Dietitians essential in mental health care

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Draft National Mental Health Workforce Strategy Response to consultation September 2021 Recipient ACIL Allen [email protected] Dietitians Australia contact Julia Schindlmayr, Policy Officer [email protected] dietitiansaustralia.org.au Draft National Mental Health Workforce Strategy 2 About Dietitians Australia Dietitians Australia is the leading voice in nutrition and dietetics and advocates for food and nutrition for healthier people and healthier communities. Dietitians Australia is the national associati on of the dietetic profession with over 8200 members, and branches in each state and territory. Dietitians Australia appreciates the opportunity to provide feedback to ACIL Allen regarding the Draft National Mental Health Workforce Strategy.

The Accredited Practising Dietitian (APD) program provides an assurance of safety and quality and is the foundation of self -regulation of the dietetic profession in Australia. Quality diet and nutrition play fundamental roles in both risk reduction and sym ptom alleviation in mental illness and related physical comorbidities. Dietary interventions led by APDs are significa ntly more effective than when delivered by other health professionals. APDs have a critical role in the mental health care team to support consumers living with mental illness.

This submission was prepared by members of the Dietitians Australia Mental Health Interest Group.

other mental health expert members and staff following the Conflict of Interest Management Policy and process approved by the Board of Dietitians Australia. Contributors include Dietitians Australia members with wide ranging expertise in mental health and mental illness across the spectrum of practice settings.

R ecommendations 1. The Strategy should include a broad definition of the mental health workforce to ensure that professions not traditionally included, like dietitians, are recognis ed for the critical role they play in mental health care.

2. The physical health of people living with mental illness should receive much greater attention in the draft Strategy to align with other government initiatives and to drive the composition of multidis ciplinary mental health care teams.

3. The ways in which the draft Strategy intend s to meet the goal of placing greater emp hasis on and facilitating prevention and early inter vention efforts need to be clarified and expanded upon.

4. Barriers in career development and progression, and access to supervision, that currently exist in professions like dietetics need to be acknowledged and strategies to mitigate those barriers should b e identified.

5. Greater emphasis needs to be given to the specific challenges faced by the rural and remote workforce, and the R ural Area Community Controlled Health Organisation model of care should be given consideration.

6. Remuneration should be addressed in the Strategy as part of the considerations for ensuring careers in mental health are seen as attractive.

7. Dietetics needs to be recognised further and throughout the Strategy to address the current barriers and challenges that face the profession.

Draft National Mental Health Workforce Strategy 3 Discussion General comments Dietitians Australia is pleased to see dietitians specifically mentioned as part of the mental health workforce and congratulates ACIL Allen on the work undertaken to date.

Areas which need more emp hasis include.

• The physical health of people living with mental illness needs to be addressed and needs in part to drive the makeup of the mental health multidisciplinary care team. Both inpatient and community health care teams need to include dietitians. The Strategy should provide for better focus on the right care in the right place at the right time • Dietitians need to be recognised as key players in prevention and early intervention and need to be brought in to care teams early • Career development in dietetics is hampered by current workforce structure and grading of positions. Career opportunities and sound supervision in dietetics is reliant on senior and management positions existing where they don’t current ly or a re l acking • Training for all health professionals needs to be more comprehensive and include mental health and mental health placements. Nutrition training for non -nutrition professionals is also needed to improve knowledge of nutrition impacts and need for dieteti c intervention • The Strategy should include all professions currently involved in mental health care while also allowing for emerging professions to be identified and included later • The role of peer workers and their training, skills and integration in to mental health care teams needs more consideration, including the co -design and joint facilitation of programs While the draft Strategy does well in identify ing current workforce issues and the priorities and actions needed to address them, innovation for future needs for a comprehensive, effective mental health workforce are still wanting.

Responses to consultation questions 1. To what extent does the aim of the draft Strategy address the key challenges facing Australia’s mental health workforce.

Dietitians Australia believes the aim of the draft Strategy addresses the key challenges facing Australia’s mental health workforce. The aim appropriately acknowledg es that people from all backgrounds and in all locations need timely access to a skilled mental health workforce in a way that best suits their needs. The aim also addresses the importance of broadening the defini tion of need beyond acute care to incorporate prevention and early intervention. Dietitians Australia would like to see a broader definition of the workforce itself incorporated into the aim to acknowledge professions not traditionally included as part of the mental healthcare team, such as dietitians, but that play a critical role in mental health and that should be recognised as mental health practitioners.

Under Roles and Responsibilities, shared responsibility between Commonwealth, State and Territory governments for funding should be clearly defined to avoid ambiguity. This section lists the current functions and funding responsibilities of the respective levels of government but does not place any impetus on them to actively work together to implement the necessary reforms. Governments will need to be proactive and committed to working together to drive reform and this expectation should Draft National Mental Health Workforce Strategy 4 be made clearer in the Roles and Responsibilities section. Responsibilities should be further defined and detailed in an implementation plan that specifies funding responsibilities, timeframes for delivery and evaluation processes.

Dietitians Australia would also like to see co -design initiatives incorporated under “Education providers” to ensure peak bodies and other relevant groups, including peer support workers, are engaged in the identification and design of appropriate training programs.

2. To w hat extent do the aim and objectives provide a strategic framework to develop the mental health workforce the Au stralian community needs.

Dietitians Australia believes t he strategy’s aim and objectives provide a framework to develop the mental health workforce, noting that the final strategy will need to be supported by an Implementation plan (or series of plans) wi th funding, timeframe and evaluation process commitments detailed.

3. Are there any additional priority areas that should be included.

Inclusion of a new model of care in rural and remote settings Dietitians Australia recommends Objective 6 be expanded to include a new model of care for rural and remote settings. An example of such a model has been proposed by the National Rural Health Alliance – the Rural Area Community Controlled Health Organisations (RACCHOs) – and is supported by Dietitians Australia. The detail of this proposed new model of care is available on the National Rural Health Alliance website. Dietitians Australia recommends a n additional Priority Area be included at 6.4: establish new models of rural health care which are structured, funded, and governed to address the particular needs of rural communities, and that this new model of care be included as a new Action 6.4.1.

Diet itians Australia believes that Objective 6 does not adequately address the rural -specific challenges in overcoming the professional, financial and personal barriers to attracting and retaining a healthcare workforce in rural Australia. These barriers are beyond those experienced more generally and are specific to rural, regional and remote Australia.

Benefits of the RACCHO model of care include providing.

• a mechanism for efficient sharing of limited funding, workforce and infrastructure • secure, ongoing employment to a multidisciplinary team of healthcare professionals • a single employer, offering a secure income for a multidisciplinary team, thus overcoming the professional isolation and problems with work -life balance associated with rural practice • a hub for professional development, support inter -professional understan ding and allow all professionals to work to their full scope of practice.

• an excellent site for mental health training placements across the scope of mental health professionals • communit y collaboration in the initiat ion and design • flexib ility and responsi ve ness to community needs • access for all community members • a range of services and continuity of care for consumers Promoting prevention and early intervention The aim of the draft Strategy includes reference to expanding mental health care to encompass prevention and early intervention, however, it is not clear how the Strategy will achieve this.

Draft National Mental Health Workforce Strategy 5 Dietitians Australia recommends including m ore specific actions related to prevention and early intervention to clearly identify how the Strategy will address this aim.

Dietetic interventions are particularly effective when delivered as preventive or early intervention measures and should be incorporated early in treatment. This needs to be supported by clear an d easily accessed referral pathways, supported through Medicare and community -based government – funded initiatives. This would be further assisted by ensuring remuneration of dietetic FTE positions is set at an appropriate and attractive level.

Access to pr imary care is critical to meet the aim of promoting prevention and early intervention and mental wellbeing. The lack of access to primary care in rural and remote Australia significantly impacts the opportunities for prevention and early intervention in me ntal health support and treatment. Rural and remote Australians are less likely to access M edicare Benefits Schedule funded primary mental health care services than their urban counterparts, yet more likely to u se the state and territory government -deliver ed community mental health care sector. They are also more likely to present to an emergency department with a mental health concern. When rural and remote Australians access hospital based mental health care, they are less likely to receive the specialised psychiatric services they need. Dietitians Australia believes this illustrates the lack of alignment between population need and access to primary mental health care outside of major cities and a resultant shifting of care to more acute parts of the health system, where people are likely to present later in the trajectory of their illness or condition with more severe symptoms. Lack of u se of primary mental health car e not only costs the health system more but is likely to contribute to poorer outcomes for rural and remote people.

The Strategy should be reviewed to incorporate Actions to strengthen support for prevention and early intervention, particularly through im proving access to primary care, including for rural and remote Australians.

4. The draft Strategy seeks to balance the need for nationally consistent approaches that support the reform agenda with sufficient flexibility for states, territories and service providers to pursue priorities that reflect their specific contexts and challenges across occupations and settings (public, private and community -based). To what extent does the draft Strategy achieve an appropriate balance.

As indicated in response to ques tion 3 above, Dietitians Australia recommends inclusion of a model of care that addresses the specific issues faced in rural and remote settings. Objective 6 identifies that there are limited links between national planning processes and local planning and highlights the need for locally -led processes. The RACCHO model would respond to this need. Models of care that work for metropolitan areas do not work for rural and remote Australia. Flexibility to pursue priorities that reflect specific contexts and challenges will be an essential element of the Strategy.

Dietitians Australia believes that there needs to be national and state/territory government acknowledgement that the current fra gmented approaches do not address the maldistribution of the health workforce, including the mental health workforce. Despite numerous strategies at various levels of government, the health workforce shortage in rural, regional and remote Australia remains severe.

5. The draft Strategy provides a high -level roadmap to improve the attractiveness of careers in mental health, with implementation approaches differing across occupations and locations. To what extent does the draft Strategy provide a useful approa ch to addressing issues that impact on the attractiveness of the sector.

Draft National Mental Health Workforce Strategy 6 Appropriate remuneration is a key driver for attracting and retaining staff, yet there is no overt mention of remuneration in the strategy. Dietitians Australia recommends that remuneration be addressed as part of Objective 1 – Careers in mental health are, and are recognised as, attractive.

Attracting and retaining a mental health workforce in rural, regional and remote settings requires add ressing the inherent barriers posed by those settings. Dietitians Australia believes that over and above the priorities currently identified in the Strategy, a rural -specific, place -based model of care is also required. See responses to questions 3 and 4 a bove.

Dietitians Australia notes that Priority Area 1.2 includes discussion around the need to increase awareness of pathways into the mental health workforce including the importance of vocationally and higher education trained occupations having the oppo rtunity to work across settings (e.g..

public, private, community settings, in regional and remote locations) and roles. The Strategy should make it clear that awareness of the diversity of the sector should include exposure to a diversity in the severity of disease from prevention, early intervention, treatment and acute care, as well as a variety of approaches and interventions.

6. A key issue for the mental health workforce is maintaining existing highly qualified and experienced workers. To what extent does the draft Strategy capture the key actions to improve retention.

Dietitians Australia believes the draft Strategy includes measures that will go some way to improving retention rates across the mental health workforce. An area that still needs further consideration are issues related to rural and remote access to services. As already explor ed in previous questions, the RACCHO model of care would achieve the aims and goals of the draft Strategy, ensuring the specific issues impacting rural and remote settings are addressed. Conditions which contribute to high staff turnover and difficulties in retaining staff are exacerbated in rural areas. Short -term contracts, low wages and employment uncertainty are a disincentive across the board, but pose an additional barrier in rural and remote areas where there usually is a requirement for incoming st aff to relocate.

Health professionals are unlikely to undertake the significant financial and personal costs of relocation for short -term, under -funded and uncertain employment.

Defined career pathways and professional support and supervision also contrib ute significant ly to feeling valued in all practice settings. Pathways into mental health in dietetics are not currently well – defined and formal structures are not in place to ensure practitioners are able to access supervision.

These issues are further exacerbated in rural areas. The importance of supporting multidisciplinary teams and ensuring appropriate professional support is critical to retaining staff across the board.

but it can be particularly important for newly graduated practitioners. It is critical that there is scope for practitioners to be supported in C ontinuing Professional Development and to ensure they can operate to their full scope of practice.

7. The Productivity Commission and other inquiries have identified the importance of improving integration of care, and supporting multidisciplinary approaches. How can the Strategy best support this objective.

One of the greatest challenges that exists in the current system is the lack of integration of services.

Far greater integration is needed to ensure consumers receive all the care they need when they need it. Both the Equally Well Consensus Statement 2016 and the Fifth National Mental Health and Suicide Prevention Plan 201 7 call for the improvement of physical health of people living with mental illness.

To achieve this goal, health services need to be integrated.

Dietitians Australia strongly supports improving integration of care and supporting multidisciplinary teams. Physical hea lth needs of people living with mental illness are minimally recogn ised in the draft Draft National Mental Health Workforce Strategy 7 Strategy. The Strategy needs to ensure the aims and objectives require that professions invo lved in mental health services that also have a role in physical health care, such as dietitians, exercise physiologists and other allied health professionals, are appropriate ly engaged. Multidisciplinary care is particularly important for people experiencing poor mental health across all settings.

For rural communities, t he RACCHO model of care is designed to bring together a range of health professionals to provide affordable, comprehensive, collaborative and integrated multi -disciplinary care. Support for this model would enhance the goals of Objective 4.

8. There a re recog nised shortages across the mental health workforce, including maldistribution across metropolitan/regional locations and settings. To what extent does the Strategy address the issues and supports required to improve workforce distribution.

Dietitians Australia supports the Priority Areas for Actions and Actions outlined under Objective 6.

Whilst acknowledging the importance of focussing on rural communities as a source of a rural health workforce, it is important to ensure that strategies al so target the whole student cohort, not just rural students. Training pathways need to be structured to provide for more time spent in rural areas.

9. Adopting a broad definition of the mental health workforce provides a platform for innovation to ensure all occupations are able to work effectively. How can the Strategy encourage innovation in service delivery models and workforce optimisation approaches.

Dietitians Australia believes that the Strategy supports innovative approaches with its focus on place – based and innovative service delivery models. Policy solutions for mental health and wellbeing are relevant to the local context and there should be scope for programs to address local needs in innovative ways. The draft Strategy can be further bolstered by inclusion of community -based interventions in all settings.

The Allied Health Rural Generalist Pathway is a n initiative aimed to enhance the rural health workforce, including for mental health. Reference to this government initiative should be included in the draft Strategy. The Allied Health Rural Generalist Pathway develop s competencies for rural generalists in allied health profession s like diet etic s, and into extended scope roles where needed.

10. Is there anything else you would like to add a bout the Consultation Draft (1,000 word limit).

For the dietetic profession, further a ction is needed to promote awareness of pathways into and within the mental health workforce, to create positive perceptions of working in mental health, and to ensure students participate in clinical placements that represent a mix of settings. Dietitians Australia recommends adding dietitians to the professions listed at Actions 1.2.1, 1.3.1 and 1.3.2 under ‘Occupations for further action (12 -24 months) across all settings. Promotion of mental health placements for student dietitians and ensuring the experience is appropriately conceived and managed is recommended for implementation. To further support the goals above, u nder Priority 4.1, Action 4.1.2, D ietitians Australia recommends that dietitians be listed under ‘Occupations for further action (12 -24 months)’ across all settings.

Dietitians Australia confirms th e existence of a national Scope of Practice for Accredited Practising Dietitians, supported by the National Competency Standards that student dietitians must meet in Draft National Mental Health Workforce Strategy 8 order to graduate from an accredited dietetic program and that practising dietitians must be able to demonstrate throughout their careers. The dietetic Scope of Practice is further enhanced by Role Statement s for different areas of dietetic practice, including one for mental health.

Under Priority Area 3.3, Action 3.3.1, dietitians are currently listed under ‘Occupations where career paths are established ‘. Dietitians Australia recommends this listing be changed and that dietitian s be included under ‘Occupations where career paths can be strengthened’. While mental health is acknowledged as an area of special interest for practising dietitians, there are no formal or defined career paths for dietitians in mental health.

Under Prio rity Area 5.2, Dietitians Australia strongly supports supervision for dietitians (Actions 5.2.1 and 5.2.3). Supervision should be appropriately remunerated or compensated for by employers in time or other allowances. A challenge for dietitians currently is having a lack of dietetic practitioners in higher -level positions who can offer supervision. Alternative supervision models, including inter – profession supervision may need to be considered. For Action 5.2.3, Dietiti ans Australia recommends including all settings for dietitians under ‘Occupations for further action (12 -24 months) ‘. Under Action s 5.3.3 and 5.4.1, Dietitians Australia recommends including dietitians under ‘Occupations for further action (12 -24 months) ‘ in all settings.

Under Prio rity Area 6.1, Dietitians Australia recommends that dietitians be included in the list of occupations needing immediate action under Action 6.1.1.

Dietitians Australia strongly supports Priority Area 6.2 and the continuation of telehealth for the provision of dietetic services in mental health where it is clinically appropriate. Dietitians Australia’s position statement on telehealth demonstrates the benefits and effectiveness of dietetic services delivered via telehealth.

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