Good afternoon Chair, Commissioners and others
My name is Patrick Lawrence and I am the CEO of Australia’s pioneer hub for adults with complex and chronic mental health. Across the Productivity Commission’s draft report three words appear almost 500 times: “integration”, “collaboration” and “team”, nearly always to describe what should be, not what is. At First Step we’ve been perfecting multi-disciplinary team care for 20 years. With no fees for clients, no referral required for many services, and an attitude of unconditional positive regard for people who seek our help, First Step also embodies non-judgement, trauma-informed care, accessibility and the policy of no-wrong-door.
The Productivity Commission’s powerful draft report was devoid of convincing examples of multi-disciplinary care for adults with mental ill-health. I am here today to provide you with that example.
First Step is a not-for-profit mental health, addiction and legal services hub in St Kilda. But it’s not just a collection of independent services on one site. First Step is an integrated TEAM of highly-skilled, highly-qualified clinical and non-clinical staff who collaborate constantly in the planning and treatment of our clients. This goes way beyond warm referrals at a single convenient location. This is detailed initial assessment and the formation of a purpose-built, multi-disciplinary team for each client, which can grow, change and reduce in size and scope (step down) according to the client’s ongoing needs.
It is important to understand the breadth of expertise and support we’re talking about here, all in one building:
GPs with clinical nursing support, addiction medicine specialists, psychiatry
Psychology (clinical and counselling), mental health nurses, care coordinators, drug and alcohol therapists, peer workers, group therapist and family therapists,
Also, psychosocial workers with access to brokerage funding, gastroenterology, Hep C nurses AND a community legal centre - the only criminal law practice within a health practice in the entire country.
What we aim for at First Step is incremental whole-of-life improvements. Any advances in recovery will be held back by the weakest link in the chain (for example harmful substance use), which is why incremental whole-of-life improvements are not a realistic goal without a multi-disciplinary team working from a single site.
At First Step we see many people at the lowest point in their lives. Our ability to stabilise, support and empower people has led Prof Patrick McGorry to describe our approach as, and I quote “exactly right to tackle the tenacious co-existence of mental ill-health and drug and alcohol problems . . . and it’s having great results.” We treat two-and-a-half thousand people every year, support more people on opiate substitution therapy than any other clinic in a Victoria, and have developed a peerless reputation among services users and indeed other services in the south east of Melbourne. In conversation with clients I am forever being told “this place saved my life.”
The critical element of First Step is our multi-disciplinary model, and its obvious benefits are the immediacy of secondary consultation and ongoing collaboration. But this approach has structural, attitudinal and ethical elements that create a unique ecosystem with countless benefits to clients, practitioners and the community.
- A greater capacity to manage risk
- continuity of care through in-house stepping up or down
- minimising the risk of ‘falling through the cracks’
- daily inter-disciplinary expansion of clinical knowledge
The Productivity Commission estimates $1,200+ for an acute bed for 24 hours. Non acute: almost $600. The Council Of Australian Governments provides figures of $300-400 per day for incarceration in Victoria. At First Step, with intensive support (multiple consultations every week) from a team including a GP, mental health nurse, care coordinator and psychosocial worker, ongoing legal support and two-monthly appointments with our psychiatrist would cost just $29 a day. That includes organisational overheads (the calculations, funding sources and other details are in your handout). $29 a day! That is comprehensive, multi-disciplinary team care in the community of a kind unique in intensity to First Step . . . for one-tenth of the cost of incarceration. Per 24-hour period that’s 6% of the cost of a non-acute hospital bed.
AND it’s about getting better. The goal all the while is to stabilise, support and empower our clients. For most people, reliance on services will reduce over time, which is the exact opposite of what happens when someone is released from prison or discharged from hospital, possibly at risk of homelessness.
First Step doesn’t claim to have insights into rural settings or indigenous communities. But in an urban setting the First Step model is absolutely scalable, and replicable by other organisations across the country. First Step looks and feels like a friendly GP clinic and is mostly funded through Medicare and the Primary Health Network, both of which, of course, apply across Australia. The Productivity Commission’s draft report identifies an upper limit of 250,000 Australians needing intermittent care with “episodic or persistent severe mental health” and “complex needs”. To support the most vulnerable 10% of that group with the most intensive First Step regime described above would cost $300M per annum. The health economists can calculate how much of the annual burden of $180B identified by the Report would be saved in terms of reduced hospitalisations, reduced imprisonment, reduced welfare payments, decreased deaths including suicide and increased well-being, social connection and participation. But it would be expenditure in millions for savings in billions.
The Productivity Commission needs to closely examine First Step and consider our successful model in its recommendations with regard to closing critical gaps in healthcare services (reform area 2) and fundamental reform to care coordination, governance and funding arrangements (reform area 5). I extend a warm welcome to the Commissioners and their staff to visit First Step, any time.