Abstract
For more than a decade, suicide rates in Australia have shown no improvement despite significant investment in reforms to support regionally driven initiatives. Further recommended reforms by the Productivity Commission call for Federal and State and Territory Government funding for mental health to be pooled and new Regional Commissioning Authorities established to take responsibility for efficient and effective allocation of ‘taxpayer money.’ This study explores the sufficiency of this recommendation in preventing ongoing policy resistance. A system dynamics model of pathways between psychological distress, the mental health care system, suicidal behaviour and their drivers was developed, tested, and validated for a large, geographically diverse region of New South Wales; the Hunter New England and Central Coast Primary Health Network (PHN). Multi-objective optimisation was used to explore potential discordance in the best-performing programs and initiatives (simulated from 2021 to 2031) across mental health outcomes between the two state-governed Local Health Districts (LHDs) and the federally governed PHN. Impacts on suicide deaths, mental health-related emergency department presentations, and service disengagement were explored. A combination of family psychoeducation, post-attempt aftercare, and safety planning, and social connectedness programs minimises the number of suicides across the PHN and in the Hunter New England LHD (13.5% reduction; 95% interval, 12.3–14.9%), and performs well in the Central Coast LHD (14.8% reduction, 13.5–16.3%), suggesting that aligned strategic decision making between the PHN and LHDs would deliver substantial impacts on suicide. Results also highlighted a marked trade-off between minimising suicide deaths versus minimising service disengagement. This is explained in part by the additional demand placed on services of intensive suicide prevention programs leading to increases in service disengagement as wait times for specialist community based mental health services and dissatisfaction with quality of care increases. Competing priorities between the PHN and LHDs (each seeking to optimise the different outcomes they are responsible for) can undermine the optimal impact of investments for suicide prevention. Systems modelling provides essential regional decision analysis infrastructure to facilitate coordinated federal and state investments for optimal impacts.
Highlights
As part of the most recent major reforms (2015), the Australian Government established 31 Primary Health Networks (PHNs) across the country to decentralise decision making and enable investments in programs, services and initiatives that better respond to local population needs, contexts and priorities[15,16]
This study aimed to answer three key questions; (1) what impact on suicide outcomes could be achieved for the region if the optimal combination of programs and initiatives were identified and implemented; (2) if the priorities of the PHN and two LHD were aligned, would independent decision making regarding the optimal combination of programs and initiatives for the PHN catchment as a whole or LHD sub-regions deliver similar impacts on suicide outcomes; (3) if the priorities of the PHN and two Local Health Districts (LHDs) were not aligned, would impact on suicide outcomes for the region be undermined
We identified the best-performing combinations of interventions for each outcome across the PHN and in each LHD, as well as all intervention combinations performing better than every other combination on at least one outcome; these latter combinations, corresponding to non-dominated or Pareto optimal solutions, may be considered as optimal alternatives where the goal is to simultaneously minimise suicide mortality, emergency department (ED) presentations, and disengagement from care
Summary
As part of the most recent major reforms (2015), the Australian Government established 31 Primary Health Networks (PHNs) across the country to decentralise decision making and enable investments in programs, services and initiatives that better respond to local population needs, contexts and priorities[15,16]. This study aimed to answer three key questions; (1) what impact on suicide outcomes could be achieved for the region if the optimal combination of programs and initiatives were identified and implemented; (2) if the priorities of the PHN and two LHD were aligned (i.e., focussed on reducing suicide deaths), would independent decision making regarding the optimal combination of programs and initiatives for the PHN catchment as a whole or LHD sub-regions deliver similar impacts on suicide outcomes; (3) if the priorities of the PHN and two Local Health Districts (LHDs) were not aligned (i.e., each were seeking to optimise the different outcomes they are responsible for), would impact on suicide outcomes for the region be undermined In addressing these questions, this study will inform optimal strategies for overcoming policy resistance and delivering significant reductions in suicide for the region and will inform whether the pooling of funds and/or the aligning of agendas across national- and state-governed agencies is important
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