1. www.cimh.unimelb.edu.au CIMH Mental Health Leadership in a Changing World Harry Minas Centre for International Mental Health The University of Melbourne

2. Centre for International Mental Health www.cimh.unimelb.edu.au Traditional role of psychiatrists 3% severe mental disorders Psychiatrists have traditionally worked on providing the best quality clinical care to the people with the most severe mental disorders In most countries this has meant a focus on hospital-based care for people with psychotic and severe affective disorders Psychiatric training has focused on the development of clinical skills for this limited patient group Psychiatrists have generally left policy and service design issues to others Research (and research skills) has been focused on basic science of mental disorders and clinical interventions, with little interest in cost- effectiveness or in research on health systems

3. Centre for International Mental Health www.cimh.unimelb.edu.au Expanded roles for psychiatrists 3% severe mental disorders 20% total mental disorder Epidemiological work has increasingly focused on the high prevalence of depression, anxiety and other disorders in populations, on the high population burden due to these disorders, and the fact that most people with these disorders are untreated or poorly treated In addition, problems with large mental institutions, and human rights concerns, have increased the pressure to move the focus from hospital-based to community-based systems The role of psychiatrists has shifted from clinical specialist to leader of multi-disciplinary teams and negotiator with governments, families, clinician colleagues working in the community (such as general practitioners), NGOs, and other (non-health) sectors

4. Centre for International Mental Health www.cimh.unimelb.edu.au Expanded roles for psychiatrists 3% severe mental disorders 20% total mental disorder Population mental health A focus on population mental health requires that psychiatrists focus on mental health promotion, illness (and suicide) prevention, and early intervention This requires a broader community leadership role and working with community groups, the media and governments

5. www.cimh.unimelb.edu.au CIMH Leadership  The process through which an individual intentionally influences another individual or, more usually, a group in order to accomplish a goal.  Leadership involves defining and communicating a vision for the future, based on some core and explicit values, aligning people with that vision, and inspiring them to work to make it happen, despite obstacles.  Transforming the current reality into the imagined future.  Leadership is always focused on change, from how things are to how they ought to be.

6. www.cimh.unimelb.edu.au CIMH Change Change is constant  What may have been acceptable in the past is less acceptable now.  Most people with mental illness:  receive no treatment  are excluded from the benefits of citizenship  work, education, decent accommodation, respect  have their rights neglected or abused  have no voice  decisions are made for them by others  Mental health service = Mental Hospital  Now a wide range of different types of service are expected to meet a wide range of different needs

7. www.cimh.unimelb.edu.au CIMH Leadership  Effective leadership infects others with:  Enthusiasm  Energy  Drive  Confidence  Determination  Belief that the common goal of the group can be achieved  The leader  Articulates the group’s mission  Gives clarity and direction to the activities of the group  Keeps the group focused and on track

8. www.cimh.unimelb.edu.au CIMH Leadership - in its simplest representation ETHICS Service to others ETHICS Service to others COURAGE Act with sustained initiative COURAGE Act with sustained initiative Strategy REALITY Clear analysis of current problems REALITY Clear analysis of current problems VISION Compelling image of what is desirable and possible VISION Compelling image of what is desirable and possible

9. www.cimh.unimelb.edu.au CIMH Problem Definition  This is the most critical, and most neglected, part of achieving mental health system reform  Mental health is a low priority  Indonesia spends 1% of the total health budget on mental health (WHO Atlas 2005)  Mental illness has to become an important national problem  Human rights  Economic burden  Barrier to social and economic development  Key public health problem  Those who have the power to define what are the important problems get the resources  Security, Global warming  There is not yet a sufficiently clear and coherent definition of the problem of mental health at national and international levels REALITY Clear analysis of current problems REALITY Clear analysis of current problems

10. www.cimh.unimelb.edu.au CIMH Social and economic burden  We know that mental illness:  accounts for a large proportion of the total burden of disease, and that this proportion will increase  is the biggest cause of disability  imposes a huge economic burden on society in terms of lost productivity, etc.  can be a substantial a barrier to economic and social development  associated with descent into poverty

11. www.cimh.unimelb.edu.au CIMH Public health problem  Mental disorders and mental health problems are risk factors for:  Non-communicable disease  Cardiovascular disease  Diabetes  Communicable disease  HIV-AIDS  Injury  Deliberate self-harm and suicide  Maternal depression and child development  Child malnutrition, stunting, impaired development  Comorbidity  Complicates help-seeking, diagnosis and treatment, and  Adversely influences prognosis

12. www.cimh.unimelb.edu.au CIMH Human Rights Problem Is this what we want mental services to be? In many parts of the world this is the current reality

13. www.cimh.unimelb.edu.au CIMH Solutions?  We have:  a better understanding of mental illness than ever before  effective and affordable treatments  evidence for what kinds of service are most effective in meeting the needs of people with mental illness  evidence for what kinds of services people with mental illness, and their families, prefer  But:  We are not making effective use of this knowledge for the benefit of people with mental illness

14. www.cimh.unimelb.edu.au CIMH Vision: What MH services should be  Mental Health Services should be:  Effective - achieve clinical outcomes  Appropriate - relevant to needs  Efficient - cost-effective  Responsive - protect rights & consider preferences  Accessible and equitable - geographic and financial accessibility, provided according to need  Safe - for patients, staff, community  Continuous - across time, programs, organisations  Capable - knowledgeable and skilled staff  Is this vision shared by all relevant stakeholders? or  Do different stakeholder groups have very different ideas about what the most important problems are and what a future mental health system should be? VISION Compelling image of what is desirable and possible VISION Compelling image of what is desirable and possible

15. www.cimh.unimelb.edu.au CIMH Test of agreement on Vision for the future If the national budget for mental health were doubled tomorrow what percentage of the additional money would you allocate to each of the following areas? % Building new mental hospitals Improving the quality of care in existing mental hospitals Establishing new general hospital inpatient psychiatry unit Improving quality of care in existing general hospital inpatient psychiatry units Expanding outpatient psychiatry clinics Establishing community mental health services Developing mental health care in primary health care services Improving psychiatric rehabilitation services Developing supported community accommodation Strengthening consumer and carer organizations Provision of community information/education about mental health and illness Community mental health promotion programs 100

16. www.cimh.unimelb.edu.au CIMH Leadership  The highest priority issues in developing a leadership strategy are:  Defining mental health as an important problem for governments  Achieving agreement among key stakeholder groups about the core elements of the vision for the future  Demonstrating that solutions are available and politically feasible Strategy REALITY Clear analysis of current problems REALITY Clear analysis of current problems VISION Compelling image of what is desirable and possible VISION Compelling image of what is desirable and possible

17. www.cimh.unimelb.edu.au CIMH Stakeholders  Governments  Ministries of Health, Finance, Social Services, Employment, etc.  General community  Patients and their families  Service Providers  Mental Health Professionals (and their associations)  Psychiatrists, Psychologists, Nurses, Social workers, etc.  General Health Professionals (and their associations)  Health Institutions  Public and private hospitals, Health insurance organisations (public and private), Pharmaceutical industry, etc.  Universities and training colleges The mental health sector is very broad, with many stakeholders:

18. www.cimh.unimelb.edu.au CIMH Stakeholders  Governments  Ministries of Health, Finance, Social Services, Employment, etc.  General community  Patients and their families  Service Providers  Mental Health Professionals (and their associations)  Psychiatrists, Psychologists, Nurses, Social workers, etc.  General Health Professionals (and their associations)  Health Institutions  Public and private hospitals, Health insurance organisations (public and private), Pharmaceutical industry, etc.  Universities and training colleges The mental health sector is very broad, with many stakeholders: Coherent Demands

19. www.cimh.unimelb.edu.au CIMH Stakeholders  The three key stakeholder groups that need to persuade government to improve mental health services are: 1. The general community (issues of community safety, cost of services to community) 2. People with mental illness and their families (issues of accessibility, quality and affordability of services) 3. Service providers (Mental health professionals are only a small part of this broad group)  A mechanism is needed for these groups to talk to each other, to discover what they agree about, and to put on hold what they disagree about  Who will do this?  ? National NGO with representation of all the key stakeholder groups  An example is the Mental Health Council of Australia  If there is no agreement between the three groups (and the sub-groups within them) about what needs to be done then taking any action is a risk for governments  When there is no clear way forward governments will prefer to do nothing

20. www.cimh.unimelb.edu.au CIMH Leadership COURAGE Act with sustained initiative COURAGE Act with sustained initiative Strategy  Taking sustained action to achieve agreement among key stakeholders about the core elements of the vision for the future is a key leadership task REALITY Clear analysis of current problems REALITY Clear analysis of current problems VISION Compelling image of what is desirable and possible VISION Compelling image of what is desirable and possible

21. www.cimh.unimelb.edu.au CIMH Leadership ETHICS Service to others ETHICS Service to others COURAGE Act with sustained initiative COURAGE Act with sustained initiative Strategy  Act with integrity in the interests of people with mental illness REALITY Clear analysis of current problems REALITY Clear analysis of current problems VISION Compelling image of what is desirable and possible VISION Compelling image of what is desirable and possible Becomes the new Reality - with new problems to be solved  Taking sustained action to achieve agreement among key stakeholders about the core elements of the vision for the future is a key leadership task

22. www.cimh.unimelb.edu.au CIMH Obstacles and Opportunities  A key obstacle to mental health system reform and development is the lack of a unified voice among key stakeholder groups about:  What the most important problems are  What the future mental health system should be  A key opportunity for psychiatrists is to lead in developing this consensus and in taking a common view to governments about what must be done