Conclusion and recommendations
6.1
Throughout this inquiry, the Senate Community Affairs References
Committee (committee) heard how people living in Australia's rural and remote
communities face a myriad of barriers to accessing quality mental health
services.
6.2
These barriers range from the obvious, such as the actual presence or availability
of services and health professionals in an area, to the more subtle, such as
the attitudes towards mental health within the community or the effects of social
determinants of health like socioeconomic status or employment.
6.3
Rural and remote mental health services across the country represent a
patchwork of strategies, models and approaches funded by all levels of
government. Few appear to be fully meeting the needs of the communities which
they service.
6.4
The recommendations proposed by the committee in this chapter seek to
address what it considers to be the most pressing and prevalent of concerns
raised by submitters and witnesses to this inquiry.
A strategic response to deliver a complex service
6.5
The delivery of health services across a nation as geographically large
and as culturally diverse as Australia is extremely complex. Added to that
complexity are the differing health responsibilities of the three levels of
government in Australia, combined with the reality that in many rural locations,
service provision crosses state and territory jurisdictional boundaries.
6.6
In recognition of this complexity, a range of national, state and territory
health strategies have been developed to assist in the design and delivery of
health services. While there are strategies for mental health services, which
make mention of the complexity of rural and remote service delivery, and
strategies for rural and remote health service delivery, which mention mental
health services, what has been lacking to date is a strategy specifically for
mental health and wellbeing services delivered in the distinct service
environments found in rural and remote Australia.
6.7
In rural and remote communities, the causes of mental illness are often
different, the culture of communities is different and the service solutions
must therefore be different to those found in urban centres. Until there is a
strategy that acknowledges the different context of rural and remote
communities, mental health service delivery in rural and remote locations will
continue to be a fragmented approach with band-aid solutions.
6.8
The committee supports the recommendation endorsed by many expert organisations,
including the Royal Flying Doctor Service, that the National Mental Health
Commission should be funded and tasked with the development of a national rural
mental health strategy. This strategy should be informed by Primary Health
Network service mapping in rural and remote areas and other key data that
identifies service shortfalls. The National Mental Health Commission should
also be tasked with monitoring and overseeing implementation of the strategy,
reporting back directly to government.
Recommendation 1
6.9
The committee recommends the development of a national rural and remote
mental health strategy which seeks to address the low rates of access to
services, workforce shortage, the high rate of suicide, cultural realities,
language barriers and the social determinants of mental health in rural and
remote communities.
Recommendation 2
6.10
The committee recommends that the national rural and remote mental
health strategy is subject to an implementation and monitoring framework which
includes regular reporting to government and that these reports are tabled in
Parliament.
6.11
Additionally, the committee considers that the development of a national
rural and remote mental health strategy should take into account matters raised
in this report, including but not limited to the improved outcomes seen by
services offering a 'no wrong door' approach to service delivery, ensuring that
patients are treated holistically and receive the support they need without
entry barriers.
6.12
The committee believes that in order to be effective, a national rural
and remote mental health strategy must also seek to address the social
determinants of health identified in this report which are fundamental to
improving mental health services and suicide prevention in regional, rural and
remote communities around Australia.
6.13
Furthermore, the committee does not believe that work on a rural and
remote mental health strategy should halt immediate progress to solve pressing
concerns that could be addressed now, or that would not require a strategy to
develop solutions. Some of these concerns and related recommendations are
discussed below.
Putting the community at the centre of the approach
6.14
During the course of this inquiry, the committee travelled to rural and
remote locations throughout Australia to gain an understanding of how mental
health service delivery impacts different communities across Australia, each
with different needs and a different service context. The committee spoke to
locals from diverse backgrounds, including mental health consumers, farmers,
miners, Aboriginal and Torres Strait Islander peoples, local councils,
teachers, nurses, doctors, academics, and committed volunteers at the front
lines of suicide prevention.
6.15
One clear message came from these very distinct communities. From small
towns in Tasmania to Aboriginal communities in the Northern Territory and from
mining towns in Queensland to agricultural regions in Western Australia, the
committee heard that the voices and experiences of local communities are not
being listened to in service design and delivery.
6.16
While there is often some level of community consultation, this is often
at the tail-end of the process when a provider has been selected and the
service has already been commissioned and largely designed. This near universal
lack of local input at the very start of the service commissioning process has
resulted in mental health and wellbeing services that are designed in urban
centres, by and for the needs of people who live in urban centres, and then
tweaked to create the appearance of a local approach or to accommodate the
travel needs of urban staff to deliver the service in a rural or remote
context.
Recommendation 3
6.17
The committee recommends an overarching approach is taken by all parties
to guarantee that the design of mental health and wellbeing services starts
with local community input to ensure that all rural and remote mental health
services meet the measure of 'the right care in the right place at the right
time'. This needs to be informed by best practice and international knowledge.
The role of the National Disability Insurance Scheme
6.18
The committee is encouraged by the creation of a psychosocial disability
stream within the National Disability Insurance Scheme (NDIS) to improve the
process of accessing the NDIS and to provide support to people with severe and
persistent mental health issues.
6.19
The committee notes that at the time of this inquiry, there was limited
information available regarding the implementation of the psychosocial disability
stream, and in particular how it will be rolled out in rural and remote
Australia.
6.20
The committee is concerned by the accounts it received that many rural
and remote Australians have experienced issues applying for the NDIS and
accessing appropriate mental health services through their NDIS plan. These
issues included: a deficit of knowledge about the NDIS by health professionals;
assessors, planners and service providers inexperienced in psychosocial
disability; and a lack of appropriate support services.
6.21
The committee believes that it is critical that the new psychosocial
disability stream addresses these issues in rural and remote communities to
ensure it meets its objective of improving access to the NDIS for people with a
mental illness.
Recommendation 4
6.22
The committee recommends that the National Disability Insurance Agency
ensure that the implementation of the psychosocial disability stream takes into
account the issues facing rural and remote communities, including barriers to
accessing mental health services and the lack of knowledge and experience in
both psychosocial disability and the National Disability Insurance Scheme.
Funding services appropriately
6.23
The committee holds serious concerns about the short-term nature of
funding cycles, noting the large number of mental health service providers
facing uncertainty in funding. Limiting funding contracts for providers to 12
months at a time is having a detrimental impact on the provision and continuity
of care in many rural and remote communities.
6.24
The committee also recognises that rural and remote communities are not
suited to a competitive tendering process for service provision. The
competitive tendering process favours city-based organisations with the
capacity to provide rural and remote services at a financial loss. However,
these organisations rarely have an understanding of communities and their needs
and frequently do not have services 'on the ground' when they are awarded the
contract. Local providers can't compete and the communities which they service lose
out.
6.25
The committee is of the firm belief that funding cycles need to be of
sufficient length to allow local service providers to develop infrastructure,
attract and retain a suitable workforce, and build trust within a community,
while also allowing for accountability and review processes within the contracted
time period.
6.26
The committee therefore suggests that the minimum initial contract
length be 5 years when funding mental health services in rural and remote
communities and in the regional centres which service those communities.
Furthermore, there should be options to extend a service provider's contract
without additional tendering, following assessment of the efficacy and acceptability
of the services provided to the local community.
Recommendation 5
6.27
The committee recommends that Commonwealth, State and Territory
Governments should develop longer minimum contract lengths for commissioned mental
health services in regional, rural and remote locations.
6.28
The committee also strongly believes that local knowledge and connection
to the community should be major considerations when commissioning service
providers in rural and remote areas. This could be demonstrated in a variety of
ways, such as a high proportion of locally-based health workers, a
local-workforce capacity-building strategy, and an ongoing community
consultation forum with genuine input into design and decision-making.
Recommendation 6
6.29
The committee recommends that Commonwealth, State and Territory
Governments should develop policies to allow mental health service contracts to
be extended where a service provider can demonstrate the efficacy and
suitability of the services provided, and a genuine connection to the local
community.
Block funding
6.30
The committee recognises that restrictive fee-for-service models of
funding combined with the loss of block funding, in many cases a result of the
introduction of the Primary Health Network commissioning model and the
implementation of the NDIS, has had a serious impact on the ability of small
service providers in rural and remote areas to meet the overhead costs of
running a service in these locations.
6.31
The committee believes that there has been market failure in rural and
remote communities, making the current style of the NDIS rollout in these
contexts a practical impossibility. The committee notes that the removal of
block funding for long-established services creates significant risk for the
individuals and communities who have voiced genuine concern that no service
will be available to them if rural or remote communities are forced to
implement the current NDIS model.
6.32
Service providers in many rural and remote communities cannot offset
overhead costs through other fee-based services as providers in urban centres
are able to do and therefore rely on block funding for the long-term viability
of their services. Without block funding, some providers have had to pull their
trusted, established services out of rural and remote communities.
6.33
The committee agrees with the view that flexible block funding is also
required for providers to adequately meet the unique and changing needs of each
rural and remote community. What works in one community may not suit the next
and providers need to be able to offer flexible services, such as community
engagement, and supports, such as transport, to improve access and attendance.
Recommendation 7
6.34
The committee recommends that Commonwealth, State and Territory
Governments consider the reestablishment of block funding for mental health
services and service providers in regional, rural, and remote areas.
Stepped care
6.35
The committee received extensive evidence that the stepped care model of
mental health service provision, while well-suited to urban centres, is failing
in some rural and remote areas. For a number of communities visited by the
committee, some of the 'steps' within the model are poorly accessible or
missing entirely.
6.36
It is the role of Primary Health Networks to identify the needs of their
local communities and commission services which address the gaps in the stepped
care model. While the committee saw some excellent examples of regions where
this has been successful, it holds concerns that not all Primary Health
Networks are addressing the needs of their region adequately.
Recommendation 8
6.37
The committee recommends that the Commonwealth Government review the
role of Primary Health Networks in commissioning mental health services under
the stepped care model to ensure effective and appropriate service delivery in
regional, rural and remote areas.
Improving access
6.38
The committee acknowledges the important role that telehealth plays in
the delivery of mental health services to rural and remote areas, particularly
through programs such as headspace and the Better Access to Psychiatrists,
Psychologists and General Practitioners through the MBS (Better Access)
initiative.
6.39
However, the committee strongly believes that access to
telecommunications infrastructure in rural and remote locations needs to be
improved if telehealth initiatives are to be a viable alternative or supplement
for face-to-face services in these areas.
6.40
The committee also heard concerns from some submitters that the way the
Medicare Benefits Schedule (MBS) funds certain mental health and primary care
services is also restricting the flexibility of providers and practitioners to
offer the care needed by consumers in rural and remote communities, both
face-to-face and via telehealth.
6.41
The committee considers that thought should be given to allowing
capacity for MBS-funded psychology referrals from allied health professionals
and nurses, such as Aboriginal Health Workers and remote area nurses, and for
greater exemptions under section 19(2) of the Health Insurance Act 1973 (Cth)
to allow provision of MBS mental health services alongside services funded from
other sources.
Recommendation 9
6.42
The committee recommends that the Commonwealth Government consider pathways
for allied health professionals and nurses in rural and remote Australia to
refer patients under the Better Access to Psychiatrists, Psychologists and
General Practitioners through the MBS (Better Access) initiative.
Strengthening the strategic framework for Aboriginal and Torres Strait
Islander mental health
6.43
Throughout the inquiry, the committee heard about the positive impact of
Aboriginal Community Controlled Health Services and the role of an Aboriginal
and Torres Strait Islander workforce in the delivery of mental health and
wellbeing services for Aboriginal and Torres Strait Islander peoples.
6.44
The committee commends the National Strategic Framework for
Aboriginal and Torres Strait Islander Peoples' Mental Health and Social and
Emotional Wellbeing 2017–2023 (Aboriginal Mental Health Framework) as an
invaluable tool to improve mental health services and notes that it is in the
early stages of implementation. However, the committee notes with some concern
that there does not yet appear to be a specific implementation plan for this
strategy, a monitoring plan has not been developed and there is no explicit
associated funding.
Recommendation 10
6.45
The committee recommends that the Commonwealth Government prioritise the
development of implementation and evaluation plans for the National
Strategic Framework for Aboriginal and Torres Strait Islander Peoples' Mental
Health and Social and Emotional Wellbeing 2017–2023.
6.46
The committee notes that a key action area under the Aboriginal Mental
Health Framework is to 'Strengthen the Foundations', in particular the
development of effective partnerships between Primary Health Networks and
Aboriginal Community Controlled Health Services.
6.47
Evidence received by this committee is that only a limited number of
Primary Health Networks have worked towards establishing such a partnership
with the Aboriginal Community Controlled Health Service sector, despite clear
evidence that the preferred model of health service delivery for Aboriginal and
Torres Strait Islander peoples is by Aboriginal Community Controlled Health
Services.
6.48
The committee notes that there is a large body of evidence about the
value of Aboriginal Community Control across the health sector and recognises
that some states and territories are actively pursuing pathways for community
control and partnerships which build capacity in communities.
6.49
However, Aboriginal Community Controlled Health Services reported to the
committee that they face funding difficulties as service contracts are
frequently given to non-local organisations that then seek to sub-contact
portions of the work to the local Aboriginal Community Controlled Health
Service as a junior partner with limited if any input into service design.
6.50
The committee strongly agrees with the statements of the Aboriginal
Mental Health Framework that Aboriginal and Torres Strait Islander leadership,
engagement and partnership in the planning, delivery, evaluation and
measurement of services and programs is critical in fostering greater trust,
connectivity, culturally appropriate care and effective outcomes. The committee
believes that not enough has been done to ensure that this principal is put
into practice in funding and service design.
Recommendation 11
6.51
The committee recommends the Commonwealth Government implement measures
to ensure that services commissioned by Primary Health Networks embody the
action plans of the National Strategic Framework for Aboriginal and Torres
Strait Islander Peoples' Mental Health and Social and Emotional Wellbeing
2017–2023 and are delivered by, or in genuine long-term partnerships with,
Aboriginal Community Controlled Health Services and other Aboriginal and Torres
Strait Islander community organisations.
Recommendation 12
6.52
The committee recommends that all Primary Health Networks have an Aboriginal
and Torres Strait Islander member on their board.
Increasing professional workforce support
6.53
The committee heard time and again throughout this inquiry that the
workforce is the backbone of mental health service delivery, and without a
well-educated and well-resourced workforce, any strategy for mental health
service delivery will be destined to fail.
6.54
The committee heard there is already a desperate shortage of
urban-trained mental health specialists who are available to work in rural and
remote locations and that, conversely, there is a lack of training
opportunities for people living in rural and remote locations to upskill and
fill those roles. The committee further heard that the ongoing registration
requirements for health professionals are often difficult to meet in rural and
remote locations.
6.55
The committee therefore believes there is a role for health professional
colleges to develop programs to provide increased support to the rural and
remote workforce, encouraging rural and remote rotations, incentivising
placements and supervision of junior staff, and providing continuing
professional development in these regions.
6.56
However, the committee believes that a strategic approach must be taken
to workforce development, which needs a multi-pronged approach to develop a
sustainable and effective workforce into the future.
Recommendation 13
6.57
The committee recommends the Commonwealth Minister for Health work with
health professional colleges to develop strategies for the immediate
improvement of professional supports and clinical supervision for registered
health practitioners working in rural and remote locations.
Cultural competency
6.58
Furthermore, the committee believes that the mental health workforce
must be appropriately trained to meet the needs of diverse communities in rural
and remote Australia, including by providing culturally competent mental health
and wellbeing services.
6.59
The committee acknowledges that a one size fits all approach cannot be
applied to cultural competence and that every community in Australia will have
different needs and a different cultural context.
6.60
The committee heard throughout its inquiry the importance of patients,
particularly Aboriginal and Torres Strait Islander peoples, having a positive
initial interaction with mental health professionals to ensure patients return
and continue to access support services.
6.61
The committee notes that culturally competent mental health services directly
impact the health outcomes of Aboriginal and Torres Strait Islander peoples and
is concerned by reports that the level of cultural competency of mental health services
is inconsistent in rural and remote communities.
6.62
The committee firmly believes that service providers should offer
training and accommodate continuing professional development for their staff in
culturally competence which is informed by, and relevant to, their local
community.
Recommendation 14
6.63
The committee recommends that all mental health service providers,
including government and community sector, ensure their workforces are
culturally competent and that such training be endorsed by and delivered in
partnership with the communities into which they are embedded.
Fly-in fly-out services
6.64
The committee understands that for some communities, fly-in, fly-out
(FIFO) mental health professionals provide valuable support to rural and remote
communities which may otherwise not have access to mental health services, due
to the shortage of mental health professionals in these communities.
6.65
However, the committee notes that like any other mental health services,
FIFO services must be designed to meet the needs of the local community and be
supported by long-term investment which enables FIFO mental health
professionals to provide reliable and regular services and build relationships
and trust within the local community. The presence of a service provider on any
day in a community ensures neither service provision nor the necessary
continuity of care known to be critical in developing the trust required to
underpin the therapeutic relationships fundamental to good mental health care
and positive patient outcomes.
Recommendation 15
6.66
The committee recommends that all providers of fly-in, fly-out mental
health services ensure that mental health professionals are supported by long-term
investment to enable them to provide reliable and regular support services to
rural and remote communities, with consistency of personnel an essential
requirement for any service provider.
Peer support workers
6.67
In many of the communities it visited, the committee heard about the
important role played by peer support workers, who provide support to people
experiencing mental illness and often fill a gap left by the shortage of mental
health professionals in rural and remote communities.
6.68
The committee notes that generally these support services are provided
by people who have had their own lived experience with mental illness but have
received no formal training in mental health support and are not employed or
paid for the support services they provide. Many rural and remote communities
rely on these outstanding members of the community to provide support to people
in times of crisis and connect them to mental health resources.
Recommendation 16
6.69
The committee recommends that peer support workers be given appropriate
training to enable them to continue their role in helping people experiencing
mental health issues. The committee further considers that peer support workers
should be recognised as a valuable support service by being paid to perform
this role in rural and remote communities.
Reducing stigma in rural and remote communities
6.70
While one in five Australians will experience a mental illness in any
given year, the stigma associated with mental health is still pervasive in
Australia's rural and remote communities. The committee believes that stigma plays
a major role in rural and remote communities accessing mental health services
at a low rate.
6.71
The committee acknowledges that there are many factors which contribute
to the ongoing stigma surrounding mental health. Many people told the committee
that they did not seek help for their mental health issues either out of fear
of facing discrimination about experiencing mental illness or because of the
culture of self-reliance in rural and remote communities.
6.72
The committee heard time and time again that concerns about
confidentiality and privacy prevented people from seeking support from local
mental health services. People in rural and remote communities don't always
feel comfortable speaking about their mental health to a person they may also
see in a social setting, or if they are not confident in the mental health
professional's ability to maintain confidentiality. This often results in
people travelling to the next town or a capital city to access mental health
support services, or simply not seeking support at all.
6.73
In some communities, visiting a particular location in town was
conspicuous and people in the community could easily deduce when a person was
seeing a mental health professional. The committee heard that some communities
are seeking to combat this issue by implementing the 'one door' approach which
co-locates mental health services with other physical medical services.
6.74
The committee supports the use of the 'one door' approach in an effort
to improve access to mental health service in rural and remote communities, but
also believes that more must be done to educate the community about mental
health in order to reduce the associated stigma.
6.75
This is particularly the case for vulnerable groups of people such as lesbian,
gay, bisexual, transgender and intersex people, cultural and linguistic diverse
populations and Aboriginal and Torres Strait Islander peoples. The committee
believes that separate communication strategies which are specific to these
vulnerable groups should be developed in recognition of the ongoing role of
education in reducing the stigma associated with mental health.
6.76
The committee believes that co-design with these communities is critical
to enable ongoing review and adaption of relevant public health services and
messaging.
Recommendation 17
6.77
The committee recommends that Commonwealth, State and Territory
Governments, as well as mental health service providers and local communities,
continue to educate rural and remote communities about mental health and advertise
local and digitally-available support services, with a view to reducing the
associated stigma.
Recommendation 18
6.78
The committee recommends that Commonwealth, State and Territory
Governments work with mental health service providers and local communities to
co-design appropriate educational materials to reduce the stigma surrounding
mental health in rural and remote communities.
Senator Rachel Siewert
Chair
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