**1. Introduction**

What does effective national monitoring and reporting of mental health care look like? The year 2022 is the thirtieth anniversary of Australia's National Mental Health Strategy, which implemented a new process for data collection as a central function to drive better accountability for mental health services [1].

This narrative review attempts to assess the extent to which Australia's efforts have yielded an effective system of accountability for mental health. This assessment is problematic. There has never been any formal evaluation of the strategy overall. Initial markers of success were not described to permit simple evaluation of progress. Evidence of impact, if available at all, is typically qualitative or summative, not quantitative.

There are some strengths, but also many weaknesses, in the approach taken. This has delivered an Australian reporting system which predominantly focuses on administrative

**Citation:** Rosenberg, S.; Salvador-Carulla, L.; Meadows, G.; Hickie, I. Fit for Purpose— Re-Designing Australia's Mental Health Information System. *Int. J. Environ. Res. Public Health* **2022**, *19*, 4808. https://doi.org/10.3390/ ijerph19084808

Academic Editor: Richard Madden

Received: 25 January 2022 Accepted: 11 April 2022 Published: 15 April 2022

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**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

data, inputs and outputs. Much is known about budgets, the number of occupied beds and outpatient occasions of services. We know staffing numbers and costs. However, few details are known about who is presenting for mental health care and why. We also know little about the type of interventions provided or their outcomes and the subsequent pathway taken by patients. Our view of key issues outside of the health sector, in areas such as housing, education and employment, is very limited. We are not able to compare or benchmark services, meaning that our system of accountability fails to impel systemic quality improvement.

As if accountability for mental health was not complex enough, past decades have seen mental health subject to multiple reforms and overlapping reporting processes. This paper traces this history and its impact on Australia's efforts to establish effective accountability across two national mental health policies, five national mental health plans, one national action plan, several other national documents, one roadmap and multiple statutory inquiries over the past three decades. More recently, COVID-19 has seen Australia's Federal governmen<sup>t</sup> establish a new National Cabinet, scrapping previous administrative structures which oversaw accountability for mental health, such as the Australian Health Ministers Council [2].

Federal, state and territory governments are currently arranging bilateral agreements which will constitute the backbone of Australia's sixth national mental health plan, including specifying data and reporting obligations. It would be folly to assume the utility of existing reporting arrangements. Indeed, under the maxim 'what gets measured gets done', there is reason to be alert to the risk of poor data collection processes reinforcing undesirable models of care. For example, if hospital beds are the currency reported, beds will remain the priority for policy and funding, regardless of the merits of alternatives.

Understanding Australia's historical approach to mental health reporting can inform the next steps and help drive the development of more robust processes designed to deliver national accountability.

#### **2. Materials and Methods**

While no formal evaluation of Australia's National Mental Health Strategy has occurred, this does not mean that there is a paucity of evidence. Comments and critiques are plentiful, generated by the frequent statutory, parliamentary and other inquiries commonplace over the past two decades. One report suggested that there had been thirty-two separate statutory or other inquiries between 2006 and 2012 alone [3]. Such inquiries relying on qualitative or summative evidence have often been initiated in response to deaths, human rights abuses or other tragedies. While they do not purport to formally evaluate the National Mental Health Strategy as a whole, they frequently touch on accountability and monitoring, making them worthy of consideration and review here.

In this context, this paper has relied on a narrative review, aiming to present a comprehensive, critical analysis of current knowledge in relation to Australia's approach to reporting and accountability for mental health. It is possible, on this basis, to discern gaps and patterns, as well as strengths and weaknesses, in the data [4].

Key documents, policies, plans and strategies are considered, demonstrating the evolution of mental health data and reporting. Historical documents are cited, including several which highlight implications arising from our federated system of government. Government and statutory reports, as well as peer-reviewed and other literature (from grey literature, websites, media sources, etc.) are referenced. The jumble of reports and inquiries needs a timeline to orient readers, and this is presented. The paper explores recent recommendations made by various reports and how these can influence the direction of future reforms. It then draws on contemporary literature to describe the components of an effective, contemporary approach to accountability for mental health.

#### *What Is Meant by Accountability?*

Accountability is an elusive concept, with multiple valid perspectives [5]. Planners would like to know the value for money. Service providers wish to understand if their work has been effective and how it could be improved. Consumers and families want to know what services and treatments work. Funders want information about cost-effectiveness and value for money, using systems such as activity-based funding to generate costs and prices and monitor system efficiency [6,7]. Researchers will want data to evaluate or compare alternative approaches, programs or services.

The community more generally will want information indicating the extent to which it has access to a mental health system that responds to individual needs and is one on which it can rely.

In relation to health care generally, accountability can increase the effectiveness of services, reduce inefficiency and provide the feedback necessary to impel systemic quality improvement [8,9].

The data generated for accountability are commonly considered across three dimensions: financial, performance and political/democratic [10]. Financial accountability relates to ensuring that funds are spent as agreed, monitoring, auditing and budgeting.

Performance accountability can refer to the assessment of services, outputs or outcomes, allowing value for money to be assessed. Political accountability is often focused on whether governments kept their promises, often with reference to notions of equity, efficiency and so on.

These perspectives on accountability overlap, but stakeholders may prioritise data differently. This diversity again lends itself to the narrative method of analysis used throughout this discussion.
