Chapter 4

Government reaction

...mental health is probably the hidden epidemic in our community. Something like one in five Australians will have an episode of mental ill‑health in any one year; it's something that is happening everywhere, but it's so often unrecognised and it's so often untreated.[1]

Former Prime Minister the Hon Tony Abbott MP

Introduction

4.1        The Government's announcement of a review into the delivery of mental health services and programmes on 4 February 2015 was strongly welcomed by the mental health sector.

4.2        Stakeholders in the mental health sector participated energetically in the Commission's review, with the Commission receiving over 2000 online and written submissions, in addition to its face-to-face meetings with stakeholders.[2]

4.3        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',[3] the government only released the Commission's report after part of the report had been leaked to the media in April 2015.

4.4        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, established an Expert Reference Group (ERG) to provide advice to the Department of Health, further to a government response being made at some date in the future.[4]

4.5        This chapter examines the government initial reaction to the Commission's report, including the processes that the Minister for Health has set in place, and the estimated timeline for a formal government response.

Delay in releasing the report

4.6        From the time the Commission delivered its review to Government in December 2014, there were calls from mental health groups for the review report to be publicly released. For example, the CEO of Mental Health Australia, Mr Frank Quinlan spoke about the need for the Commission's review to be released as part of a public discussion about mental health sector reform. Speaking on 2 March 2015 about the release of three major reports by non-profit groups, Mr Quinlan said:

In the face of these reports, we renew our call on government to release the National Mental Health Commission’s Review of Mental Health Services and Programmes to allow consultation and planning, and to commit to ending funding uncertainty for mental health organisations who are delivering essential services across all these areas.

The mental health sector is committed to reform and renewal, it’s time to get started.[5]

4.7        On 14 April 2015, more than four months after the report was provided to the Government, the ABC's 7.30 Report program obtained part of a leaked report.[6] In response to the resultant pressure from experts and mental health groups,[7] the government released the full report on 16 April 2015.[8]

4.8        In announcing the release of the full review report, the Minister for Health argued that given the complex nature of the findings of the review, 'a consultative and collaborative approach is essential to achieving this and I intend to seek bipartisan agreement to revive a national approach to mental health at tomorrow’s COAG [Council of Australian Governments] meeting of Health Ministers.'[9]

4.9        With one exception, the Minister's announcement appears to be the only government response made to date to the review's recommendations:

...the Government does not intend to pursue the proposed $1 billion shift of funding from state acute care to community organisations, as we want to work collaboratively in partnership with other levels of Government.[10]

4.10      Decisions regarding the implementation of the Commission's findings are subject to the outcome of two main processes: deliberations by the COAG Health Council and advice from the ERG.

4.11      However, mental health is a policy area which overlaps significantly with that of primary care, including the Medicare Benefits Schedule (MBS) and the Primary Health Networks (PHNs). Other government processes such as the Primary Health Care Advisory Group (PHCAG), the MBS Review, and the establishment of the PHNs, will necessarily have a bearing on any decisions the government may make about the Commission's recommendations.

4.12      Additionally, the transition of government programmes such as Partners in Recovery (PIR) to the National Disability Insurance Scheme (NDIS) is also part of the environment in which the Commission's recommendations must be considered.

4.13      The processes specific and ancillary to the government's consideration of the Commission's review are examined below.

Government response—processes and timeline

4.14      In her comments on the release of the Commission's receive on 16 April 2015, the Minister for Health emphasised that the Commission's review must be placed in context:

...[it] is a report to government, not of government, and while many recommendations offer positive ideas, others are not conducive to a unified national approach or require further investigation by experts...[11]

4.15      The Minister for Health advocated for having national support for reform, as well as support from the mental health sector, in place before any new policy in response to the Commission's review is announced.[12] To this end, the Minister announced that the government response to the Commission's recommendations would not be released until the COAG Health Council had completed its deliberations and the ERG had made its report.

4.16      Asked at the 16 April press conference why, given the comprehensive report of the Commission, there was the need for a COAG working group and an ERG to advise government the Minister told journalists:

Because we'll be implementing these recommendations and Government policy together. So this is an important part of the process. Having received the report, having worked through the recommendations, having taken careful note, I will now be in close consultation with the mental health sector to reform this fragmented approach and this multisector organisational delivery that we all acknowledge doesn't get the best spend for our mental health dollar – and let's not forget, this is not just about dollars, it's about people. It's about patients, it's about lives and it's about a commitment that I know all Health Ministers want to make to do better. So we're not extending a consultation process, we're implementing an important phase of that consultation process.[13]

4.17      However the timeline on the Minister's consultations at national, state, and stakeholder levels is not fixed. As discussed below, the establishment of a COAG Working Group on Mental Health has not yet proceeded.

4.18      In response to questions about timeframe, and in particular about funding for mental health services while consultation was ongoing, the Minister said:

...we've extended funding [for mental health services] for another 12 months and we're going to use that 12 months to work through how we implement these recommendations and government policy and practice.[14]

4.19      A breakdown of timeframe for decisions in the 12 months specified by the Minister is not available. Mr Mark Cormack, Deputy Secretary of Strategic Policy and Innovation in the Department of Health told the committee that:

What we are working to do is to support the Expert Reference Group to complete its advice to government. Government will then release its response to the commission's report and within that response we anticipate that there will be a greater degree of certainty about the timing for contract extensions, renewals and any changes or modifications in the way that services are delivered. Certainly our minister has been making sure that we support the work of the Expert Reference Group to get the advice to her as quickly as possible and then it is really a matter for government decision making. As I said, we believe that the information from the ERG will be made available to government in the time that it is requested and then the deliberations of government will continue on from there, at which time we should be able to identify the impacts on the sector as a result of government decision making... The precise timing of the government response is a matter for government. But all the indications are that they want us to support that being delivered very quickly.[15]

4.20      Stakeholders in the mental health sector are understandably concerned about the prospect of another 12 months without any government response to the Commission's review. Mr Frank Quinlan, Chief Executive Officer, Mental Health Australia told the committee that this uncertainty was unprecedented:

We have really been on hold, largely, in terms of major policy decisions since the government commenced their Review of Mental Health Programs and Services [in February 2014]. Beyond the temporary extension of certain programs just to keep the doors open a couple of times during that period, there have not been substantial reform measures undertaken—this at a time when, I think it is fair to say, there has never been greater unity or clarity from a very broad and diverse sector about the need for reform and, in large measure, about the steps that are required in order to undertake that reform.[16]

4.21      The concerns of stakeholders such as Mental Health Australia, and the issues they raised with the committee are examined in Chapters 5 and 6.

COAG deliberations

4.22      The Minister described the COAG process as 'essential to developing a co‑ordinated, binding national approach long-term'. She went on to state that the Government would therefore seek to establish a COAG Working Group on Mental Health Reform  to coordinate consultation and decisions with state and territory governments.[17] There is no information publicly available on whether the working group has been established at the time of writing.

4.23      Neither the 17 April 2015 COAG Communique nor the 23 July 2015 Special COAG Communique mention the NMHC Review of Mental Health Services and Programmes and the cooperation of state and Commonwealth governments to implement the review's recommendations.[18]

4.24      The COAG Health Council (CHC) also met on 17 April 2015. The communique issued on 19 April stated that the CHC discussed the release of the NMHC's review and noted Minister Ley's rejection of the review's recommendation to move $1 billion from hospital funding to community-based services. The communique also noted:

Ministers agreed to work cooperatively with the Commonwealth on a national approach through the COAG Health Council to progress a response to the recommendations of the Review.[19]

4.25      However there was no mention made of the establishment of the COAG Working Group on Mental Health in the communique.

Expert Reference Group

4.26      Alongside the consultations that will take place within COAG, the Minister described the Government's approach to including the mental health sector in decisions regarding the implementation of the review's findings. The Minister announced the establishment of an Expert Reference Group (ERG) which would:

...inform the entire process, including the development of short, medium and long-term strategies in four key areas based on the findings and recommendations presented in the National Mental Health Commission’s Review in four overarching mental health areas:

• Suicide Prevention;
• Promotion, prevention and early intervention of mental health and illness;
• The role of primary care in treatment of mental health, including better targeting of services;
• National leadership, including regional service integration.[20]

4.27      The purpose of the ERG is to provide 'expert advice to inform the development and implementation of the Government's response to the Review.'[21] The ERG had its first meeting on 18 June 2015,[22] and presented its report to the government in October 2015.[23] A list of the members of the ERG is provided in Appendix 6.

4.28      The ERG's advice to the Department of Health will centre on the 'policy, programme and service changes' proposed in the review, with specific attention to:

• The evidence base underpinning changes to mental health programmes and services;
• Potential options for and implications of programme redesign;
• Workforce and regional infrastructure issues;
• Process issues in relation to consulting on and developing a response to the Review.[24]

4.29      Terms of reference for the ERG make it clear that the group's purpose is to provide expert advice and not to be a decision-making body. The ERG's expert advice will be supplemented by 'advice obtained from stakeholders through a broader consultation, and existing ongoing mental health advisory groups over the coming months.'[25]

4.30      The ERG's terms of reference set out the linkage between the work of the ERG and the process of COAG consultation:

Advice obtained from the Expert Reference Group will also help to inform the Commonwealth’s input to discussion with states and territories under the COAG Health Council on the development of a new National Mental Health Plan as well as inform deliberations of the Primary Health Care Advisory Group and the Medicare Benefits Schedule Review taskforce.[26]

4.31      The ERG will be supported by a number of other processes:

• Broad stakeholder workshops to ensure mental services and organisations at the frontline can have direct input into this process;
• An NDIS Mental Health working group;
• An Aboriginal and Torres Strait Islander Mental Health and Suicide Prevention Advisory Group;
• Setting better access to mental health services as a priority for the Government’s new Primary Health Networks;
• And an inter-governmental approach to ensure Commonwealth agencies respond to the report’s concerns about fragmentation of payments and services and better co-ordinate future systems and policies.[27]

Primary Health Care Advisory Group

4.32      Another current process which may influence the government's mental health priorities is the broader Primary Health Care Advisory Group (PHCAG).

4.33      The Minister announced the establishment of the PHCAG on 22 April 2015, alongside the establishment of the Medicare Benefits Schedule (MBS) Review Taskforce.[28] The PHCAG members were announced on 4 June 2015.[29]

4.34      Announcing the role of the PHCAG, the Minister noted that the PHCAG will 'examine opportunities for reform and to develop them into a series of proposals for consultation, prior to reporting to Government'.[30] Supported by the Department of Health, the PHCAG will 'identify opportunities for health system reform' and focus on:

• Primary / Acute care interface, including the proposed and potential roles of [Primary Health Networks];
• Innovative care models for target groups such as those with complex, chronic disease;
• Funding models that best support proposed service improvements;
• Potential revised roles for existing players in the health system that support proposed service improvements; and
• Better recognition and treatment of mental illness.[31]

4.35      The PHCAG released its discussion paper Better outcomes for people with Chronic and Complex Health Conditions through Primary Health Care on 4 August 2015. The discussion paper contains limited mention of mental health care in terms of chronic illness. PHCAG consultations have taken place in capital cities and regional centres, and concluded with a national web-linked consultation on 21 August 2015.[32]

4.36      According to the Department of Health website, the PHCAG will report government by the end of 2015.[33] Dr Steve Hambleton, Chairman, Primary Health Care Advisory Group told the committee that they had been asked to report in November 2015.[34]

4.37      Dr Hambleton also noted that the PHCAG had not been provided with a copy of the report or any of the work of the ERG.[35]

Primary Health Networks

4.38      In announcing the establishment of the PHCAG, the Minister noted that there would be wide consultation and that the PHCAG (and the accompanying MBS Review) would:

...draw on a broad range of expertise and experiences to inform the process, including: Clinicians (GPs and Specialists); Consumer and Patient Representatives; Academics; Primary Health Networks; Nurses; Allied Health Professionals; Health Economists; and States and Territories.[36]

4.39      The Primary Health Networks (PHNs) are likely to play a significant role in the intersection of primary healthcare and mental health. The NMHC review proposed that the PHNs could play an important role in cementing mental health in the delivery of primary care. This would enable better early intervention and prevention, and assist in de-stigmatisation of mental illness:

The development of 30 Primary Health Networks (or Primary and Mental Health Networks—PMHNs) across Australia provides the ideal opportunity to harness this infrastructure and better target mental health resources to meet population needs on a regional basis.

These new entities will be the meso-level organisations responsible for planning and purchasing services on a regional basis. They can work in partnership and apply targeted, value-for-money interventions across the whole continuum of mental wellbeing and ill-health to meet the needs of their communities, enabling a stepped care approach with the aims of:

• promoting mental health and wellbeing
• reducing risk factors
• preventing mental ill-health
• reducing or delaying the onset of mental ill-health experiences
• managing and supporting people in the community as much as possible
• providing timely access when needed to hospital and other acute services
• managing the handover from hospital back into the community, step‑down care and rehabilitation, aged care and palliative care
• reducing adverse events, waste and duplication.[37]

4.40      The PHNs therefore have a role alongside both the ERG and the PHCAG to include mental health in primary care as a means to implement the NMHC recommendations. Further discussion on the role of the PHNs in mental health care is in Chapter 5.

National Disability Insurance Scheme

4.41      The Commission's review findings included the need to 'set clear roles and accountabilities to shape a person-centred mental health system'. To implement this finding, the review recommended that the Government:

Urgently clarify the eligibility criteria for access to the National Disability Insurance Scheme (NDIS) for people with disability arising from mental illness and ensure the provision of current funding into the NDIS allows for a significant Tier 2 [now called 'Information, Linkages and Capacity Building'] system of community supports.[38]

4.42      The Minister's announcement of 16 April 2015 states that the ERG will be supported by other processes, including 'an NDIS Mental Health working group'.[39]

4.43      A group called the NDIA Mental Health Sector Reference Group was established in late 2014, 'to develop a strong working partnership between the mental health sector and the NDIA'.[40] The group has held a number of meetings since its establishment and is:

...is chaired by Strategic Adviser to the NDIA, Mr Eddie Bartnik. Membership consists of consumers, carers, peak associations, NDIS Independent Advisory Council members and key government representatives including Mental Health Commissions.[41]

4.44      The transition of mental health programmes and services to the NDIS and related issues is discussed in Chapter 7.

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