Executive Summary
This interim report is the fourth of a series in which the
Senate Select Committee on Health proposes to report its findings and
conclusions to date.
This report focuses on the Federal Government's approach to
mental health. Unfortunately, mental health policy and funding in Australia is
in a state of suspended animation while the government re‑reviews, re‑consults
on, and re-considers the findings of the National Mental Health Commission's
review of the delivery of mental health services and programmes.
Meanwhile, organisations providing mental health services
and programmes are forced to survive on year-to-year funding. The uncertainty
caused by the government's constantly delayed decision making has caused
workforce instability and increasing uncertainty for mental health consumers
and carers. This is an unacceptable situation.
Mental health in Australia – situation: crisis
The National Mental Health Commission (the Commission) begins
its report on Mental Health Services and Programme Delivery with a stark set of
facts about the prevalence of mental ill-health in Australia:
Each year, it is estimated that more than 3.6 million people
(aged 16 to 85 years) experience mental ill-health problems—representing about
20 per cent of adults. In addition, almost 600,000 children and youth between
the ages of four and 17 were affected by a clinically significant mental health
problem. Over a lifetime, nearly half of
the Australian adult population will experience mental illness at some point—equating
to nearly 7.3 million Australians aged 16 to 85. Less
than half will access treatment.[1]
Mental ill-health can have devastating consequences for
individuals and their families. For instance the Commission's report identified
suicide as a major issue in mental health:
In 2012 more than 2,500 people died by suicide, while in 2007 an estimated 65,000 Australians
attempted to end their own life. Suicide
is the leading cause of death among people aged between 15 and 44 years old, and is more likely among men, Aboriginal and
Torres Strait Islander peoples and people living outside of major cities.[2]
Disturbingly, a large number of people, particularly young
Australians, do not seek or delay seeking help. Dr Michelle Blanchard, the Head
of Projects and Partnerships at the Young and Well Cooperative Research Centre
told the committee:
In the case of young people, 25 per cent of young people
experience a mental health difficulty and 70 per cent of those do not seek help
and do not receive care. It is a very high figure for a younger population, and
that figure is higher again for young men...
We know from international evidence that the time between the
onset of symptoms for someone with a mental illness and the time they receive
the right care is up to 10 years.[3]
Previous mental health reviews
The Commission's review is the latest in a long line of reviews
and inquiries which have considered the most effective and efficient means of
delivering mental health services and programmes. Mr Sebastian Rosenberg, a Senior
Lecturer at the University of Sydney's Brain and Mind Centre reflected on the
growing list of past inquiries:
Despite four national plans and two national policies, one
road map, two report cards and one action plan, genuine mental health reform
seems as far away as ever. There is a sense that things have changed and that
the asylums have closed in Australia. Well, there are still 1,831 beds in
asylums across Australia costing about half a billion dollars per year. Large
elements of the old system are still very much in place in our current system...
One of the main things that was through all the history of Australian mental
health policies and plans has been the desire to establish community-based
mental health care, but in fact what we have is an extremely hospital‑focused
system of care. Even when the National Mental Health Commission suggested a
very small change to those arrangements, Minister Ley unfortunately seemed to
indicate that that would not be pursued.
We were interested very much in promotion, prevention and
early intervention, but in fact we have a system which really is about
postvention and crisis management.
We were very much interested in e-mental health technologies,
some of which Australia has led in, but in fact what we have is a continued
dependence on face-to-face care and fee-for-service type approaches.[4]
Mr Rosenberg told the committee that there have been 32
reviews into mental health between 2006 and 2012. Chief amongst these was the
landmark work of the Senate Select Committee on Mental Health in 2006.
The overall findings of the Select Committee on Mental Health
are remarkably similar to our current situation:
...there is much work to do in the area of mental health. There
needs to be more money, more effort and more care given to this neglected part
of our health care system. There is not enough emphasis on prevention and early
intervention. There are too many people ending up in acute care, and not enough
is being done to manage their illness in the community. There are particular
groups, and people with particular illnesses, who are receiving inadequate
care. Many of these findings have been confirmed by other organisations and
reports in recent years.[5]
Findings of the National Mental Health Commission
The Commission found that despite various system-related
issues, and a lack of proper evaluation of programmes, at a service level there
were:
...many examples of wonderful innovation and...effective
strategies do exist for keeping people and families on track to participate and
contribute to the social and economic life of the community. The key feature of
these strategies is that they take a person-centred, whole-of-life approach.[6]
Overall the Commission's findings indicated serious problems in
the effectiveness and efficiency of the current 'patchwork of services,
programmes and systems for supporting mental health'. The Commission stated
that as a result, 'many people do not receive the support they need and
governments get poor returns on their substantial investment'. According the
review the current spending on mental health by Commonwealth, state, and
territory governments was about $14 billion per annum.[7]
The case for reform of the mental health system is irrefutable,
with the Commission describing the current situation in its report:
The need for mental health reform has had long-standing
bipartisan support. Yet as a country we lack a clear destination in mental
health and suicide prevention. Instead of a “mental health system”—which
implies a planned, unitary whole—we have a collection of often uncoordinated
services that have accumulated spasmodically over time, with no clarity of
roles and responsibilities or strategic approach that is reflected in practice.[8]
Duplication
The Commission also found duplication in the current system.
This manifested in a lack of flexibility of service delivery which means that
services and individuals may be mis-matched.[9]
The Commission also found that the duplication of services leads to significant
gaps in service availability, particularly for Aboriginal and Torres Strait
Islanders peoples.[10]
Funding priorities
In terms of resourcing, the Commission found that much of the
current funding was focussed on acute care, and very little targeted to early
intervention and community‑based support:
Nationwide, resources are concentrated in expensive acute
care services, and too little is directed towards supports that help to prevent
and intervene early in mental illness. Of total Commonwealth spending of $9.6
billion, 87.5 per cent is in demand-driven programmes, including income
support, and funding for acute care. This means that the strongest expenditure
growth is in programmes that can be indicators of system failure—those that
support people when they are ill or impaired—rather than in areas which prevent
illness and will reap the biggest returns economically and ‘future proof’
people’s ability to participate and live productive, contributing lives.[11]
Focus on acute care not early
intervention
Related to the funding for acute care, the Commission observed
the biggest inefficiencies in the system came from:
...doing the wrong things—from providing acute and crisis
response services when prevention and early intervention services would have
reduced the need for those expensive services, maintained people in the
community with their families and enabled more people to participate in
employment and education.
In fact, there is evidence that far too many people suffer
worse mental and physical ill-health because of the treatment they receive, or
are condemned to ongoing cycles of avoidable treatment and medications,
including avoidable involuntary seclusion and restraint.[12]
Financial risk to Commonwealth from
current funding structure
The Commission identified significant financial risk for the
Commonwealth in the current model of funding for mental ill-health:
The Commonwealth’s role in mental health creates significant
exposure to financial risk. As a major downstream funder of benefits and income
support, any failure or gaps in upstream services means that as people become
more unwell, they consume more of the types of income supports and benefits
which are funded by the Commonwealth.[13]
The Commission found that a major contributor to government
financial risk, and to increased government spending, was a lack of
coordination:
Ironically, much risk comes from within
governments—portfolios working in isolation of each other, aiming to minimise
their exposure and their costs without taking into account the downstream costs
to their fellow agencies and the overall costs to their government.
For example, many of the services required to keep people
well and participating in their homes and the community lie outside the formal
health system. This includes areas such as accommodation, education, employment
and family and community services. Yet a breakdown in housing or relationships
for an individual can pitch them into crisis, resulting in ED [Emergency
Department] presentations and extended periods of hospitalisation and acute
care. This means that agencies within governments, as well as agencies across
governments, need to work together, collaborate and coordinate to manage
overall costs and risks.[14]
Need for overall system change
From these findings, the Commission made 25 recommendations
aimed at making substantial system-wide changes to the delivery of mental
health services and programmes:
Overall, the findings of this Review present a clear case for
reform. The status quo provides a poor return on investment for taxpayers,
creates high social and economic costs for the community, and inequitable and
unacceptable results for people with lived experience, their families and
support people... Managing these costs effectively and sustainably requires a
carefully designed programme of practical reforms that rebalance the system to
reduce demand for services in the first place and improve the range and
appropriateness of support options. This will deliver better mental health
outcomes for individuals and promote economically and socially thriving
communities.[15]
Government inaction
The Commission provided its report to the Government on
1 December 2014. However, despite the Government's commitment to 'building
a world-class mental health system',[16]
the government only released the Commission's report after part of the report
had been leaked to the media in April 2015.
Since the release of the report, the government has not
formally responded to the Commission's recommendations. Instead, the Minister
for Health, the Hon Sussan Ley MP, responded to the commission's report
with another review by establishing an Expert Reference Group (ERG). The
Minister has recently announced that she intends to respond to the Commission's
report by the end of the year.[17]
Mental health sector response
Mental health policy has been on hold since the beginning of
the Commission's review in February 2014. In October 2015, ten months after the
completion of the Commission's thorough review, the government has still not
responded to the Commission's recommendations. As a result, the mental health
sector struggles with ongoing funding uncertainty and indecision about the
future direction of mental health policy in Australia.
The committee heard the concerns of mental health groups,
advocates, service providers, consumers and carers in relation to the uncertain
future direction of mental health funding and policy. These groups all gave the
committee similar evidence: the government needs to respond positively to the
Commission's recommendations and it needs to do so before the end of 2015.
For instance Mr Ivan Frkovic, the Deputy Chief Executive
Officer of National Operations at service provider Aftercare, told the
committee:
...we support the directions that were set in the Mental Health
Commission report, particularly, again, from a consumers and carer perspective.
Let's have a system that focuses and is incentivised for outcomes, not for
maintenance, whether it is the public system, the private system or the NGO
system.[18]
Similarly, Professor David Perkins, the Director and Professor
of Rural Health Research at the Centre for Rural and Remote Mental Health
observed that:
If we start with community members and people who live in
rural and remote areas and ask what they want and need, I think we find the
answers have been articulated well by the National Mental Health Commission and
by my state's mental health commission. People want a contributing life. They
want to live well. They want a secure home, reliable income, education or
employment, and to be able to take part in their communities, and they want
their symptoms addressed...[19]
Professor Ian Hickie, a Commissioner of the National Mental
Health Commission spoke of the consensus which has been built around the
Commission's findings:
I think what has happened here is very unusual. The whole
Australian mental health community, through both its lived experience and its
technical experts, has combined to say to our respective governments that there
is a fundamental need to move away from a programmatic funding approach in response
to each crisis and towards locally led and organised services that work in
regional Australia.[20]
Committee recommendations
The Senate Select Committee on Health's examination of the
issues around mental health services and programmes is relatively brief in
comparison with the work done by the Senate Select Committee on Mental Health
in 2006. However, the committee notes that the same issues have been raised in
both its inquiry, and in the Commission's review of the delivery of mental
health services and programmes.
By examining the work of the Commission, the issues raised by
witnesses, and the lack of government response to the Commission's review, the
committee has demonstrated that once again mental health policy is at a
crossroads. Both the issues and the necessary reforms are well documented
throughout many inquiries. The committee believes that action now is essential
if Australia is to reform its mental health system.
The committee heard from those with lived experience of mental
illness, those who care for mental illness suffers, mental health
organisations, service providers, and researchers. The evidence from all
witnesses was unanimous support for:
-
significant change in mental health policy;
-
the findings of the National Mental Health Commission; and
-
the urgent need for government decision and leadership.
The committee's 13 recommendations reflect what the committee
has been told by the mental health sector and those with lived experience of
mental illness. The committee considers that the government's lack of response
to the Commission's findings has caused significant harm. The committee
therefore calls on the government to announce its response as a matter of
urgency.
As Professor Hickie said when interviewed on 5 October by
ABC Radio's The World Today program:
The Abbott government gave a commitment at the 2013 election
to conduct a review and implement reforms during this period of government. So
it's good to see the [Health] Minister's finally working her way through these
issues, but really, really, it's time for action – not more talk.
So we don't need more reviews, we don't need more
consultation, we don't need more discussion about discussion – we actually need
the Prime Minister, the new Prime Minister, working in combination with the
states, so that people get the services that they need no matter where they
live.[21]
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