequately considered the geographic distribution of services relative to the population, which creates inequities in service provision.
  • There is a confusing mix of age eligibility arrangements across services—some treat young people up to the age of 25 and some up to 18. This is because in 2006, DHHS began increasing service eligibility to 25, but stopped the rollout midway through when the government changed.
  • DHHS has not considered CYMHS's particular workforce challenges and needs that can vary from the adult sector, and the recent DHHS mental health workforce strategy does not specifically address CYMHS workforce issues. DHHS advises that the new Centre for Mental Health Learning is now mapping workforce needs, including for CYMHS.

While the cause of this lack of a strategic approach to CYMHS is unclear, high staff turnover in leadership roles and lack of specific performance oversight of CYMHS are likely contributing factors.

DHHS's commitment to reform the mental health funding model into activity‑based funding has not progressed for CYMHS. DHHS has taken no action to address the known problems with transparency and equity in the current funding model.

Monitoring performance, quality and outcomes

DHHS's performance monitoring of CYMHS comprises seven separate systems that are conducted in silos. The different areas that hold responsibility for monitoring within DHHS do not coordinate to identify common or systemic issues, nor do they share the information they collect. The current arrangement offers significantly limited oversight of CYMHS:

  • The Mental Health Branch's program meetings discussed CYMHS only once in four years for four health services.
  • Key performance indicators (KPI) to measure CYMHS differ from the national mental health performance framework limiting performance benchmarking.
  • The two CYMHS KPIs that inform DHHS's quarterly performance discussions with chief executive officers (CEO) only concern services provided to patients who have had an inpatient admission.
  • There are no KPIs or monitoring of some significant issues in CYMHS, such as long inpatient stays, accessibility, service coordination or family engagement in care.

The lack of service performance expectations and the limitations of DHHS's performance monitoring systems for CYMHS also hinder its ability to accurately advise government on how this important system performs, or what improvements are needed.

Monitoring the quality and safety of service delivery

The Chief Psychiatrist has legislated responsibilities to monitor service quality and safety in CYMHS. The Office of the Chief Psychiatrist (OCP) has delivered a large program of activities to review and improve service quality across mental health services; however, there has been no attention to the unique issues in CYMHS. Rather, the monitoring is reactive and crisis-driven, with limited focus on systemic issues.

DHHS does not routinely monitor the quality of CYMHS service delivery. Further, DHHS has commissioned two significant evaluations and reviews of new CYMHS services that have not been publicly released, and their findings have not been communicated to the CYMHS that were reviewed. A further nine reviews and analyses that DHHS conducted internally include information about CYMHS that could contribute to broader service quality improvement; however, these have not been provided to health services.

Access for vulnerable populations

DHHS has not identified priority populations or enabled health services to provide priority access to those most in need. Only one of the five audited health services has implemented the Chief Psychiatrist's 2011 guideline to prioritise children in out-of-home care. DHHS has not reviewed the guideline or its implementation since its release. Furthermore, DHHS's data does not record a client's legal status, which means there is no mechanism to reliably identify children in out-of-home care in the CYMHS system.

DHHS has not reviewed its triage scale since its introduction in 2010. DHHS is aware that the triage scale is not optimal for children and young people because it does not consider developmental risks and does not enable prioritisation of access for high-risk population groups.

Service coordination around multiple and complex needs

Young people are routinely getting 'stuck' in CYMHS inpatient beds when they should be discharged, because they cannot access family or carer support and/or services such as disability accommodation or child protection and out-of-home care. DHHS does not monitor this issue of inpatient stays that are clinically unnecessary despite health services having raised it repeatedly.

Current data systems prevent definitive monitoring of clinically unnecessary stays in CYMHS inpatient beds. However, the five audited health services provided to this audit 29 case studies from the prior 12 months that show at least 1 054 bed days used by patients without clinical need to be mental health inpatients. While some of the drivers of this problem are complex social and family issues, DHHS has not taken strategic action to address systemic issues with service coordination that they have the authority to resolve.

Monitoring long inpatient stays would provide a partial indicator of clinically unnecessary stays. DHHS could not explain why it monitors long stays over 35 days for the adult mental health system, but not for CYMHS, despite our data analysis showing that there have been 228 long stays in four health services over three years, of which 107 were children under 18 years.

In one region, there has been a long‐running dispute between two service providers over referral and discharge processes. DHHS has acted to resolve this issue, which caused longer inpatient stays for approximately 300 adolescents per year, by advising the health services to meet monthly and to escalate matters that cannot be resolved to the Chief Psychiatrist.

Clients with intellectual or developmental disabilities complicated by mental health problems account for many long and/or clinically unnecessary inpatient stays. DHHS has not responded adequately to CYMHS's reports about the service gap for young people with dual disability and the significant negative impacts on CYMHS's resources, workforce and the young people and their families.

DHHS and the Department of Justice and Community Safety's (DJCS) shared Multiple and Complex Needs Initiative (MACNI) provides case management for people aged 16 and over with mental illness, complex needs, and dangerous behaviours. Eligibility criteria are too narrow and processes too slow for this service to assist CYMHS with complex clients who are 'stuck' in inpatient units.

A $5.5 million pilot project that DHHS funded three years ago, and another CYMHS's independent service development, have lessons and resources that DHHS has not shared with other CYMHS. DHHS has not responded to either of these services' recommendations to address gaps in accommodation and service coordination for these young people, nor taken any action to support other CYMHS with providing services to clients with dual disability who have complex needs.

Recommendations

We recommend that the Department of Health and Human Services:

  1. in conjunction with child, adolescent and youth mental health services and consumers, develop strategic directions for child, adolescent and youth mental health services that include objectives, outcome measures with targets, and an implementation plan that is supported by evidence‑based strategies at both the system and health service levels (see Section 2.2)
  2. when implementing the six recommendations from the VAGO audit Access to Mental Health Services, ensure that the needs of children, adolescents and young people as well as child, adolescent and youth mental health services are considered and applied, wherever appropriate (see Section 1.4)
  3. establish and implement a consistent service response for 0–25 year-olds in regional Victoria that need crisis or specialised support beyond what their local child, adolescent and youth mental health services' community programs can provide, including reviewing the extent to which the six funded regional beds are able to provide an evidence-based child and adolescent service (see Sections 2.4 and 3.2)
  4. establish and implement a transition plan towards achieving a consistent service response for 19–25 year-olds with moderate and severe mental health problems (see Section 2.5)
  5. develop and implement a child, adolescent and youth mental health workforce plan that includes understanding the specific capability needs of the sector and specifically increasing capabilities in the area of dual disability, that is, intellectual or developmental disabilities complicated by mental health problems (see Section 2.7)
  6. refine, document and disseminate the performance monitoring approach for child and youth mental health services so it consolidates current disparate reporting requirements and includes:
    • measures that allow monitoring of long inpatient stays, priority client groups, clinical outcomes and accessibility of child and youth mental health services
    • introducing quality and safety measures of child and youth mental health services community programs in the Victorian Health Services Performance Monitoring Framework
    • the role of the Chief Psychiatrist in performance monitoring, and how the information it receives from mandatory reporting informs the Department of Health and Human Services' performance monitoring
    • documenting in one place all reporting requirements for child and youth mental health services from all areas of the Department of Health and Human Services, including administrative offices Safer Care Victoria and the Victorian Agency for Health Information
    • how the Department of Health and Human Services will respond to performance issues (see Sections 3.2 and 3.6)
  7. ensure that six-monthly mental health program meetings occur and information received is consolidated to identify systemic and persistent issues (see Section 3.4)
  8. initiate negotiations with the Department of Treasury and Finance during the state budget process to ensure that Budget Paper 3 performance measures include monitoring of child, adolescent and youth mental health services (see Section 3.6)
  9. disseminate evaluations and reviews of child, adolescent and youth mental health service projects and services to all child, adolescent and youth mental health service leaders (see Section 3.7)
  10. formally respond to all recommendations made in the 2016 review of the role of the Chief Psychiatrist and advise the Minister for Mental Health on intended actions (see Section 3.7)
  11. in consultation with health services, ensure that the Chief Psychiatrist's guidelines and directions are effectively communicated to those responsible for their implementation in child, adolescent and youth mental health services and that their implementation is supported and monitored (see Section 3.7)
  12. benchmark the performance of child, adolescent and youth mental health services in Victoria at the system level against other jurisdictions, and national and international targets, and report the findings and opportunities for improvement subsequently identified in the Mental Health Annual Report (see Section 3.8)
  13. ensure that the data that the Department of Health and Human Services and/or health services need to collect about child and youth mental health services for their reporting and monitoring obligations, including the outcome measures and targets developed through Recommendation 1, is consistent with what is collected and recorded in the Client Management Interface database and develop a single and comprehensive source of guidance and business rules about data reporting requirements (see Section 3.9)
  14. update the triage scale and process so it is developmentally appropriate for children, adolescents and young people, and considers how triage can be provided at peak periods of demand such as evenings and weekends (see Section 4.2)
  15. ensure the registration forms that the Department of Health and Human Services issues to health services can record a child, adolescent or young person's legal status with regards to guardianship, out-of-home care, and restrictive interventions or compulsory treatment under the Disability Act 2006, that the information can be entered into central databases, that business rules exist for doing so and data entry is monitored to ensure it is occurring (see Section 4.2)
  16. provide written guidance to child and youth mental health services' leaders about both the Department of Health and Human Services' Complex Care Panels and the Multiple and Complex Needs Initiative, which includes how to refer clients to each, how to contact the necessary staff in each Department of Health and Human Services geographic area for information and advice, which clients are eligible for each, and is updated at least annually (see Section 4.3)
  17. consider establishing a High-Risk Complex Care Child and Youth Panel, with executive representation from out-of-home care, disability services, and mental health areas of the Department of Health and Human Services, with remit to:
    • allow health services to rapidly escalate cases to the panel when a local service response is not meeting a young person's needs, to prevent a clinically unnecessary inpatient stay that may cause deterioration of the young person's health and wellbeing
    • identify and address service gaps and service coordination challenges that are contributing to clinically unnecessary inpatient stays
    • liaise with the National Disability Insurance Agency, as required (see Section 4.4)
  18. create a channel for the Chief Psychiatrist to independently brief the Minister for Mental Health or the Secretary, if they deem it necessary (see Section 4.4)
  19. establish and implement a consistent service response for 0–25 year-olds who have intellectual or developmental disabilities and moderate to severe mental health problems (see Section 4.5)
  20. establish a mechanism for operational and clinical leaders of all child, adolescent and youth mental health services to collaborate with each other and with the Department of Health and Human Services to improve service response consistency, and strengthen pathways between services for clients and families, including reviewing catchment boundaries and access to specialised statewide programs (see Section 4.5).

Responses to recommendations

We have consulted with DHHS, Albury Wodonga Health (AWH), Austin Health, Eastern Health, Monash Health and the Royal Children's Hospital (RCH) and we considered their views when reaching our audit conclusions. As required by section 16(3) of the Audit Act 1994, we gave a draft copy of this report to those agencies and asked for their submissions or comments. We also provided a copy of this report to the Department of Premier and Cabinet.

DHHS provided a response. The following is a summary of its response. The full response is included in Appendix A.

DHHS accepted each of the 20 recommendations, noting that implementation of the recommendations will be informed by the outcomes of the Royal Commission into Mental Health, particularly recommendations relating to system design. DHHS will develop strategic directions and refine the performance monitoring approach for services, share reviews and evaluations, update triage and registration processes, provide guidance around complex care panels, consider establishing a High-Risk Complex Care Child and Youth Panel, establish a mechanism for health services to collaborate and create a means for the Chief Psychiatrist to independently brief the Secretary or Minister for Mental Health.

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