**4. Discussion**

#### *Lessons Learned—Towards a Better Process of Accountability and Planning*

From the experiences of the past thirty years, several important trends and challenges have emerged in relation to how Australia and other nations can engineer more effective and useful data collection and accountability for mental health. In recognition of the increasing role and potential of primary and community-based mental health care, new datasets continue to emerge, requiring intelligent amalgamation with existing systems to exploit new opportunities [50,51]. There is merit in considering how these issues might shape a new process or framework for mental health reporting and planning.

Improved reporting must finally accept the significance of understanding not just basic inputs and outputs, but the whole mental health 'ecosystem' [52], drawing on a broader set of metrics which properly reflect the mental health and wellbeing of communities. This poses new problems in organising and gathering requisite data from multiple agencies, not just health departments. The coordination of this kind of whole-of-government monitoring was one rationale for several jurisdictions to establish mental health commissions [53].

As stated, the issue of regional data is increasingly recognised as key to enabling better local planning in mental health. Despite commitments made to establish regular benchmarking in mental health over past decades [20,54], the establishment and reporting of data at this level is not ye<sup>t</sup> a feature of mental health reporting in Australia, though the AIHW publication of Medicare data by statistical local area (SLA) is an exception [55]. Australia's failure to develop a suitable mental health performance managemen<sup>t</sup> framework with agreed, consistent indicators and targets has been pinpointed as a key drawback to reform [46].

Engaging mental health stakeholders in developing such a framework would build an understanding of the process and confidence in the results [56]. To date, MHISSC and associated governments have been largely responsible for determining how mental health is reported. MHISSC relied for twenty years on external consultants to manage the process of data collection and reporting [57]. The benefits of broadening this process have been recognised [46]. Specific mention must be made of consumers and carers in this context. The National Community Advisory Group (NCAG) mentioned earlier was disbanded after just three years in 1996. Structures to engage consumers and carers in framework co-design will require considerable development [58].

Another design element should be the widespread use of new personal technologies which permit services users to be the key reporters of real-time and local data pertaining to their care [59], as has already been demonstrated both in Australia [60] and elsewhere [61]. This should be part of a fundamental re-design of accountability for mental health, one that recognises the broader social context of mental illness beyond health, considering issues such as employment, education completion and social connectedness. Despite some initiatives [62], Australia still lacks a validated, national collection of the experience of care of mental health consumers and carers.

Finally, the way mental health is reported relates to how it is planned, and this is a matter currently up for national debate. Historic, centralised approaches to planning are being challenged by more local or regional models of governance and decision-making, as encouraged by the Productivity Commission [46] and the National Mental Health Commission.

There are new decision-support systems which enable this local planning and modelling [63–65]. There are clearly limitations in the extent to which existing state and territory-focused mental health data collections can provide the information these new models need to facilitate better local decision-making, or what other information might be necessary. The examination and resolution of these issues is a key element of more effective planning and reporting of mental health care.

Key bodies internationally have recognised the inability of existing mental health data systems to propel the desired processes of benchmarking and quality improvement [66]. They have embarked on projects designed to make mental health data systems more robust and useful. The World Health Organisation has, for example, prioritised the creation of a mental health data platform aiming at routinely collected information on mental health systems' performance and on the mental health status of the population. These Australian lessons could inform this work [67].

The Australian experience demonstrates the importance of establishing an accurate historical account of the evolution of the core policy and planning processes underpinning mental health reform, giving context and meaning to the status of national and regional mental health systems. Our experience has shown how complicated this process can be, even in countries with significant resources.
