5.1
The Committee’s terms of reference identified the mental health workforce as a critical focus for the inquiry both in terms of capacity to respond to events such as the 2019 bushfires and COVID-19 pandemic, and strengthening its capacity meet the increasing demands.
5.2
Accordingly, the Committee examined the roles, training and standards for health and allied health professionals who contribute to mental health care, that are required to deliver quality care at different levels of severity and complexity, and across the spectrum of prevention, early intervention, treatment and recovery support.
5.3
In addition, the Committee considered the valuable contribution of peer workers, carers and volunteers and the support needed for these groups, and workforce wellbeing.
Australian Government review of workforce
5.4
The Productivity Commission Inquiry Report on Mental Health (Productivity Commission Report) identified workforce reforms as integral to healthcare reforms, suggesting that increasing use of supported online treatments and group therapy would help to free up psychologists and other care providers to assist those with more complex needs. Refer to Chapter 4 of the Committee’s report for further discussion about digital and online services.
5.5
However, the Productivity Commission anticipated that ‘there would still be workforce shortfalls in some specialisations and in some locations’ and that workforce planning and changes to workforce education could ‘help reduce both these workforce shortages and professional stigma.’
5.6
The Productivity Commission Report recommended increasing the efficacy of Australia’s mental health workforce, and outlined a series of reforms to workforce planning and established workforce practices, and sector perceptions for consideration by the Australian Government and state and territory governments.
5.7
In responding to the Productivity Commission’s Report, the Prime Minister emphasised the centrality and need for a skilled, comprehensive workforce:
Building up our care workforce, and in particular, our mental health workforce, will be vital to how successful we are. We must build a workforce inside and beyond the health system from peer workers, community workers. And as well, of course, our clinical workforce. It must be compassionate and it must take a recovery-based approach.
5.8
The Australian Government’s 2021-22 Budget followed up on the government’s commitment with a $128.4 million package of investments to increase capacity and improve the capability of the mental health workforce, including $58.8 million for growing and upskilling the mental health workforce.
5.9
To address workforce issues, the Australian Government established an independent taskforce, the National Mental Health Workforce Strategy Taskforce, to work with the Commonwealth Department of Health and the National Mental Health Commission (NMHC) in jointly developing a 10 year National Mental Health Workforce Strategy.
5.10
The strategy would address the quality, supply, distribution, and structure of Australia’s mental health workforce, and integrate with other related workforce strategies including the National Medical Workforce Strategy, the Stronger Rural Health Strategy, the National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework and Implementation Plan 2021-2031, and state and territory mental health workforce strategies.
5.11
A consultation draft was released in August 2021 to seek views from stakeholders. The final strategy is expected to be provided to the Australian Government before presentation to all governments under the Australian federal relations architecture.
Overarching workforce views
5.12
In its interim report, the Committee expressed concern about workforce shortages and reiterated its intention to hear stakeholder views on the distribution of registered mental health professionals both geographically and across specialities, the role of professional bodies and recognition of the various mental health professions, and the drivers for workforce participation.
5.13
The Black Dog Institute raised concerns around the contradiction of increasingly encouraging help-seeking for mental problems when there are not enough mental health professionals to meet demand. On this basis, the Institute identified workforce issues as the top priority to enabling reform of the mental healthcare system:
There are simply not enough mental health professionals in Australia. There are not enough psychiatrists, psychologists, mental health nurses, GPs [general practitioners] with a special interest … Of course, part of the solution to this is going to be more funding for training, but that alone is not going to be enough … we need a comprehensive plan around recruitment, around training, around retraining other professionals to come into mental health and around retention.
5.14
The Royal Australian and New Zealand College of Psychiatrists (RANZCP) reinforced access challenges, particularly in regard to psychiatrists. To help alleviate the pressure on psychiatrists, RANZCP suggested increasing ‘the capacity and the knowledge and skills of people who interface with patients who present with psychiatric problems’, noting this would include general practitioners (GPs), emergency physicians, geriatric physicians and nursing care professionals.
5.15
Similarly, NMHC identified an immediate need to embed in educational processes the importance of mental health training, particularly tertiary education for professional disciplines. NMHC suggested moving this training ‘from being optional to being a core component of their education’.
5.16
Equally Well noted that frequently the physical health of people living with mental illness is overlooked. To address this, it recommended:
Ensuring quality physical healthcare for people living with mental illness be included in the roles, training and standards of all health and allied health professionals who contribute to mental healthcare, including peer workers and general practice.
5.17
Mental Health Australia (MHA) cautioned government ‘to resist the urge to do small or targeted pieces of renovation to the system rather than think of the whole system’, particularly when considering workforce. Similarly, Mental Health Victoria submitted that a fragmented system cannot be fixed with a fragmented approach to reform. Instead, MHA recommended taking multiple approaches across the spectrum of care.
5.18
A clinical and medical model alone has not provided the complete solution over the last 50 years, said HelpingMinds:
… we feel that complementary supports—such as peer supports, recovery colleges, alternatives to suicide peer support groups, peer-led Safe Haven cafes—are vital if we're looking to find solutions, going forward.
5.19
Further, Beyond Blue lobbied for the inclusion of lived experience across all sectors to underpin sustainable, large-scale reform of the mental health and suicide prevention systems:
This transformational re-centring of lived experience requires a concerted shift and must bring everyone along the journey. It must be done in partnership, not only with consumers and carers, but also the sector organisations, mental health services, peak bodies, clinicians and the non-clinical workforce. The delivery of joined up care involves everyone and an informed and balanced system must embrace all voices and expertise.
Defining roles and scope of mental health professionals in workforce planning
5.20
The National Mental Health Workforce Strategy consultation draft recognised the indivisible connection between people’s physical, psychological, social, emotional and cultural wellbeing, noting it drew heavily on the National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing 2017-2023. The draft strategy defined the mental health workforce across four categories – health and social and emotional wellbeing workforces; social services workforces; carers, families and communities; and alternative therapists – and included the following distinction:
people who work exclusively in the mental health sector (for example Aboriginal and Torres Strait Islander mental health workers, mental health nurses and psychiatrists)
those working in other health settings who frequently treat, interact with, care and support people experiencing suicidality, mental distress and/or ill-health (for example allied health, general practitioners and nurses).
5.21
Noting the chronic workforce shortage, headspace called for a ‘greater emphasis and understanding of what exactly is required from a range of different mental health clinicians—those with lived experience, peer workers and others within the primary healthcare system’.
5.22
Professor Ian Hickie from the Brain and Mind Centre at the University of Sydney pointed out that the first priority should be determining ‘what do people do, and what is their role in achieving the outcome of interest’, and how that role factors into a multidisciplinary workforce:
… the appropriate use of professional skills at critical points along the illness journey, results in much more efficient care.
5.23
Family and Relationship Services Australia reiterated that ‘workforce issues impacting the mental health sector extend beyond the parameters of the health system’, noting that ‘many family and relationship services sector workers share common skills, training, knowledge and qualifications’. It recommended that a complementary family and relationship services workforce strategy be developed alongside the National Mental Health Workforce Strategy.
Building a connected, diverse and engaged mental health workforce
5.24
Orygen and SANE Australia called for greater incentives to encourage people to join the mental health workforce, with initiatives to reduce professional stigma and highlight the potential for a career with a great sense of purpose. Professor Patrick McGorry from Orygen suggested a national campaign:
You know the ads that you see on TV [television] for joining the military? They make it sound like it's the most wonderful experience of your whole life. So marketing and communications would be a key thing as well that could be done straight away.
5.25
The Productivity Commission Report recommended further steps be taken ‘to reduce the negative perception of, and to promote, mental health as a career option’, and ‘to incorporate mental health stigma reduction programs into the initial training and continuing professional development requirements of all health professionals’.
5.26
The Queensland Mental Health Commissioner identified a number of areas that need to be addressed to attract and retain staff:
reducing system and back-office requirements placed on clinicians to free them up to spend more time doing what they were trained to do
place a greater focus on a shared workforce between public, private and non-government sectors
expand the workforce to include peers and degree level counsellors
improve training for mental health staff, and enhance mental health skills and capabilities in workforces employed by sectors, such as child safety, education, corrections and housing.
5.27
The Northern Territory Department of Health reinforced the view that the current mental health system remains a medicalised model of care, noting ‘access to a skilled workforce remains limited with counsellors and psychotherapists outside of the MBS [Medicare Benefits Schedule] umbrella’. The department identified peer workers as a priority and asserted that ‘workforce development should cover associated elements of integrated planning, implementation science and change management’.
5.28
In terms of positioning the workforce for the future, Professor Francis Kay-Lambkin highlighted the national consultation around capacity-building needs of the mental health workforce undertaken by Australia’s Mental Health Think Tank, and put forward a series of practical solutions to address the gaps and opportunities:
For those in the early stages of their career, create a network of peers to promote and support cohort interactions, interactions with key stakeholder groups.
Short, flexible and easily accessible modules to improve transferable skill development based on evidence, support the development of professional skill building for both service delivery as evidence emerges for Doctors of Philosophy and research embedded in everyday mental health service delivery and help people position themselves for clinical and research leadership in mental health.
Seed funding collaborations and schemes, leveraging and enhancing that link between research and practice, including embedding researchers into mental health services and vice versa.
A navigation function to help people map and understand the multiple career pathways for mental health workforces in Australia and internationally, including beyond traditional approaches.
5.29
To create workable solutions in mental health, Professor Maree Teesson from the Matilda Centre for Research in Mental Health and Substance Use at the University of Sydney and Chair of Australia's Mental Health Think Tank suggested harnessing Australia’s capacity for innovation to bring together major national innovators in workforce education and training, and break down the silos of expertise.
5.30
MHA supported the proposition that the Australian Government ‘create a national workforce institute to drive national mental health workforce reform, professional development, and leadership across the mental health sector’.
5.31
Professor Alan Rosen from Transforming Australia’s Mental Health Service Systems explained that the institute should be nationally inclusive of other partners to ensure coordination and representation in every state and territory, with a focus on consistent, up-to-date, evidence based modules of care being trained in teams. Professor Rosen also noted the importance of ‘all-of-system support’:
… in other words, a platform for consistent supervision. A lot of mental health staff either don't get supervision or don't stay because they don't get sufficient supervision in a complex field. The other piece of that is also having consistent pastoral mentorship and communities of practice so that people have company in developing the best way to sustain those innovations.
Committee comment
5.32
The Committee remains concerned that a career in mental health may be considered by some as a second rate medical career, rather than the opportunity to embark on a pathway dedicated to helping people live their best lives.
5.33
In addition to dealing with any remaining stigma associated with pursuing a career in mental health, the Committee would like to see clearly understood education and career pathways for anyone interested in joining the mental health workforce. To increase the diversity of the workforce, the pathways should be visible, accessible and appropriate and encourage entry of people from vulnerable and disadvantaged populations.
5.34
The Committee endorses the concept of a national workforce institute for mental health, and would like to see this realised as a priority. Innovation and collaboration will help drive forward the reforms needed to build a connected, diverse and engaged mental health workforce.
5.35
The Committee has found that a workforce strategy is key to improving the mental health of all Australians and on this basis recommends that the Australian Government provide funding and other supports needed for the immediate development of a national workforce institute for mental health. The institute must:
include Aboriginal and Torres Strait Islander peoples and lived experience expertise
incorporate professional stigma and burnout reduction strategies
develop avenues for mental health supervision and debriefing for all participants in the mental health workforce.
Competing for professionals
5.36
An unintended consequence of the substantial increase in demand for mental health services and additional funding being provided to help address service shortages is competition for scarce human resources across the public, private and non-government sectors.
5.37
Evidence received from across the sectors acknowledged the challenges of attracting and retaining staff, and the increasing difficulty where there were compounding issues such as funding shortfalls and geographical challenges.
5.38
Acknowledging the supply side challenges, SANE Australia noted that the introduction of the National Disability Insurance Scheme (NDIS) had exacerbated competition for people with skills and qualifications both for junior levels and clinical roles:
… especially when a number of measures are announced at once we're now … in competition and trying to get our job ads out as quickly as possible.
5.39
In Western Australia, Adjunct Associate Professor Learne Durrington highlighted the relatively mobile workforce and the difficulties non-government organisations (NGOs) face in attracting mental health professionals:
… particularly those psychologists and clinical psychologists that we'd want to see working in not-for-profit organisations in our country areas. They're often employed in the state system for no other reason than salaries, conditions, wages and other things that an NGO can't afford.’
5.40
Stride Mental Health explained that the limited pool of people and direct competition with public services meant it was not always possible to retain experienced and qualified people:
It's across our sectors, our revenue streams and our service streams. So it doesn't matter if it's a psychologist, practitioner, support worker or residential worker—it is about finding people. It becomes more and more difficult the more you enter into the rural areas. It becomes, in some cases, near impossible to find somebody that could actually help us, even if we had funding.
5.41
headspace agreed that ‘it's always been hard in rural and remote and regional Australia’ but pointed out that outer metropolitan areas equally struggle to attract and retain mental health professionals.
5.42
Acknowledging the competitive labour market system employers face, headspace outlined the impact of this, including the breaking of therapeutic relationships, impacting the trust that had been established and potentially seeing people disengaging from services:
They might associate themselves with coming to headspace, and that might be great, but it's actually about the relationship and rapport that they build with the individual worker. In some cases it can be a peer worker or a clinician. If there's a high turnover, that's not good for managing a service and keeping up with the demands and complex needs people are presenting with.
Regional, rural and remote workforces – growing local services
5.43
Beyond Blue suggested that to address psychologist and psychiatrist shortages it is necessary to invest in new and different workforces, including peer workers and mental health coaches, as a means to deliver early intervention services in rural and remote communities:
… where there are ongoing difficulties in attracting the workforce, we can really build up the capacity of the community to support their own community and to look after their mental health. That's an important piece of the puzzle.
5.44
The Australian Rural Health Education Network (ARHEN) acknowledged the importance of medical practitioners, but noted that GPs in rural and remote areas are stretched and people’s mental health needs could be supported by increasing availability of a range of health professionals:
There's recognition across the range of recent reports and inquiries about the role and value of allied health, particularly the capacity of allied health professionals to work from the continuum of early intervention and health promotion through to acute care and through to rehabilitation and support for people with chronic conditions. Being able to grow that capacity in rural and remote communities would be very welcome and, I think, would go a long way to helping to support the wellbeing of people in the bush.
5.45
In addition, the Royal Australian College of General Practitioners (RACGP) research indicates ‘GPs practising in rural and remote locations would like to engage in advanced mental health training but are deterred by the financial cost and the time away from practice’. RACGP recommended ‘incentive schemes equivalent to those for procedural skills would support GPs to develop or refresh advanced skills in mental health’.
5.46
In terms of encouraging mental health professionals to live and work in rural and remote areas, ARHEN noted that many of the barriers are non-monetary and these need to be addressed in order to entice people to come and those who are already there to stay:
… it's also about personal factors; professional factors; how well people are supported by their health service, by their colleagues, by their team; their quality of life; where they live; how their family is supported; the kids' schools; the partner's employment options and so forth.
5.47
ARHEN recommended modelling the investment in pathways in medicine in rural and remote regions for allied health and nursing students. ARHEN suggested helping students understand what a career pathway could look like in a rural and remote location provides both an incentive to go there and stay longer term:
… one of the new models we're developing is a student led clinic. We encourage students to come and do their psychology placements or clinical placements in rural Victoria. They come for 20 weeks and they carry a case load, so those students are providing care to some of our patients and freeing up our senior clinicians to concentrate on complex care …
Even if they [return to] work in an urban area, they just tend to be more supportive of rural practitioners.
5.48
The 2021-22 Budget included $11 million to boost the psychiatrist workforce by increasing the number of training places available, including in regional and remote areas, as well as additional funding to provide scholarships and clinical placements for nurses, psychologists and allied health practitioners.
Committee comment
5.49
Over the years Australian governments have made commitments to providing equity of services to regional, rural and remote communities. Yet, Australia still has unacceptably high numbers of people unable to access the services they need in the right place at the right time.
5.50
The Committee was pleased to see the additional money in the 2021-22 Budget to increase training places for psychiatrists, and scholarships and clinical placements to develop other mental health professionals. Noting the skewed distribution of the mental health workforce, the focus of these placements should be on strengthening the regional, rural and remote mental health workforce.
5.51
The Committee recommends that the Australian Government leverage the existing Australian Rural Health Education Network by providing funding for clinical placements in regional, rural and remote university clinics, and using these clinics to trial multidisciplinary, hybrid mental health hubs that integrate digital services and face-to-face services.
Aboriginal and Torres Strait Islander workforce
5.52
There has been extensive research, strategies and frameworks developed over many years by governments, Aboriginal and Torres Strait Islander organisations, academics, NGOs and more, yet limited progress has been made toward building the Aboriginal and Torres Strait Islander mental health workforce.
5.53
The draft National Mental Health Workforce Strategy background paper acknowledged the ‘difficulties in accessing data on the size of the Aboriginal and Torres Strait Islander workforce’, and as with other areas that lack data, this impedes workforce planning. However, the paper was clear that Aboriginal and Torres Strait Islander peoples are under-represented within the mental health workforce, and there has been no real improvement.
5.54
The Australian Government 2021-22 Budget included ‘$8.3 million to support greater representation of Aboriginal and Torres Strait Islander peoples in the mental health workforce through additional mental health-specific scholarships and to provide training to support healthcare workers to deliver culturally safe care’.
5.55
A refreshed co-designed National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework and Implementation Plan 2021-2031 is expected to be launched soon.
5.56
The National Aboriginal Community Controlled Health Organisation (NACCHO) confirmed the ‘lack of Aboriginal and Torres Strait Islander mental health service providers, and culturally competent services’, noting this as ‘one of the main drivers of poor access to services and poorer mental health outcomes for our people’:
Sufficient recommendations to address this shortfall were missing from the recent reports presented to government. There is a significant shortage of Aboriginal and Torres Strait Islander psychiatric leadership and trained mental health professionals, particularly clinical psychologists.
5.57
NACCHO called for new funding measures to attract and retain mental health professionals within the Aboriginal Community Controlled Health Organisations:
Long-term and sustainable funding is needed to ensure that our Aboriginal Community Controlled Health Organisations can create integrated and sustainable workforces and ensure existing staff receive appropriate training to provide consistent access to services for clients. This needs to occur in line with the strategies for the upcoming national Aboriginal and Torres Strait Islander Work Force Plan 2021-31.
5.58
The Queensland Aboriginal and Islander Health Council called for governments to ‘establish an Aboriginal and Torres Strait Islander mental health and social and emotional wellbeing workforce target’, and develop the Aboriginal and Torres Strait Islander Community Controlled Health Organisations sector’s capability to develop a local skill-based workforce to meet local demand.
5.59
The Aboriginal Health and Medical Research Council of NSW drew attention to the ‘lack of scholarships available outside mainstream organisations to expand the existing workforce, noting that mainstream organisations have an inconsistent approach to cultural competency practices including in training staff.’
5.60
The Committee heard improving access and outcomes for Aboriginal and Torres Strait Islander peoples will require growing the workforce capability and capacity. Gayaa Dhuwi (Proud Spirit) Australia advised it is working with key partner organisations to ‘encourage enabling opportunities for the immediate establishment of a highly skilled and supported Aboriginal and Torres Strait Islander workforce, operating in a clinical, competent and culturally safe way within community controlled services and within the mainstream system’, including by:
… [developing] career pathways for the Aboriginal and Torres Strait Islander mental health workforce, and by having Aboriginal and Torres Strait Islander led national standardised assessments for cultural safety and the services of staff in mainstream mental health and human services.
5.61
Both Gayaa Dhuwi and the Kimberley Aboriginal Law and Cultural Centre (KALACC) advocated for training to take place on the ground rather than bringing people into cities. KALACC stated:
… nothing beats actually engaging a local Aboriginal owned and directed institution with the resources to deliver that learning on the ground. In that sense I think it's more about partnerships than training … on the ground, people are working side by side with dealing with day-to-day issues that are requiring immediate responses, so they will draw on that expertise. That expertise needs resourcing within community based organisations.
5.62
Noting that COVID-19 had driven increased use of digital services, Gayaa Dhuwi suggested exploring options of ‘a good mixture of place based education and training, but also enabling people to come together.‘
5.63
Professor Rosen from Transforming Australia’s Mental Health Service Systems highlighted the importance of national consistency of training and supervision, and ensuring that Aboriginal mental health workers and healers are included in every interdisciplinary team. However, he noted that to do this required sufficient Aboriginal mental health workers trained:
There is only one coherent degree training program in Australia. That's Charles Sturt at Wagga, and some other states, particularly Edith Cowan, feed into that and send their students there, sometimes virtually. But the important thing is that these should be established consistently around the country.
5.64
Professor Rosen pointed out that one state and one territory had set important precedents by legislating to require that ‘when somebody is being considered for involuntary care, they should be assessed by an Aboriginal mental health worker or a traditional healer within the team setting’. However, he raised concerns that ‘we haven't got the workforce trained to be in those positions’.
Committee comment
5.65
The Committee is acutely aware of the need to make real progress on increasing the number of Aboriginal and Torres Strait Islander peoples in the mental health workforce across all professions. There is not a need for more words. Instead, this is a call to action for all those in decision-making positions to take note of the work that has been done and focus on implementation.
5.66
While acknowledging the tangible step of making funding available in the 2021-22 Budget for scholarships, the Committee remains concerned that those taking up these scholarships may find themselves in learning institutions that are not teaching culturally appropriate, trauma-informed programs that have been co-designed with Aboriginal and Torres Strait Islander peoples.
5.67
The Committee draws attention to the comments and recommendation in Chapter 8 on improving cultural competency across the mental health workforce.
5.68
In addition, the Committee calls for more to be done to open the pathways to careers in mental health and suicide prevention, support Aboriginal and Torres Strait Islander students who have chosen to follow a mental health or suicide prevention pathway and improve university completion rates.
5.69
The Committee recommends that the Australian Government led by Aboriginal and Torres Strait Islander representatives, engage with state and territory governments, education authorities, schools and tertiary institutions to increase visibility and promote careers in mental health and suicide prevention for Aboriginal and Torres Strait Islander peoples, including students at high school and tertiary institutions.
Coordinated care for suicide prevention, intervention and postvention services
5.70
Recommendation 4 in the National Suicide Prevention Adviser Final Advice to the Prime Minister proposed ‘evidence-based and compassion-focused workforce development to drive cultural change in and improve the capacity and capability of all (formal and informal) workforces involved in suicide prevention’. Ms Christine Morgan, in her capacity as National Suicide Prevention Adviser to the Prime Minister, outlined the immediate actions required for implementation:
clinical health staff evidence-based contemporary training so that anybody in health services knows what to do about suicide and suicidal ideation
compassion-based training for frontline workers responding to distress, especially financial, employment and relationship support, which will assist the responder to identify distress and work toward safe containment
development of a national suicide prevention workforce strategy.
5.71
Guided by the final advice of the National Suicide Prevention Adviser, the Australian Government’s 2021-22 Budget allocated $298.1 million towards suicide prevention, including funding:
for a National Suicide Prevention Office to oversee the national whole-of-government approach to suicide prevention [including workforce reform], and
to expand the National Suicide Prevention Leadership and Support Program.
5.72
Suicide Prevention Australia advised that while it had not quantified the clinical workforce needed for suicide prevention services, ‘less than half of the people who die by suicide access or need access to the mental health system’. Instead, it suggested that the first step is to ascertain where the need is coming from and what supports are most appropriate:
It's often other life events that can lead a person to suicidal distress, such as marriage breakdown, economic instability and/or job loss, and housing distress. They are the elements that have an impact on a person's potential suicide risk …
There is that model of peer support, where it's not about a clinical issue but mates helping mates … Those sorts of workforces, so to speak, are critical in ensuring there's that safety net for people, preventing them from getting to suicidal distress.
5.73
The Northern Territory Department of Health encouraged a strong focus on evidence-based decision making to ensure that approaches taken in different areas match the needs:
Workforce capability across the care continuum should focus on ensuring that skillset gaps are targeted across all roles and responsibilities, as opposed to only strengthening suicide prevention focussed roles. All roles, when taking into account a health and wellbeing approach to suicide prevention, have the capacity to prevent trajectory towards suicidal behaviours.
5.74
Referring to suicide prevention in Aboriginal communities, KALACC noted that funding continues to go toward building evidence, despite the extensive research base already available, ‘some 40 reports over a period of 15 years’. KALACC referred to a 2012 paper ‘Cultural wounds require cultural medicines’, in which the author concluded that ‘cultural wounds require cultural healing; they don't require more health workers’. The role of culture in mental health is explored further in Chapter 8.
5.75
The Zero Suicide Institute of Australasia proposed that ‘until such time as prevention is achieved establishing services to meet immediate need for de-escalating a crisis is critical and should be done in an integrated way’. Further, the Institute flagged insufficient suicide prevention content in undergraduate courses, meaning that ‘many of the people who are mental health trained have not had that additional experience of being trained to work with suicidal people’. It suggested that training include increasing capabilities around undertaking suicide risk assessments and developing safety plans with at-risk individuals.
5.76
Wesley Mission noted the importance of training front-of-house staff to intervene and support people at risk of suicide:
… if they can recognise that Joe, who called in today, sounded different from the day before and wanted an imminent appointment with the GP, perhaps with that training there's a mechanism whereby the administration workers are able to create a five-minute window in the GP's day and that enables access. It also enables a greater sense of support and common language to assist the GP operating day-to-day in that practice.
5.77
Forensicare called for ‘additional training and support for GPs and frontline staff, including psychologists, regarding additional considerations for suicide and self-harm risk assessment and management of people released from prison’. Forensicare noted that experience has shown that ‘they're often ill-equipped to manage the group, let alone to deal with the suicide and self-harm risk’.
5.78
More broadly, Lifeline Australia recommended ‘the inclusion of suicide prevention training standards in the National Mental Health Workforce Strategy for all health and allied health professionals to ensure people at risk of experiencing suicidal behaviour are supported into appropriate care’.
5.79
With a focus on aftercare, StandBy highlighted the need for greater capability in postvention across all workforces who may be in touch with people bereaved by suicide, including clinical and non-clinical staff, as well as health, justice, education and housing. StandBy recommended a national workforce competency based framework to improve coordination and capability, noting that it had started work at the state level with funding from New South Wales (NSW) Ministry of Health.
A holistic approach to upskilling for suicide intervention
5.80
The Zero Suicide Institute of Australasia commended its Zero Suicide Healthcare Framework as a highly effective means of achieving reductions in suicides in people who present to the health system, and outlined the workforce requirements:
... a commitment by leadership to a just and restorative culture, one that removes blame when an adverse event occurs, one that has a belief that suicide is an unacceptable outcome in a modern healthcare setting and that lived experience leadership is integral to their service. There is also a teamwork approach where staff are trained and competent and confident to work with people who are suicidal in a respectful manner that is free from discrimination; collaborative management of suicidality that actively involves the individual, their clinician and their support network; and data and implementation signs are used to deliver continuous improvement.
5.81
The Gold Coast Mental Health and Specialist Services (GCMHSS) began implementing the Zero Suicide Healthcare Framework in 2016 and ‘[w]ithin a three year period, they had achieved a better than 23 per cent reduction in suicides for those who came to their healthcare system’. Clinical Director, Dr Kathryn Turner, provided additional background on the change in management processes, training, and support put in place at GCMHSS:
It really was around changing attitudes and beliefs of clinicians. That whole-of-service approach, that whole framework, is what makes this different from just implementing a new team or implementing a particular intervention. What it also does is allow you, within that framework, to implement interventions effectively. A lot of it is about a change management process, which is incredibly difficult to achieve in complex services. We engaged all of the workforce. We trained all of the workforce, in specific interventions, so they had greater confidence. We gave a clear pathway ... It's both that clinical focus and that cultural focus, and that's about engaging with families following incidents and supporting them, and it's about supporting clinicians and about having a learning organisation where we can learn and continuously improve …
We've worked in partnership with, in state-wide training, the Queensland Centre for Mental Health Learning. They had some training directly targeted towards emergency departments. We liked some components of that, particularly that they were training in the chronological assessment of suicide events but also about attitudes and beliefs, well, and about risk factors et cetera. They are the basics that we've probably all been doing for a long time, in terms of the basic risk assessment. The Chronological Assessment of Suicide Events is from the US, from Shawn Shea, and it particularly skills clinicians. It's often very difficult to elicit suicidal intent when you are seeing someone, and it gives clinicians increased skills ...
The other sort of investment that we had was in a senior psychologist who can go out to teams and continually supervise, model and provide feedback. So it's an ongoing process after that initial training, because you can't expect that you will get much change with one day of training ...
… we see huge volumes of consumers and you can't predict who will go on to suicide. Yet, when something happens, the old way of doing incident reviews used to make the assumption that someone could have predicted it. That contributes to a sense of, 'How can we make a difference if we can't even predict who will go on to suicide?' So this shifts the whole thinking to a prevention oriented one: we can't predict but we can put in a whole range of steps and we can support staff and engage with consumers and provide a better level of care that we believe will prevent many suicides.
Committee comment
5.82
Zero suicides are what Australia is seeking to achieve. While aspirational, this reminds us that there should not be any suicides that occur because there were no effective services available at the time of need, or in the after-care period of an attempt.
5.83
The Committee commends the sizeable investment in suicide prevention in the 2021-22 Budget, but notes that successful implementation will depend on building capability and capacity of a dedicated suicide prevention workforce, as well as upskilling the existing mental health workforce and those in frontline services.
5.84
The establishment of the National Suicide Prevention Office is a good first step and the Committee looks forward to seeing meaningful progress on workforce reform, including the integration of lived experience, and coordination with states and territories.
5.85
While the National Mental Health Workforce Strategy consultation draft includes references to suicide prevention, the Committee would like to see a discrete section on the development of the suicide prevention and aftercare workforce, and endorses Lifeline Australia’s recommendation to include suicide prevention training standards in the National Mental Health Workforce Strategy.
5.86
The Committee was impressed by GCMHSS’s complete redesign of services and change in management process to shift the workplace culture for suicide prevention. It is critical that there is a mechanism to harness these best practice examples and enable them to be embedded in education and training, and hospital settings around Australia.
5.87
In relation to the workforce to support Aboriginal and Torres Strait Islander peoples, the Committee encourages an increased focus on prevention and postvention through integrating culture into suicide prevention services and training and education for the Aboriginal and Torres Strait Islander mental health workforce.
5.88
The Committee also believes that the mainstream health, mental health and suicide prevention workforces would benefit from learning more about the role of culture, both in terms of supporting Aboriginal and Torres Strait Islander services, and in looking at ways to engage other vulnerable communities.
5.89
The Committee recommends that the Department of Health and the National Mental Health Workforce Strategy Taskforce include in the National Mental Health Workforce Strategy:
suicide prevention training standards for all health and allied health professionals and other professionals that form the suicide prevention workforce
national standardisation of suicide training in risk assessments and safety plans, to ensure consistency and evidence-based training delivery
specific references to the workforce development requirements for suicide aftercare and postvention.
Professions contributing to the mental health and suicide prevention workforce
5.90
The following section reviews the professions contributing to the mental health and suicide prevention workforce. A number of recent reports, including the draft National Mental Health Workforce Strategy background paper, have provided details on the role, training, regulation and supply of component occupations. The discussion below reflects the areas that the Committee believed warranted further examination.
5.91
Chapter 6 explores funding arrangements for medical professionals, including through the Medicare Benefits Schedule (MBS) and Primary Health Networks (PHNs).
General practice
5.92
RACGP advised that member surveys indicated that psychological problems have been the most common reason for visiting the GP, particularly during COVID-19:
General practice is definitely a very attractive place for people with mental health problems to go; they genuinely want to do it. I would say that for most GPs, at least 20 per cent of their workload would be directly dealing with people with mental health conditions.
5.93
The Australian Medical Association (AMA) asserted that GPs should retain the role of first point of contact and care coordinator for mental health problems to ‘deliver the right care to the right patient in the right way’. However, this was predicated on the basis patients in Australia should have access to a regular GP.
5.94
AMA raised concerns that policy discussions have been ‘shifting away from medically informed models of care and moving towards a more fragmented system’:
We believe that more has got to be done to bolster the mental health workforce and to support patients to access care in a coordinated and, of course, timely manner, and that's where GPs come in. They are the best place to coordinate mental health care treatment. GPs are at the core of our current system. They respond most rapidly to the needs of health in the community, partly because the rest of the system is so hard to access.
5.95
This was a view supported by RACGP, which noted that while it may be tempting for people to go directly to a psychologist, this would remove the opportunity to do a physical health assessment prior to treatment being recommended. In addition, RACGP suggested that GPs are well-placed to support patients to adjust the intensity of treatment with a step-up, stepdown, or sideways to another mental health provider, as needed. Finally, acknowledging the shortage of psychiatrists, RACGP suggested that GPs have been able to filter those who may do well with a lower intensity intervention.
5.96
However, the Productivity Commission found that the Australian Government needed to take action ‘to improve practitioners’ training on medications and non-pharmacological interventions’. Appearing before the Committee, the Productivity Commission explained that after taking feedback from GPs, consumers, psychologists and psychiatrists, the evidence was clear that mental health treatment plans were variable in quality:
Some are great, but many are not really fulfilling the function that they're meant to be. They're really little more than a referral.
5.97
AMA commended the Australian Government’s 2021-22 Budget inclusion of $15.9 million to help support GPs and other practitioners through training, which included:
subsidies for approximately 3,400 GPs to undertake training to provide focused psychological therapies under the General Practice Mental Health Standards Collaboration
developing a nationally recognised Diploma in Psychiatry for medical practitioners.
Education and training
5.98
According to RACGP, mental health is ‘embedded in GP training and is a core part of RACGP’s Curriculum for general practice and The Fellowship in Advanced Rural General Practice: Advanced Rural Skills Training – Curriculum for mental health’.
5.99
RACGP explained that GP training starts in medical school, with the introduction of the concepts of diagnosis and treatment of mental illnesses and communication skills to support discussion of psychological concerns. This training is then complemented with ‘at least two years in the hospital sector, where they will meet people who experience psychological difficulties or, indeed, mental illness’.
5.100
RACGP noted that mental health is interwoven into the three-year GP training program, and subsequently, GPs have the option to do an extra six hours of Mental Health Skills Training:
Over 90 per cent of Australian GPs have done that training, and then a smaller number of GPs have done up to 20 hours of training in focused psychological strategies. There are probably 500 to 1,000 GPs who have done that training …
Focused psychological strategies are skills that are evidence based [and include] teaching patients simple cognitive and behavioural strategies, relaxation techniques, behavioural activation, structured problem solving—those kinds of techniques.
5.101
However, RACGP raised concerns that disincentives are in place in the way Medicare funding for focused psychological strategies is structured within the Better Access initiative. RACGP recommended that:
Access to mental health services in general practice will be improved by not counting mental health treatments provided by FPS [focussed psychological strategies] registered GPs in general practice as part of the capped number of psychologist services that are available to patients.
5.102
Reflecting on the education and training that junior doctors and medical students receive, AMA observed that most of their practical experience is likely to be in the public hospital sector:
… often the education and training is focused on more severe, complex illnesses such as schizophrenia and other psychotic illnesses. We think there is much more to mental health care than what ends up in the public hospital ward.
5.103
AMA noted that while continuing professional development requirements are about to change, there will continue to be no compulsory ongoing education in terms of mental health. While there is some financial incentive, this may be borne by the patient in non-bulkbilling practices:
There is some degree of training, not mandated, that is linked to Medicare for mental health, to provide mental health treatment plans and a couple of other mental health items. If you've done further training, that is rebated to the patient at a higher rate than it is for GPs who haven't done that additional mental health training. So, while it's not compulsory, there is a financial incentive to the patient or to the doctor, depending on the billing model, to have undertaken some further training in mental health.
5.104
Further discussion on MBS funding is included in Chapter 6 of the Committee’s report.
5.105
The Black Dog Institute suggested that one of the more immediate actions to address gaps between primary and secondary mental health care would be to provide a clear pathway for training more GPs who have a special interest in mental health.
5.106
To address urgent and growing needs in the community, Brisbane South PHN and Metro South Addictions and Mental Health Services facilitated research to identify potential improvements in delivering collaborative and coordinated, integrated care developed around the child and their family. The report recommended ‘[improving] the capacity and capability of GPs to assess and manage the mental health needs of children and young people’, including through:
Implementation of GP Psychiatrist Support Line, to connect GPs with psychiatrists who can provide advice on diagnosis, investigation, medication and safety planning.
GP-focused capability development project with a focus on common child and adolescent mental health clinical dilemmas for GPs … This will include practice guidance/resources, education/training and specialist advice/support (as directed by GP reps), and leverage resources already in existence.
5.107
AMA pointed out that ‘at the moment, the Medicare rebates for mental health care are not equivalent to these similar physical health presentations’ and contended that the general practice workforce should be remunerated and valued for the ‘complexity and challenging nature of dealing with mental health problems’.
5.108
In addition, AMA lobbied for:
targeted investments into areas of the workforce, including mental health nurses and counselling services, ‘to support GP clinics to deliver optimum and coordinated mental health care’:
We want to see a commitment to medically governed, multidisciplinary teams supporting mental health care through both GP clinics and, of course, psychiatry practice at the higher acuity end. Of course, these things need to be designed at the local level to be responsive to local needs.
recognition of both the time and potential effect on clinicians undertaking complex mental health consultations:
AMA suggests that the government may wish to consider options around a formalised process of voluntary clinical supervision to allow debriefing and support for doctors working in mental health.
Committee comment
5.109
The Committee agrees that the ideal scenario is for all people to have a regular GP who is able to provide holistic, comprehensive care, encompassing physical and mental health. However, the reality for many people, especially those socioeconomically or geographically disadvantaged, is that the best GP is the one that you can afford and is accessible at the point of time where a referral is needed.
5.110
Further, while a GP may list mental health as an area of interest, there does not appear to be a standardised requirement to indicate whether the GP has completed the training necessary to access the higher MBS rebate. The question becomes how people know in advance whether their GP has mental health training and how to ensure that patients are not disadvantaged with lower rebates because of a decision of the GP.
5.111
The Committee also notes that on graduation, GPs may have had limited exposure to the sorts of mental health presentations most prevalent in the community, and may benefit from placements in community settings to have greater exposure to people experiencing lower intensity mental health problems, including mild to moderate anxiety and depression.
5.112
The Committee would like to see universities increase the focus on mental health and suicide related education to reflect the high level of exposure that all medical doctors, and particularly GPs, are likely to experience.
5.113
The Committee notes that RACGP has taken a leadership role, including through chairing the government funded General Practice Mental Health Standards Collaboration (GPMHSC) Committee,which has developed the ‘Mental health training standards 2020–22: A guide for general practitioners’. The Committee would like to see further promotion of this training and the development of incentives to encourage GPs to undertake GPMHSC approved training and complete ongoing mental health continuing professional development.
5.114
In addition, the Committee supports the introduction of a diploma of psychiatry for medical practitioners and implementation of a national GP psychiatrist support line, to connect GPs with psychiatrists.
5.115
The Committee recommends that the Australian Government work with the Medical Board of Australia and the Royal Australian College of General Practitioners to:
review the core competencies required in mental health and suicide prevention for all medical students
identify pathways for general practitioners in training to complete mental health and suicide prevention clinical placements that will expose them to the types of mental health presentations likely to be seen in practice
develop incentives for general practitioners to access General Practice Mental Health Standards Collaboration approved training and continuing professional development.
Psychiatry
5.116
Many people who would benefit from access to a psychiatrist are either unable to do so or face lengthy waitlists, particularly for specialty areas including child psychiatrists. The draft National Mental Health Workforce Strategy background paper identified a critical shortage of psychiatrists, with only 66 per cent of the National Mental Health Service Planning Framework target reached.
5.117
According to RANZCP, Australia has become reliant on international medical graduate specialists, particularly for gaps in outer metropolitan, rural and regional areas.
5.118
As AMA noted, mild to moderate mental health problems are often able to be managed by GPs, working with a psychologist, counsellor or other allied health support. Nevertheless, there is a significant number of people who need psychiatry input for more severe or complex presentations.
5.119
The Australian Government 2021-22 Budget provided $11 million to boost the psychiatrist workforce by increasing the number of training places available, including in regional and remote areas.
5.120
RANZCP pointed out that government funding for more training positions would not necessarily have an impact straightaway but ‘if there are more training positions and we can attract more people into psychiatry straightaway it would help to distribute the workload and meet the demands we are facing’. RANZCP set out for the Committee the training required to become a psychiatrist:
In order for someone to become a psychiatrist, first of all, they need to do a medical degree. They need to have an MBBS [Bachelor of Medicine/ Bachelor of Surgery], or the equivalent medical degree, from a university in Australia or internationally. Once they have a medical degree and they've completed their internship, they can apply to get into a training position to become a psychiatrist—which is similar to all other specialties, whether you want to be a surgeon, a physician or a paediatrician. That training program is over a five-year period.
5.121
RANZCP submitted that while it does not have a set number of accredited psychiatry posts, there are a number of factors that limit the number of training positions:
Funding for training positions from the relevant state departments of health.
Availability of RANZCP Fellows who are able to provide supervision. This can impact positions in rural locations.
The capacity for the position to be able to meet RANZCP accreditation standards.
The requirements and decisions of the service (including the service having mental health services and capacity to facilitate trainees).
5.122
To increase access to psychiatric expertise, RANZCP suggested leveraging Commonwealth funding around training positions in the private sector:
The MBS services are there. If there is a private psychiatrist who's working in a group practice or in a hospital practice and doing outpatient clinics, if they can have one, two or three—whatever number—of training positions, suddenly what happens is that that trainee can see more patients. It expands the number of people that psychiatrists can provide care to.
5.123
The Black Dog Institute agreed that while part of the solution is more funding for training, it advised that the status of mental health, and observing the overwhelming burden in the system, discourages interest in a psychiatry career. To address this, the Institute recommended development of ‘a comprehensive plan around recruitment, around training, around retraining other professionals to come into mental health and around retention’.
5.124
Professor Perminder Sachdev expressed a similar sentiment about professional stigma in psychiatry, but noted there has been a gradual process bringing about change. Professor Sachdev suggested that there needed to be more done to address ‘the pressure on psychiatrists and their disempowerment’:
… there is more managerial control of mental health services, much more so than other medical disciplines. Psychiatrists' power has gradually been taken, and students notice that. They notice the kind of work psychiatrists do and that probably does not really endear them to the profession to some extent.
5.125
The Independent Private Psychiatrists Group raised concerns about a perceived move away from a psychiatrist led system of mental health treatment, suggesting that the lack of a ‘requirement to liaise with the treating psychiatrist, has led to extreme fragmentation of care, and increased chance for adverse outcomes’.
5.126
While supportive of multidisciplinary models, especially for community psychiatry, Professor Sachdev contended that the model should respect the different disciplines and the expertise the different disciplines bring:
… these are serious illnesses, a big burden on the individual as well as the family. We have good treatments available, if they're applied appropriately. We can do much better than what we are currently doing. For that, you need a team with a psychiatrist leading that team and a number of different disciplines coming together to assist in that process—liaison with other services, rehabilitation services and the community in general.
5.127
One further area explored by the Committee was models to enhance the capacity of psychiatrists to provide care, as well as potentially reduce stress and burnout. RANZCP highlighted the former Mental Health Nurse Incentive Program (MHNIP) and lobbied for it to be reinstated, noting it could be used to encourage other allied health practitioners to engage in multidisciplinary collaboration:
… [the program] provided an incentive payment to community-based general medical practices, private psychiatrist services and other appropriate organisations who engage mental health nurses to assist in the delivery of clinical care for people with severe mental health conditions. It was reviewed in 2010 which found that 'overall there was wide acceptance of the program and feedback from all stakeholders was extremely positive'. In 2016-17, MHNIP funding was transitioned to the PHN primary mental health flexible funding pool. Since that funding move, it has been incredibly difficult for private psychiatrists to secure funding from the program to employ a nurse to support them in practice.
In December 2020 the MBS Review Taskforce released the report from the Nurse Practitioner Reference Group, where the introduction of MBS funding for nurse practitioners was not supported. This was disappointing given it could have delivered a clear avenue of funding for mental health nurses within private practice.
Committee comment
5.128
The Committee is of the view that immediate action needs to be taken to ensure that those who need access to psychiatric expertise are able to do so at the point in time it is required.
5.129
The Committee acknowledges that when dealing with complex and serious mental illness, a psychiatrist may be best placed to provide care and lead the attendant multidisciplinary team.
5.130
However, noting the long lead time for training psychiatrists, more needs to be done to allow psychiatrists to operate at top of scope. This could be achieved by more psychiatrists being utilised in a consultancy model, for example as a contributing expert in a multidisciplinary team, or providing advice to mental health trained GPs via a helpline or chat service.
5.131
An additional option to support psychiatrists in private practice may be to incentivise models for mental health nurses to be employed and utilised to support consultations and provide a triage facility.
5.132
The Committee recommends that the Department of Health and the National Mental Health Workforce Strategy Taskforce engage with psychiatry peak bodies to develop a workforce strategy that maximises access to the expert skills of psychiatrists for those with complex and serious mental illness, including through:
increasing support for mental health nurses to provide pre- and post-appointment services
a multidisciplinary team or consultancy function, where other health professionals can quickly access psychiatry expertise.
Nursing
5.133
The Nursing and Midwifery Board of Australia (NMBA) highlighted the key role that mental health nurses and midwives play, particularly in relation to perinatal anxiety and depression, in the current mental health workforce. NMBA outlined that:
There are currently 377,000 practising registered nurses and 72,000 practising enrolled nurses in Australia. In 2018, almost one in 15, or about seven per cent of nurses, including registered and enrolled nurses, who were employed in Australia indicated that they were working principally in mental health.
5.134
Recognising nursing as a critical component of the mental health workforce, Orygen and Forensicare raised concerns about ongoing shortages, particularly those with mental health expertise and specialist skills for working with vulnerable groups.
5.135
The National Rural Health Alliance highlighted the pivotal role that nurses play in the provision of rural and remote health care services, with nurses standing out as the ‘most well distributed of all the health professions in rural Australia’. The Alliance drew attention to the fact that generic nursing training may not include specific expertise in mental health issues, and also noted research indicating a projected shortfall in the future due to an older age structure outside major cities.
5.136
Drawing data from the Modified Monash Model, the draft National Mental Health Workforce Strategy background paper indicated:
an apparent oversupply in urban areas of registered nurses and enrolled nurses
a significant oversupply of enrolled nurses in mental health but a shortage of registered nurses
pronounced shortages in FTE [full-time equivalent] availability as rurality increases
a projected shortfall of mental health nurses of between 11,500 and 18,500 by 2030.
5.137
The Productivity Commission Report recommended the addition of a discrete unit on mental health in all nurse training courses, along with the development of a new curriculum standard for a three-year direct-entry undergraduate degree in mental health nursing.
5.138
Nurses were included in the 2021-22 Australian Government Budget measure, which provided funding for scholarships and clinical placements to increase the number of practitioners working in mental health settings.
Education and training
5.139
NMBA advised that education for both enrolled and registered nurses provides ‘integrated knowledge of care across the life span, across all body systems and across all main contexts of nursing practice’. In addition:
The current NMBA approved programs leading to registration as a registered nurse in Australia all include standalone subjects with foundational education in mental health.
5.140
However, the Queensland Nurses and Midwives Union (QNMU) contended that mental health training in the undergraduate degree does not go into sufficient depth and raised concerns that mental health placements are not mandatory:
The QNMU believe that undergraduate nursing or midwifery degrees should be bolstered with more mental health content that includes models of suicide prevention and relevant clinical placement. Mental health should not be a separate curriculum but be included in the nursing or midwifery undergraduate degree to build a flexible, holistic and integrated mental health workforce with the capacity to address mental health concerns and suicide prevention across all health services.
5.141
QNMU outlined the postgraduate qualification pathway from graduate certificate to masters available for nurses who wish to gain a specialist qualification in mental health or register as a nurse practitioner. Noting that cost was a barrier for many nurses, QNMU commended the Victorian Government’s scholarships made available through its Chief Mental Health Nurse's office.
Further developing the role of nursing in the mental health workforce
5.142
NMBA recognised the need to bolster placements, supervision and incentives, including financial, in the transition to specialty practice for nurses post registration.
5.143
The mental health nursing workforce includes services led by mental health nurses, nurse navigators, nurse practitioners, school nurses and midwives. In order to leverage this workforce, QNMU stated that nurses and midwives must be empowered to work autonomously and to their full scope of practice.
5.144
The Gidget Foundation outlined its innovative efforts to overcome the barriers presented by Medicare's Better Access initiative, which excludes rebates for mental health nurses, and enable nurse-led services:
We brought the New South Wales government together with the local PHN—being Murrumbidgee in this case—and with Tresillian in the family care centre and with Gidget, offering our services. The state funded Tresillian to have the family care centre. Gidget came into the family care centre and we spoke to Murrumbidgee PHN and said: 'There are no clinicians in Wagga that we can access to run this service. We need a mental health nurse. We have identified two that are fabulous and that have the right experience who could be delivering this service. Will you support us to have an alternate workforce?' They said yes. So that was one of those moments and times where it's like: 'Wow! How great is this? We have got state and federal governments and two independent NGOs all working together to create this wonderful service in regional New South Wales that didn't previously exist.'
5.145
AMA commended the huge role mental health nurses are able to play in a joined-up system, but noted the lack of proper access in general practice.
5.146
QNMU proposed the development of mental health incentive opportunities, along the lines of the general practice nurse incentive program, where GPs are incentivised to employ nurses in general practice:
… many people with their first experience in mental health issues front up to their GP. It's the first place where health services get alerted to the fact that someone has a mental health problem, and that early intervention by a mental health nurse in the general practice environment would be of substantial benefit.
5.147
Additional areas highlighted by QNMU for a stronger, sustainable mental health workforce included:
Leveraging the leadership capacity of nurses and midwives in the community to expand nurse-led programs.
Developing the role of mental health nurse navigators, and increasing its coverage across communities, and in the private and aged care sectors.
Implementing minimum standards for clinical supervision that are financially supported by the workplace and can be adjusted based on the professional judgement of the nurse.
Recognising the value of mentorship and peer support, and provide training in these skills.
5.148
Finally, to provide leadership and coordination, and to improve mental health services in both inpatient units and the community, QNMU strongly recommended the introduction of a chief mental health nurse for all states and territories.
Committee comment
5.149
Nurses and midwives are the backbone of the health system. They are embedded and experienced in working in multidisciplinary environments, providing wrap around services supporting people through all manner of life events.
5.150
Noting the increasing prevalence of mental health problems and suicide-related presentations, and the frontline nature of nursing, the Committee considers that more needs to be done to increase mandatory mental health components in undergraduate study.
5.151
Likewise, with as many as one in five Australian women experiencing ‘diagnosed perinatal depression and anxiety’, midwives must be skilled on graduation to address the common mental health issues of pregnant woman and mothers.
5.152
Similar to GPs, many nurses will work in community settings and therefore training and subsequent placements need to reflect the broad range of mental health problems they may encounter rather than just the more serious and complex cases likely to present in a hospital setting.
5.153
The vital importance of the role of nursing in the mental health workforce needs to be recognised. This can be done by ensuring mental health nurses have clear career pathways and there are chief mental health nurses to work alongside the chief psychiatrists at both the federal and state and territory levels.
5.154
Chief mental health nurses could work with stakeholders to:
review the curriculum to ensure nurses and midwives are skilled and experienced in supporting mental health problems and suicide related presentations
develop innovative placement opportunities across public, private and NGO sectors
promote the capabilities of mental health nurses for expansion of mental health services in community settings
share learnings with state and territory counterparts to embed best practice across Australia.
5.155
The Committee recommends that the Australian Government appoint a chief mental health nurse to work alongside the Deputy Chief Medical Officer for Mental Health, and encourage states and territories to adopt an equivalent position, if they have not yet done so.
Psychology
5.156
Psychologists are experts in mental health and wellbeing, and an integral part of the mental health workforce. According to the Australian Psychological Society (APS), psychologists ‘should be differentiated from medical and allied health professionals who provide mental health services as an adjunct to their profession’.
5.157
The Psychology Board of Australia’s latest report on national registration and accreditation indicated that there are 41,817 registered psychologists in Australia, and 6,491 provisional registrants. Of the registered psychologists, approximately 80 per cent are women and around 35 per cent hold an endorsement for one of the nine areas of practice, with the majority of endorsements in clinical psychology (10,380). The Board noted that:
An endorsement does not restrict the scope of practice for the psychology profession. The only practice limitations for psychologists relate to their knowledge and skills and their obligation to practise within the boundaries of their own scope of competence.
5.158
The draft National Mental Health Workforce Strategy background paper identified psychologists as having the largest shortfall compared to the National Mental Health Service Planning Framework workforce targets in terms of absolute workforce gaps. Consistent with other mental health professions, the deficits remain more pronounced in rural regions.
5.159
APS called for the psychological workforce to be expanded, ‘given the unprecedented demand for mental health services across the community in the wake of recent events’.
5.160
Between April 2020 and April 2021, the Australian Health Practitioner Regulation Agency (AHPRA) and the National Board implemented a temporary pandemic response sub-register to provide a pathway for experienced and qualified psychologists to return to the workforce to assist with the COVID-19 pandemic. There were 652 psychologists listed on the sub-register, though there was no obligation to practice.
5.161
The Committee heard calls to enable provisional psychologists ‘to provide an agreed level of Medicare-subsidised services, including a loading for psychologists providing services in rural and remote areas’.
5.162
However, the Australian Clinical Psychology Association (ACPA) disagreed with any proposal that would lower requirements for psychologists, even on a temporary basis:
During the time of COVID, waiting lists for both public and Better Access subsidised psychology services have blown out. There appears to be some suggestion from government about increasing the number of psychologists by shortening the training requirements, but this is problematic. Australia currently holds the lowest minimum standards for training for the registration of psychologists in the Western world.
5.163
The Australian Association of Psychologists Inc pointed out that the Psychology Board of Australia adopted the International Declaration on Core Competencies in Professional Psychology, ‘as part of its commitment to developing an internationally recognised and endorsed set of core competencies for the psychology profession’.
5.164
In its Green paper, the Psychology Board advised that the ‘aim of the Declaration is to serve as the foundation for a coherent global system for equating psychology registration, accreditation and training and conduct at the time of entry into the profession’. However, the Board also noted that:
… there are opportunities to better align competencies of the psychology workforce in Australia with international benchmarks and to maximise the endorsement framework as a regulatory mechanism for the benefit of the public and profession.
Education and training
5.165
While reviewing the regulatory mechanisms and registration requirements are important, ACPA argued for increased funding to support specialist training programs to ‘increase the number of practitioners who can provide the right level of expertise’.
5.166
Witnesses raised concerns that a significant barrier to providing the right type and level of expertise was the ‘crisis of diversity’ in the psychology workforce and education programs available. APS explained:
We are not a flat mental health profession. Psychology has nine different areas where additional accredited training brings value to the Australian population. These programs—including those providing special focus on children or workplaces or custodial populations, for example—are, devastatingly, closing under university funding pressures. Psychology is the only workforce with this type of training. Once lost, it's simply not going to be replicated within the system elsewhere.
5.167
In addition to ‘a lack of government funding’, Dr Davis-McCabe noted that the combined impact of the introduction of the Better Access initiative in 2006 has led to ‘quite devastating consequences for postgraduate university programs’:
We've seen in recent years many areas of practice endorsement programs close across the country. This means that the number of work-ready graduates is falling, and this is a real problem for the Australian people, who will ultimately lose access to the specialist skill set of these psychologists. This is a pressing concern at a time where the public need quick access to advanced psychology services.
5.168
APS called for government funding to enable universities to ‘keep training both general psychologists and area of practice endorsement psychologists’, and suggested modelling strategies that have worked in medical training ‘to correct workforce maldistribution’:
… things such as zone allowances, funded supervision, scholarships and supported supervisor training, particularly in rural and remote locations.
5.169
In addition to the decreasing diversity of specialisation options available at the postgraduate level, ACPA advised that additional barriers included the cap on Commonwealth supported places and funding to support placements. ACPA called for expansion on the basis that the demand is there:
At the University of Sydney we get 500 applications every year for 20 places so there are a lot of people who do want to do clinical psychology training ... Schools of psychology struggle to fund programs to give the necessary training that we have to do on the ground.
5.170
Dr Davis-McCabe noted that one of the factors restricting universities increasing the diversity of specialisation was that the costs of placement and supervision vary across programs:
I have 45 students, for example, in the master of psychologist professional, and we have only about 10 in the counselling psychology and clinical psychology, and that's due to the cost of placement. If we are able to get a placement that has supervision, that's great. But quite often placements don't come with supervision, so it falls to the university to pay for that … For general registration, students only have to complete one placement, but for the areas of practice endorsement they need to complete three.
5.171
In addition to cost as a barrier to increasing places, ACPA advised that placements for clinical psychology students in public settings were becoming increasingly difficult to secure:
One of the reasons we wouldn't increase our places is that we think, 'Are we ever going to be able to provide placements?' because that would be our responsibility. Again, this flows on to the lack of clinical psychology services in the public sector, because if the supervisors aren't there we can't place students there. Private practice is not very helpful because often there are not those sorts of supports. And, of course, we can't have students charging for Medicare, so private practitioners don't want to take students on.
5.172
In its pre-Budget submission, APS made three recommendations to address the shortage of placements for psychology students and ‘a lack of willingness from organisations, including Government organisations, to offer postgraduate psychology student placements’:
Review the funding model for psychology courses to reflect the actual cost of these courses, or alternatively review the model and the requirement for intensive placement and supervision, which is expensive and difficult to source.
Provide incentives to higher education providers to offer 5th year psychology programs, including through distance education.
Fund the APS to develop a placement and internship coordination program to ensure provisional psychologists and course providers are financially supported to complete their training. This is required to address the increasing trend for organisations, including public sector services, charging fees to take on provisional psychologists undertaking a placement or internship.
5.173
The APS submission identified additional solutions to improve the number of psychology program places and placements:
Provide scholarships for students on placement – particularly in rural and remote locations.
Provide a public sector salary loading to those psychologists who agree to supervise.
Develop health system training positions within hospitals, similar to medical training.
Federally fund payment for supervisors.
Provide targeted funding for placements and supervision in nominated areas of greater need.
Career pathways
5.174
According to ACPA, early career clinical psychologists often seek to work in the public sector ‘because they see that that's where they can hone their skills and get appropriate supervision and appropriate support’. However, due to the lack of positions and a need to make a living, they move into private practice.
5.175
There was broad agreement by Beyond Blue, SANE Australia and headspace that while they are able to attracts students and early career psychologists, retention has been difficult. headspace explained:
We get students who come through. They think it's fantastic to work in a team based environment in the very vibrant type of arrangement that we have. Some of them come back as graduates and do their early training post their work through the university. Then it comes to, 'Now I need an ongoing job.' All too often we see young people—graduates and students—leaving for private practice somewhere else because they can make a better income.
5.176
The PHN Cooperative reinforced the dilemmas around attraction and retention in the not-for-profit sector, noting that new graduates are ‘often employed in the state system for no other reason than salaries, conditions, wages and other things that an NGO can't afford’.
5.177
Gidget Foundation came up with an innovative approach to attract psychologists to an NGO environment, enabling them to build specialist skills and the Foundation to expand the service. The Foundation worked closely with the state service, Sydney North Health Network, and was able to secure some support from the Commonwealth, on a project to recruit supervisors:
… within our network of the 68-plus clinicians that we have, we have people with significant experience. So perhaps we need to be utilising that experience to recruit those people as supervisors to train, mentor and supervise more junior clinicians to deliver psychological treatment and to specialise in the areas of perinatal mental health.
5.178
While early in career, the public and NGO sectors may be an attractive option, ACPA noted that the private sector offers established psychologists more flexibility to practice in a location and in areas of their choice, and set their own working hours.
Committee comment
5.179
Psychologists are the specialist workforce able to deal with the full spectrum of mental health problems, mental illnesses, and suicide prevention and postvention. Psychologists are registered and regulated, and able to make a valuable contribution in public, private and NGO settings.
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The importance and value of professional supervision for psychologists cannot be understated, especially for providing support to new psychologists and maintaining the resilience of the psychological workforce.
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The Committee recognises this, and would like to see governments work with the growing number of psychologists within the private sector to expand supports for professional supervision, to increase practitioner access.
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However, we are losing the opportunity to grow specialisation into critically important areas such as educational and developmental psychology and forensic psychology.
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Chapter 6 refers to the lack of Australian studies available that compare the outcomes between registered psychologists with clinical endorsement and other registered psychologists. It also discusses how MBS inequities are impacting on demand for other psychological specialities.
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The Committee calls for the diversity of psychology specialties to be supported through both regulatory acknowledgement and increasing university master's level programs to improve distribution across the nine areas of practice endorsement.
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The Committee would also like to see support for specialisation that provides and promotes career pathways that enable progression and opportunities to contribute to public, private and NGO sectors.
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The Committee recommends that the Australian Government support the growth and diversity of psychology specialties by:
funding ongoing Australian research to compare outcomes across the nine areas of practice endorsement in the psychology profession, and using this research to inform future policy and funding decisions
increasing university master's level programs to improve distribution across the nine areas of endorsement, with at least one educational and developmental psychology program in every state and territory
dedicating a percentage of Commonwealth funded scholarships to psychology specialisations outside of the primary clinical psychology pathway
providing funding or tax incentives to registered psychologists:
to increase their capacity to offer placements to psychologists in training and ongoing clinical supervision
for continuing professional development.
Allied health professionals
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Allied health professionals include professions such as pharmacists, counsellors, social workers, occupational therapists, dietitians, exercise physiologists and physiotherapists, and speech pathologists. Individually and as part of multidisciplinary teams, allied health professionals play a pivotal role in helping people achieve, reclaim or maintain physical, social and emotional wellbeing.
Pharmacists
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Pharmacists are involved across the spectrum of mental health, from providing highly accessible community hubs to being part of a multidisciplinary team in a psychiatric ward.
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In response to the bushfire crisis and the COVID-19 pandemic, the Australian Government further utilised pharmacists to ensure Australians had continued access to medicines even if they could not get to the doctor for a renewed prescription. The temporarily expanded arrangements – Continued Dispensing (Emergency Measures), which includes most Pharmaceutical Benefits Scheme medicines supplied through community pharmacies – were subsequently extended until 31 December 2021.
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Research funded under the Fifth Community Pharmacy Agreement revealed that community pharmacies have ‘potential value as an accessible, inexpensive and safe health space that empowers consumers through information and connection to relevant support services’.
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Pharmacists are regulated through the AHPRA supported Pharmacy Board of Australia. The Board noted that:
Pharmacists are often the most accessible health professionals the public encounter and pharmacy is among the most trusted professions in Australia. Pharmacists have earned this trust through their competence, demonstrating consistently high standards of skill and care and building strong relationships with the community.
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The Pharmacy Guild of Australia highlighted its efforts to encourage the concept of a pharmacy as a safe space, and noted that the majority of pharmacies now have consultation rooms, where people who are experiencing mental health issues are able to have an initial discussion with the pharmacist:
An episode doesn't wait for a doctor's appointment. In some country areas we have to wait eight weeks to see a doctor. We do have the health lines. We do have various phone services at your fingertips, but ultimately, when it comes to mental health and health care in general, people like human-to-human interaction and the ability to have that interface and sit down and talk with that person.
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Pharmacists have also been able to work with patients and doctors as part of a comprehensive medication review, ‘ensuring there is a diagnosis that matches a pharmacotherapeutic need’ and addressing matters such as deprescribing, interactions and referral pathways. The Pharmaceutical Society of Australia noted pharmacists could do this work across a range of settings, including within GP practices and community pharmacy, or through a program such as Integrating Pharmacists within Aboriginal Community Controlled Health Services.
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As pharmacists increasingly engage in mental health matters at the community level, the Pharmaceutical Society of Australia, advised of efforts underway to ensure graduating pharmacists are well prepared to ‘tackle the conversations around suicide and severe mental health crises’.
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The Pharmacy Guild of Australia highlighted programs aiming to further develop pharmacist capabilities that had been developed through collaboration with states and territories, NGOs and universities. These included the Mental Health Community Pharmacy Program in NSW, and the PharMIbridge Randomised Control Trial, funded by the Commonwealth Department of Health as part of the Sixth Community Pharmacy Agreement.
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The NSW program was designed and delivered to community pharmacists and pharmacy assistants to build confidence and skills ‘to recognise and respond to people in distress and those with mental health conditions, to refer to local mental health services where appropriate and to improve referral pathways between community pharmacists and local area mental health services’. The Pharmacy Guild of Australia stressed the importance of involving the whole staff in training as pharmacy assistants are often the first point of contact.
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However, the Pharmaceutical Society of Australia mentioned that whilst ongoing training has been made available, ‘it can be in a slightly ad hoc, reactionary manner’, and recommended a continuous funding source:
So bushfires roll out one lot; drought rolls out one lot. It would be nice to see some more coordinated, comprehensive, ongoing programs that exist in a funded capacity to ensure it's not ad hoc and depending on different trends, because mental health needs will remain ongoing.
Committee comment
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Pharmacists are one of the most accessible in-person health professionals, and their value was clearly demonstrated throughout the COVID-19 pandemic, providing an accessible, trusted service throughout. This has been particularly important for people who have experienced mental health problems exacerbated by the bushfires and pandemic and needed to have a consistent supply of medication when access to GPs was constrained.
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Mental health and suicide prevention needs to be considered a core part of a pharmacist’s education. This should be followed up with coordinated, ongoing and compulsory mental health training for pharmacists and pharmacy assistants.
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Training provided to pharmacists empowers them to take on an active role in ensuring the welfare of people who come through the door. Further, it will allow them to feel more confident and position them to have their opinions taken more seriously in the broader mental health workforce if they are empowered and trained appropriately.
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If we are going to leverage this widely accessible, professional community resource to further enhance the mental health workforce, funding should be provided to enable the training and education required.
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The Committee recommends that the Australian Government consider continuing and expanding the Continued Dispensing arrangements, which have enhanced access to vital medicines and improved patient outcomes during the COVID-19 pandemic including for those living with mental ill health, especially in regional, rural and remote areas.
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The Committee recommends that the Australian Government evaluate the efficacy of pharmacy mental health training programs and strengthen funding to support an expansion of best practice training in mental health and suicide prevention for all pharmacists and pharmacy staff.
Registered counsellors
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The role of counsellors as part of the mental health workforce, and the use of the term ‘counsellor’, has been identified as an area that needs clarification. Counsellors are not recognised by the MBS and therefore are not entitled to rebates for their services. As further outlined in the draft National Mental Health Workforce Strategy background paper, there is no national minimum standard of training in this self-regulated industry or national standardised data set on the workforce.
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This has led to concerns such as those expressed by ARHEN. Dr Sharon Varela noted that while she had worked with ‘some very excellent counsellors in remote areas, and their skill set is really important,’ it was necessary to ensure the counsellor had a suitable standard of qualification:
… if we are going to allow unregulated professionals in to be doing work, we have to have really clear parameters around what that looks like and who is going to hold duty of care, because there is always a risk to the public.
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There are two main bodies that represent counsellors - the Australian Counselling Association (ACA) and the Psychotherapy and Counselling Federation of Australia (PACFA). Together, they have established the Australian Register of Counsellors and Psychotherapists to provide an independent, national register to help potential clients identify practitioners that:
have completed professional qualifications in counselling or psychotherapy
meet ongoing professional development requirements and have clinical supervision of their practice to ensure they provide a quality service to clients
abide by the ethical guidelines of the profession.
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However, the two bodies have differing standards, membership categories, and thresholds for qualifications in order to be recognised as a counsellor.
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In terms of regulation, ACA noted that it is seeking to trademark the term ‘registered counsellor’, and compared its system to that of social workers, noting that:
We self-regulate through the peak bodies as opposed to being regulated through AHPRA. However, we provide exactly the same processes, standards and quality of service as any AHPRA regulated industry. The only difference is that, obviously, we don't have the legislative authority or powers that AHPRA has.
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Noting the strong demand for mental health support and the extensive waitlists for many psychologists, PACFA recommended designing ‘a policy environment where counsellors could assist more people and complement the work of psychologists, social workers and mental health nurses in supporting the Australian community’.
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ACA shared this view, calling for more to be done to expand services for all Australians and enable the development of multidisciplinary teams:
Waiting six to eight years for more psychologists and psychiatrists to graduate is too long, when thousands of tertiary qualified counsellors are available to enter the workforce now.
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The Black Dog Institute and Wesley Mission identified the need for a group of professionals that could be utilised to fill gaps between primary and secondary care and potentially provide immediate access for those who may need only brief or lower level interventions. By way of example, the Black Dog Institute described the UK experience with retraining groups, such as counsellors, to fill gaps:
The most prominent of that was the IAPT system in the UK, the Improving Access to Psychological Therapies … The IAPT system trained a whole range of other health professionals to be able to deliver those brief psychological treatments, and it has done that at scale. There are certainly a number of publications that have demonstrated that that has been able to fill a gap that was there and has resulted in some improved outcomes.
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However, the Black Dog Institute also noted the importance of clear pathways to clinical psychologists and psychiatrists for ‘those that do not recover from those initial brief treatments’.
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PACFA asserted that having immediate access to a counsellor can provide both early intervention and a triage opportunity, particularly for people with suicidal ideation, ‘a counsellor is ready and able to refer a person to specialist services’. PACFA noted that counsellors are substantially more accessible across the country than psychologists, with a recent member survey indicating that 62 per cent could see a new client within two weeks and 23 per cent could see a new client within 48 hours.
Committee comment
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Registered counsellors provide valuable support to people through talk therapies, are already widely used by the NDIS and other support services, and have the potential to provide a larger contribution to the mental health and suicide prevention workforce.
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However, the Committee has reservations about the current registration and regulatory structures for counsellors. It was noted that the peak bodies representing counsellors do not have consensus on the academic and experiential requirements for registration.
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The Committee notes that, unlike psychologists, counsellors are not covered by AHPRA. While acknowledging the self-regulatory role taken on by the peak bodies, membership is not mandatory and there are no legal requirements to have specific qualifications or experience. Instead it relies on employers to set standards of training and consumers to assess credentials.
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Counsellors are already dealing with vulnerable people as NGOs struggle to afford the higher costs of psychologists or access them due to shortages. While not wanting to raise the cost of doing business, people need to know that the care they are receiving is safe.
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Accordingly, if this workforce is to be leveraged to relieve the pressure on existing mental health services, the regulation of counsellors must be effective. This requires consensus on national minimum standards set for education, supervision requirements, continuing professional development and adequate oversight.
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The Committee recommends that the Australian Government review the existing self-regulated standards being used by the counsellor and psychotherapist peak bodies and use the results to determine appropriate terminology, national minimum standards for education, supervision, continuing professional development and oversight requirements.
Social workers
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The peak body, the Australian Association of Social Workers (AASW), contended that social workers have a ‘unique professional position on mental health’, as when ‘working with people experiencing mental ill health, social workers take a whole-of-person approach rather than treating presenting symptoms’:
While social work plays a key role in providing counselling to individuals, couples and families, the profession strongly believes that health and wellbeing, including mental health and wellbeing, are socially determined.
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The draft National Mental Health Workforce Strategy background paper noted that ‘social workers are self-regulated and accredited by the Australian Association of Social Workers’, and ‘there are no FTE counts for the supply of social workers’.
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Agreeing that it is difficult to confirm numbers, AASW estimated there are approximately 40,000 social workers at any one time in the profession. Of these, around 15,000 choose to be a member of AASW.
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AASW outlined its self-regulation model, noting that it develops professional standards, a code of ethics and practice standards, manages complaints and accredits higher education providers and specialised streams including mental health:
... social workers who are members of the AASW and have gone on to develop their learning and experience in mental health can seek an accredited mental health status … the postnominal they'd have is Accredited Mental Health Social Worker. The AASW is an accrediting authority recognised by the federal government, and we have more than 2,500 accredited mental health social workers across Australia.
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While AASW advised that it takes its regulatory and credentialing role seriously, it strongly recommended ‘that the social work profession be registered under the national registration scheme to ensure that only qualified social workers with the necessary skills can support and work with people experiencing vulnerabilities, including people experiencing mental ill health, and for broader public safety and protection’.
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This view was shared by ARHEN on the basis that ‘they work in a lot of spaces that psychology work in, their degrees are four years so they're no different than any other allied health, and they're working in spaces that are quite remote, where regulation would be really important’.
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AASW also noted that Australia is the ‘only country in the English speaking world where social work is not registered’. In addition, of particular concern to AASW was the fact that users of social worker services and decision makers may not be aware that there is no official oversight or regulation of the use of the title.
Committee comment
5.227
Social workers provide significant value in mental health support and suicide prevention, actively addressing and accommodating the full range of social determinants that intersect with individual wellbeing.
5.228
The Committee shares the concerns expressed by witnesses in regard to the lack of protections around the use of the title ‘social worker’, noting that the profession often deals with society’s most vulnerable individuals.
5.229
It is critical that when vulnerable people interact with services, that they can trust the professionals to have met and maintained professional standards.
5.230
The Committee would like to see ‘social worker’ become a protected term, and the implementation of a more robust regulatory and oversight mechanism.
Occupational therapy
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Occupational Therapy Australia highlighted that mental health service provision has been ‘a longstanding and core area of practice in occupational therapy’:
Occupational therapists work across the full spectrum of mental health, treating relatively common conditions, such as anxiety and mood disorders, as well as those which require more targeted interventions, such as psychosis and trauma-related conditions.
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Similar to social workers, occupational therapists consider the whole person and how they ‘engage in meaningful and important activities such as self-care, school, work, leisure activities and social interactions’:
Through our client-centred approach, occupational therapists use a range of evidence-based interventions to support recovery in the person's meaningful environments. This means that occupational therapists work across the full spectrum of mental health, from prevention and early intervention to discharge.
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While occupational therapy complements other mental health services and can form a valuable part of a multidisciplinary health team, Occupational Therapy Australia noted a lack of awareness as one of the ‘significant barriers to the most effective deployment of occupational therapists in mental health care’:
The profession's holistic role in occupational performance is not well understood either in the community or by other professionals. This negatively impacts the uptake of occupational therapy services, which in turn impacts the number and kinds of mental health roles which are available to occupational therapists.
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Occupational therapists are one of the allied health professions regulated through an AHPRA supported board – the Occupational Therapy Board of Australia. The draft National Mental Health Workforce Strategy background paper noted that ‘accredited mental health occupational therapists are not required to complete any additional training, unless delivering services under the Better Access program’.
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Occupational Therapy Australia advised that all occupational therapy programs are accredited by the Occupational Therapy Council of Australia and meet strict national and international standards:
To receive accreditation, occupational therapy courses must provide holistic training addressing and treating both physical and mental health-related illnesses, disabilities, challenges and limitations. As such, all occupational therapy courses include education on mental health conditions and their treatment through a range of evidence-based and occupation-focused interventions.
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In addition to the education component, Occupational Therapy Australia noted that in order to meet the international standards set by the World Federation of Occupational Therapists, occupations therapy students are required to complete a supervised clinical placement of least 1,000 hours:
During this time, all will work with clients presenting with some degree of psychosocial or emotional difficulty. These accreditation requirements ensure that all occupational therapists graduate with a sound knowledge of mental health assessment and intervention and mental health services. Suitably experienced occupational therapists are endorsed to provide focused psychological strategies through the Commonwealth government's Better Access initiative and … deliver psychological treatments for eating disorders under the Medicare Benefits Schedule.
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Commenting on the importance of strong supervision, Occupational Therapy Australia highlighted issues ‘around availability of discipline-specific supervision, mental health occupational therapists supporting mental health occupational therapists in the different areas of practice’.
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Noting the lack of discipline-specific mental health roles and entry-level programs, Occupational Therapy Australia proposed thinking more innovatively about ways to expand access to clinical supervision proposing a stepped supervision model:
… [it] is about rethinking models of supervision where we could have a more experienced clinician supervising younger clinicians who then can have more students … We have to think beyond all the boxes that we ever thought that we had, to enhance the number of placements, the way that we provide placement in clinical education and the delivery of our services.
Committee comment
5.239
Despite delivering valuable mental health supports and targeted interventions, the Committee was concerned to hear that the value of the occupational therapy workforce is not widely understood in the community and even across the cohort of health professionals that may be involved in prescribing mental health services.
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Exposure to multidisciplinary settings and engagement with other faculties in early stage education may help to boost mutual understanding across professions.
5.241
Providing detailed information back to the GP, who make referrals to the occupational therapist, on the interventions and outcomes could also help increase understanding about the extent of improvement that can be realised through allied health services.
5.242
The Committee is also very interested in the concept of a ‘stepped supervision’ model to increase access to supervision, and considers this an area that warrants further exploration.
Dietitians
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Dietitians have an important role to play in mental health and wellbeing. Dietitians Australia explained that the modification of diet and lifestyle factors is both cost effective and ‘one of the first steps in clinical guidelines for the treatment of mood disorders’:
Well-delivered dietary interventions lower healthcare costs, reduce hospitalisations and reduce burden on individuals and society. According to a very recent New Zealand health workforce report, for every one dollar invested in dietary intervention there's a five-dollar return.
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The draft National Mental Health Workforce Strategy background paper noted that the dietetic workforce is self-regulated through Dietitians Australia, and there is no national standardised data set. The lack of data, along with no requirement to be a member of Dietitians Australia, ‘makes it challenging to estimate the size, distribution or sufficiency of supply of this workforce’.
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While not accounting for the full dietetic workforce, Dietitians Australia outlined its role, estimated membership, and minimum training standards for membership:
Dietitians Australia is the peak body for nutrition and dietetic professionals, representing over 8,000 members … We have a self-regulation system that is modelled on AHPRA registration. Dietitians complete a minimum of five years university and intensive planning and have a rigorous professional development program ...
… at least 30 hours of professional development each year.
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Dietitians Australia contended that upon graduation, entry-level Dietitians have ‘enough knowledge to conduct assessment and monitoring of mental health disorders. They understand how to inform clients on nutrition intervention, and they also have enough knowledge for successful collaboration with multidisciplinary teams’. It also noted that through continuing professional development (CPD), additional training is available for those who wish to specialise in mental health, in either severe mental disorders or eating disorders specifically.
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Dietitians Australia raised concerns that despite having completed training in mental health and evidence showing that the most effective dietary interventions are those delivered by Dietitians, referrals are low and funding pathways are inadequate:
… accredited practising dietitians are not recognised as mental health practitioners … and there are far too few dietitians funded to work in mental health in an inpatient setting.
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The Committee heard that a lack of visibility, access and funding may be leading to delays in referral to a Dietitian, missing the important early intervention window. Dietitians Australia noted that it is important that people have access to support that is safe and appropriate, and that this is available by providing access to accredited practising dietitians:
At the moment, we have a workforce that is ready and able to work in mental health nutrition. We see the easiest way to facilitate that is by recognising us as mental health practitioners.
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In addition, Dietitians Australia suggested establishing phone counselling and other initiatives to help increase visibility in the community, and understanding of the role and qualifications of an accredited practising dietitian.
Committee comment
5.250
With the prevalence of disordered eating and development of eating disorders, Dietitians need to be front of mind as part of the mental health treatment team well before hospital presentation.
5.251
Dietitians are qualified professionals providing health advice to people, many of whom are being seen due to disordered eating or other health concerns.
5.252
While it is positive that the term Dietitian is protected, it is concerning that as with other self-regulated professions, there is no requirement to be a member of Dietitians Australia and meet the standards set for the industry.
5.253
On this basis and noting the serious nature of eating disorders, the Committee would like to see the regulation and oversight of Dietitians reviewed.
Exercise physiology and physiotherapy
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There is broad consensus on the interrelationship between physical and mental health, and the significant burdens of both mental health problems and chronic pain. As stated by the Australian Physiotherapy Association, in addition to the impact on healthcare systems, ‘[u]ntreated or inappropriately treated pain can be a major factor in mental health’:
So any person with reduced or poor physical mobility, loss of function or experiencing chronic pain is less able to participate in aspects of life, and that includes work, social, exercise and travel. The pain impacts on family and physical relationships.
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However, Exercise and Sports Science Australia (ESSA) pointed out that despite recognition of the importance of physical health and the role of exercise in maintaining or regaining mobility and pain management, uptake has been slow in both the mental health and medical space.
5.256
The draft National Mental Health Workforce Strategy background paper did not include physiotherapists or exercise physiologists within its definition of the mental health workforce. While still not referred to as part of the mental health workforce, the National Mental Health Workforce Strategy consultation draft does refer to these groups in priority area 3 – ‘The entire mental health workforce is utilised’, identifying physiotherapy as an occupation with its scope to be confirmed and exercise physiology as an occupation with its scope to be developed.
5.257
While physiotherapy is regulated through an AHPRA supported board – the Physiotherapy Board of Australia, exercise physiology is a self-regulated profession. ESSA advised that while its professions have been mapped against the standards required by national regulation, it does not meet the risk criteria set by the government to cross the threshold for regulation through an AHPRA supported board.
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The Australian Physiotherapy Association reiterated the need for removing siloed treatment of physical and mental health and fully embracing multidisciplinary team-care arrangements. The Australian Physiotherapy Association recommended that ‘governments undertake transformational change’ and recognise physiotherapists ‘as valued participants of multidisciplinary mental health care’. It noted that:
… accredited physiotherapists know that exercise is incredibly valuable in the treatment of some forms of depression, PTSD [post-traumatic stress disorder] and other disorders. Improving mobility and addressing health issues that are barriers to exercise should be recognised as part of assessment and treatments for people experiencing mental illness.
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In order to raise the profile of how exercise can support mental health, ESSA recommended starting by better educating GPs:
… patients still believe in the word of the GP. If the GP is going to tell them to do something, they're going to look at it, so we need the doctors to go, 'Right, we need to get you moving. How do we do that?' So that is a bit of the barrier, that it's not suggested as one of the options.
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Likewise, the Australian Physiotherapy Association recommended ‘investment in education across the mental health sector to raise understanding of the important role of physiotherapy in recognising, assessing and treating many physical illnesses and painful conditions’.
Committee comment
5.261
The Committee was surprised to see physiotherapy and exercise physiology excluded from the listed occupations in the National Mental Health Workforce Strategy consultation draft, noting the mounting support for the role of exercise and pain management in mental health treatments.
Speech pathology
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Speech pathologists help with swallowing and communication difficulties. Speech Pathology Australia explained that in addition to treating individuals, speech pathologists are able to work with clinicians to modify interventions, such as cognitive behavioural therapy, to increase accessibility:
For this reason, Speech Pathology Australia believes that speech pathologists should be an essential part of each multidisciplinary mental health team across Australia to ensure effective prevention, early detection, diagnosis, treatment and recovery across the whole of life.
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However, Speech Pathology Australia noted a lack of awareness across other health professions as to the skills speech pathologists can bring to a multidisciplinary mental health team. While currently a challenge, Speech Pathology Australia speculated that this will change as more speech pathologists undertake specialist mental health training:
We're going to have our own speech pathologists that are trained not only in the speech pathology area but also in the mental health area because it really is important that we understand consumers' mental health needs as well as their physical needs, especially in our ageing population.
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The draft National Mental Health Workforce Strategy background paper noted that speech pathology is self-regulated by Speech Pathology Australia and ‘there is no national standardised data set on the supply of speech pathologists’.
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As with other self-regulated professions, membership of professional organisations is not mandatory. Speech Pathology Australia noted that while membership is required in order ‘to receive payments through various funding programs such as the NDIS, MBS, DVA [Department of Veterans’ Affairs] and private health insurance’, those working in the public sector are not required to do so. Speech Pathology Australia estimated this amounts to approximately 20 per cent of the workforce.
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Speech Pathology Australia outlined work underway to overcome a lack of accurate workforce data and enable strategic workforce planning:
Speech Pathology Australia will be undertaking a specific Workforce Analysis Project to capture and understand the speech pathology workforce and to understand the future needs of the profession and community. The Workforce Analysis Project will aptly provide a detailed profile of the supply, demand and distribution of the profession, including locations, context and factors related to shortages in services and influences in recruitment and retention.
The project aims to create Australia’s first interactive geospatial map of the speech pathology profession. This map will enable a comparison of speech pathology ratios by geographic area and population demand, determined by a range of factors, including age groups, socio-economic status and health determinants. The outcomes of this project will provide invaluable data to inform Speech Pathology Australia’s capacity to develop strategies to address the needs of the community.
Committee comment
5.267
The Committee commends Speech Pathology Australia’s efforts to capture and analyse accurate workforce data. This type of project should be replicated across all self-regulated allied health professional bodies to support workforce coordination.
5.268
The Committee has made further commentary on the need for data collection, monitoring and evaluation, and research to support policy decisions in Chapter 7.
Committee comment on allied health professionals
5.269
Despite best efforts, we have not been able to meaningfully reduce the incidence of mental ill health or number of suicides, and demand for services continues to outstrip supply. It is important that every opportunity is explored to produce a variety of interventions that can provide support and hope to Australians enduring mental illness or suicidal ideation.
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The allied health workforce is trained, developed and able to complement more traditional mental health supports. These services need to be further integrated into multidisciplinary mental health teams and be provided as options by GPs to patients as valuable components of mental health plans.
5.271
In order to increase integration of allied health professionals into the mental health workforce, there needs to be promotion of the roles and the referral pathways for each of the allied health professions, both for members of the public and other health professionals.
5.272
However, the Committee is concerned that while the sector is looking at innovative and integrative options to strengthen and diversify the mental health workforce, there are significant variations on education and training standards, governance and regulatory requirements.
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Those seeking support for mental health problems need to be sure that the professional providing services is appropriately qualified, engaging in professional development and supervised in a manner that ensures safety and protections.
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The Committee recommends that the Australian Government strengthen the frameworks for allied health professions to be fully integrated into the mental health workforce, including by:
reviewing the regulation and oversight of allied health professions that contribute to the mental health workforce, and specifically the need to establish national boards supported by the Australian Health Practitioner Regulation Agency where they do not currently exist
providing funding or incentives to increase the availability of discipline-specific supervision to expand the number of places for allied health professionals wanting to specialise in mental health
recognising the full spectrum of allied health professionals, including physiotherapists, exercise physiologists and Dietitians, and their contribution to the mental health workforce as allied health professionals in the final National Mental Health Workforce Strategy and subsequent implementation plans
developing and implementing a strategy to promote the mental health related interventions that allied health professionals can offer. This should include information targeted at both consumers and other health professionals.
Crisis support – volunteers
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Volunteers are an integral part of the mental health workforce, often providing the first point of contact on helplines or providing support in community-based mental health services. VolunteeringACT noted that many community services rely heavily on the volunteer workforce, and as a result there is a critical need to invest in volunteering to ensure mental health services reliant on volunteers can meet increasing demand.
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While noting the lack of official data, Volunteering Australia provided a number of estimates that put the number of volunteers in the health or welfare sector at over 680,000 volunteers. Organisations utilising volunteers include:
Lifeline Australia, whose last annual report indicated it had a 10,000 strong volunteer workforce, which supported around a million calls over the course of a year.
MATES in Construction, which advised that its program is ‘supported by over 20,000 trained volunteers on the ground in workplaces across the country’.
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Highlighting the substantial contribution to society and the economy, Volunteering Australia pointed out that ‘volunteers and volunteering contribute to every government portfolio, except perhaps for Defence, but there is no whole-of-government strategy to volunteering’.
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Despite the importance and number of volunteers in the mental health workforce, neither the National Mental Health Workforce Strategy consultation draft nor draft background paper has included reference to volunteers.
5.279
The Productivity Commission Report made a number of references to volunteers, including a section on the benefits of volunteering, but this did not lead to any recommendations. Volunteering Australia identified this as a ‘critical gap’ in the Productivity Commission’s Report recommendations:
[There was] no reference to the role of volunteering in mental health prevention or recovery, nor the role of volunteers in the mental health workforce. We urge that this is addressed in the implementation process.
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Volunteering Australia called for volunteering and the role of volunteers to be made explicit in the implementation of recommendations coming out of recent reports and strategies, and for the voices of volunteers and organisations utilising volunteers to be at the table:
Volunteering does not just happen. It requires leadership, investment and strategic oversight. The role of volunteering in supporting mental health and suicide prevention needs to be highlighted, supported and be an integral part of the implementation process.
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Similarly, Lifeline Australia submitted that ‘the value of the volunteer mental health workforce, and considerations of their role, training, and standards should be included in the development of any comprehensive mental health workforce strategy’.
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In terms of the training and development of volunteer crisis supporters, Wesley Mission emphasised that it is not them as training counsellors or clinicians for the Lifeline services it operates. Wesley Mission noted that the training and ongoing professional development was comprehensive and meets accreditation standards set by Lifeline Australia:
… we require volunteers to do call-coaching sessions with our qualified clinicians. We have PACFA-qualified and TAE- [Training and Education] qualified crisis support supervisors who do call coaching. Also, once a volunteer has reached a certain amount of volunteer hours in the system, we ensure that volunteers are engaging in what we call group supervision, which is a space to do that reflective practice linking one's personal experiences on the calls with that of their peers and looking at different techniques to be able to attend to the helpseekers' needs.
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Lifeline Australia advised that in addition to the training, there were clear processes in place for support when volunteers are on-shift and for escalation pathways:
… while we're on shift we always have ready access to a supervisor who can listen in and support us in the calls if we're experiencing something we may not have experienced before …
If our crisis supporters identify there's immediate danger, we have quite detailed and practical procedures in place where we connect with emergency services. That's a critical part of the training for our team...
Committee comment
5.284
The Committee expresses its thanks to all those who volunteer their time to help others in times of need, and acknowledges that many who volunteer do so because they have at some point been impacted by mental illness, suicide or other life challenges.
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Volunteers are giving, and in return, they must be recognised not only by the organisation they work for, but also within the structures that underpin the mental health and suicide prevention workforce. This means having volunteers and those who employ them represented on national mental health workforce taskforces, and in the strategies and implementation plans being developed.
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Lifeline Australia and its service delivery partners have done a lot of work to ensure a high standard of training and development, consistency across centres and a safe work environment for its volunteers. This provides a sound model that could be leveraged when considering the development of the lived experience (peer) workforce.
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The Committee recommends that the Australian Government formally acknowledge the value of the volunteer mental health workforce, with consideration of its role, training, and standards included in the final National Mental Health Workforce Strategy and subsequent implementation plans.
Lived experience (peer) workers
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The concept of lived experience (peer) workers is not new but peer workers have recently received increasing recognition for the important contribution that they can make as part of the mental health workforce. batyr’s youth ambassador, Bella Cini, shared her story with the Committee:
I think the role of the peer worker is one of the most valuable roles within the mental health sector and is something that we definitely need to be emphasising a little bit more. Through personal experience working with young people in a peer support role, I found it to be so effective in helping that person move along in their journey and helping them receive and reach out for the help that they need ... I've been sharing my experience for four years in the peer work programs. I can be with kids for a couple of hours, but the amount of students that you talk to who are feeling so empowered and understood, and who feel like they can relate to you and what you're saying, proves to me that that peer work works and is effective and is really helping young people come to terms with what they're going through.
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The National Mental Health Consumer and Carer Forum (NMHCCF) outlined the critical role of peer workers ‘in the transformational changes necessary to develop recovery-oriented mental health services and systems’:
Employing peer workers in the mental health system resets the balance of power and significantly advances greater equity, rights, and justice.
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Overwhelmingly, witnesses expressed support for growing the peer workforce:
headspace – ‘lived experience needs to be embedded at the forefront of change through structure, policy and practice … Mental health and suicide prevention services and supports will only work if they harness the expertise of users, and the experiences of people improve’.
Mental Health Carers NSW – ‘the value of peer workers for carers is enormous ... we need to provide support for carers by people who understand what it is to support someone with a mental health issue and the difficulty that that presents and who do not have the stigmatising attitudes’.
National Mental Health Consumer Alliance – ‘surveys have shone a light on how important peer support work actually is—just to have someone who is a role model or who people can talk to’.
Professor Brin Grenyer – ‘People with lived experience give people with personality disorders a different message of hope and encouragement than they can get from health practitioners’.
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Included in the National Suicide Prevention Adviser’s recommendation for all governments to integrate lived experience knowledge and leadership, was a priority action that ‘all governments commit adequate funding and implement support structures to build the lived experience workforce, including the lived experience peer workforce’.
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While structures and governance arrangements for the peer workforce are still being developed, the Royal Flying Doctor Service (RFDS) encouraged taking a risk managed approach:
… we often assess the risk of what we're doing, but we often don't compare it to the risk of not doing anything. I think that's important too. I'm not suggesting for a moment that anyone gets careless, but the risk of us not delivering services and not taking every opportunity to recruit folks from the local communities also presents risks to us.
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SANE Australia posed a range of questions that it considered need answering ‘if we want to see a really modern integrated collaborative workforce’:
… what does that look like? And critically, how do these roles intersect in a collaborative way, in an equal way with clinical roles? I think that's some of the area of opportunity for development of training courses, research and innovation but also of opportunities to encourage new people to think about these as possible career pathways.
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The Western Australian Association for Mental Health (WAAMH) suggested that the peer role is complementary, and that a stronger emphasis on a well-supported integrated peer workforce might reduce distress for those presenting and ease pressures on the responding clinical workforces.
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Determining the scope of peer workers and the intersection with clinical roles was raised by Carers ACT, noting that from a carer perspective, peer workers ‘provide a reduction in isolation and sense of feeling alone in their caring role’ but do not replace the need for engagement with the clinical workforce:
… what carers need most is understanding of diagnosis, understanding of treatment, skill and education in the provision of that treatment and the ability to know how to act and react in an effective manner when they're providing the bulk of the care. And the carers we represent would say that a peer workforce doesn't provide that and that only a clinical workforce would provide that degree of education and expertise.
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With a focus on integrating lived experience, Brisbane South PHN has introduced its implementation framework, which runs from co-design right through to co-production and co-evaluation:
… we have a lived experience coordinator who is working between metro south mental health service and PHN. We are very lucky to have him, and he is supporting us to implement our lived experience advisory panel and a lived experience taskforce that will then ensure that lived experience is lived, essentially, throughout our entire implementation framework.
Representative professional association
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The draft National Mental Health Workforce Strategy background paper indicated that the peer workforce had ‘the largest relative gap in mental health workforce supply’, and while still an emerging workforce, is expected to grow as recognition of its value increases. To support growth of the peer workforce, there has been a resounding call in recent reports and by a range of organisations for the establishment of a national association of peer workers.
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NMHCCF strongly supported the professional association recommended in the Productivity Commission Report, outlining its view of the associations role:
Such a professional association would develop peer worker role delineation, develop and implement peer supervision pathways, support data collection at both national and jurisdictional levels, and develop and deliver training programs to other members of the mental health workforce. The availability of existing programs, such as nationally recognised training programs, and the peer workforce guidelines, which are soon to be released by the National Mental Health Commission, will support the activities of the professional association.
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Lived Experience Australia (LEA) drew attention to its report ‘Towards Professionalisation’, which was the product of an 18-month national scoping project for the establishment of a member-based organisation for the peer workforce. The report noted that there are established policy commitments in all states and territories, but a national association is needed to increase understanding and provide role clarity for organisations and ‘enable access to resources, specialised training, supervision and communities of practice to support professionalisation of the peer workforce’.
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However, both LEA and NMHCCF remained concerned about the Productivity Commission Report proposal to provide one-off seed funding. NMHCCF called for a longer term investment:
Without the financial commitment for the establishment of a peer workforce professional association, with guaranteed funding for at least the first five years of operations, it is possible that the funded training opportunities may not achieve the desired outcome.
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Mental Health Victoria suggested that rather than additional government funding, once established, the professional association could be funded through member and organisation fees.
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The Australian Government’s National Mental Health and Suicide Prevention Plan indicated that ‘the Government will work with mental health stakeholders to investigate and co-design future national peak body arrangements to ensure a greater role for lived experience, through the 2021-22 Budget’.
Training and support
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WAAMH predicted a rise in demand for peer and community sector workforces once reforms are implemented, and noted that:
Focused attention and investment are needed to identify, train and support these workforces to meet this demand and provide quality services. Lived experience workforces will also need supportive and enabling structures to shift cultures within services and allow this workforce to reach their potential and drive systemic change.
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The Australian Government provided ‘$3.1 million to sponsor up to 390 peer workers to undertake vocational training’ in the 2021-22 Budget.
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The draft National Mental Health Workforce Strategy background paper noted that while there is not currently a mandatory qualification for peer workers, there is ‘a nationally recognised Certificate IV in Mental Health Peer Work’.
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The Productivity Commission Report questioned the benefit of requiring a minimum standard of qualifications for peer workers, and on this basis did not make any specific recommendations about the regulation, training or qualifications for peer workers. The Productivity Commission referred the Committee to its report commentary:
The unique value of peer workers is that they bring to bear their lived experience of mental ill-health and recovery, rather than qualifications through education (2021, p. 731).
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However, for those that are looking to develop a career as a peer worker, headspace suggested that there needs to be thought given to ‘how young professionals or lived experience professionals can progress in their career’. headspace noted that this may include different qualification offerings, but would require allies prepared to champion these kinds of roles within the broader mental health workforce.
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WAAMH noted that the existing peer work qualification, implemented by the vocational training sector providing certificate III and IV level skills, is ‘fairly well established’.
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SANE Australia suggested developing broader academy style approaches to the lived experience workforce beyond the certificate IV. SANE Australia advised that this ‘would require structural investment in research and development and should be led by lived experience’.
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To help those wishing to go beyond being a peer worker, SANE Australia endorsed the recommendation of the Royal Commission into Victoria’s Mental Health System to establish a lived-experience-led agency. SANE Australia suggested that the intention would be ‘to set it up as a registered training organisation to support people with lived experience to develop, design and lead their own organisations’.
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AASW highlighted that ‘many highly qualified mental health practitioners also have lived experience, on which they draw in their professional work’, but in doing so are able to differentiate which aspects are appropriate to share:
… that task itself is something that requires professional education and supervision.
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ReachOut recognised the need to ensure training and safe practices are in place for those people with lived experience who are providing support for others:
That extends all the way through to things like making sure we've got debriefs, clinical supervision of the peer workers themselves, as much as we are thinking about the experience of the young people accessing the service.
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Youth Insearch outlined the criteria it has stipulated for those wanting to become youth leaders, and the protections that have been put in place. In addition to attending a number of its workshops, prospective peer workers need to demonstrate ‘that they have the capacity or that they have begun to work on their issues’:
We are very aware and concerned about the risk of having a youth, peer-led workforce, and for that reason we have ongoing training for them as well—monthly training that they attend. They have constant support by staff members. They are never in a situation where they are on their own working with young people. They're always surrounded by supports that are available to them at any time.
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LEA also raised the important role of reciprocal training, where views of those with lived experience are able to be incorporated into training products for the wider mental health workforce:
Lived Experience Australia has developed 5 online educational models comprising the views of consumers, a carer, a GP, and a psychiatrist. LEA has acquired CPD points from the Royal Australian and New Zealand College of Psychiatrists and the Australian College of Mental Health Nurses. To cement these learnings into clinical practice LEA has targeted psychiatry trainees and now provides an annual award titled: ‘Best practice in consumer and carer inclusion’ for those who undertake the training and submit a reflective piece about how their learnings have changed their clinical practice.
Enabling the peer workforce into practice in the community
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While noting that ongoing funding continues to present challenges, RFDS provided a working example on how it partnered with Lifeline Australia to upskill local communities and develop peer workers, supporting mental health in rural and remote settings:
It's a non-clinical peer advocate program where we've identified leaders in the community around far west New South Wales. It's a pastoral focused program; they're graziers living on cattle stations and they have a lived experience with mental health. We employ them and train them and provide mental health support to them in their role. They can receive phone calls from their neighbours and peers, they will speak at local community events, they will visit people on properties, they're essentially contactable 24/7 as peer advocates and they will help link people in. It's not a service for everyone, but it's on the ground and local; it's a linkage pathway, I suppose. One of those champions has indicated she's about to enrol in the cert IV peer mental health program, so she's identified wanting to do more training and become more qualified, I suppose, to deliver more services herself.
… The champions, as we call them, have monthly education sessions with each other and with various members of our clinical staff. They have one-on-one debriefs or reflective practice with a trained mental health professional, and that's at least monthly or as needed. Through Lifeline, they have a counsellor for their own mental health and wellbeing, and that's also monthly or as needed ... There's an interview process and a panel that have to endorse this community member to become a champion. They're not obligated to stay if at any time they don't feel comfortable.
Committee comment
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To realise the full potential of the emerging lived experience (peer) workforce, help people navigate complex mental health systems and provide support and reassurance throughout the process, there needs to be some degree of professionalisation.
5.317
While the Committee acknowledges the Productivity Commission’s view on the unique nature of the lived experience (peer) workforce, it differs on the need for regulation, training or qualifications.
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In order to protect the lived experience (peer) workers and the people they seek to assist, there must be a minimum level of structured induction and training. This is to ensure that prospective workers have ongoing supports and understand how to safely integrate their experience into the role.
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The Committee is of the view that professionalisation will reduce sector stigma and support recognition across the mental health workforce and community, helping lived experience (peer) workers to be better integrated into multidisciplinary care and other team settings.
5.320
Noting the amount of work that has already been done by state and territory governments and NGOs, the Committee supports the establishment of a lived experience office, similar to that recommended in the Royal Commission in Victoria’s Mental Health System. This should sit within the Department of Health portfolio and could leverage the administrative structures in place as for the National Suicide Prevention Office.
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The lived experience office should be tasked with bringing together best-practice lived experience (peer) workforce practices from each of the states and territories, and engage with stakeholders to develop a nationally consistent set of guidelines for lived experience (peer) workers. The office should also consider the practicalities around a national registration system and whether this should be facilitated by government or a professional association, and establish a monitoring and evaluation framework to support a safe and thriving lived experience (peer) workers sector.
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The Committee also supports the establishment of a national professional association for lived experience (peer) workers, which could:
contribute to defining the role and scope of lived experience (peer) workers, and constructing a recognisable identity for the workforce
promote the development and integration of lived experience (peer) workers as part of the mental health and suicide prevention and aftercare workforce
provide education and training, professional development, certification, supervision and debriefing mechanisms to support a safe and effective workforce
engage with non-lived experience (peer) workers to develop training packages that help to reduce stigma, discrimination and increase understanding of the value of lived experience (peer) work
consolidate information on different programs, products, practices, and policies across the lived experience (peer) sector, and provide advice to government on what is and is not working.
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The Committee recommends that the Australian Government support the development of the lived experience (peer) mental health and suicide prevention workforce by:
establishing a lived experience office within the Department of Health portfolio to support the growth of a safe and effective lived experience (peer) workforce, led by a National Lived Experience Officer
providing seed funding for the establishment of a national professional association for lived experience (peer) workers, with additional guaranteed funding for the first five years of operations.
Carers and family
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Often unpaid and largely unrecognised, carers supporting people with mental health problems or providing suicide aftercare provide a valuable contribution to the community and reduce the burden on health systems. Tandem Carers provided insight into the role of a carer, and expectations placed upon them, following a suicide attempt, and called for carer inclusive policies:
After a suicide attempt, for instance, it's predominantly women and families who are charged with ensuring that further attempts are prevented through suicide watch. Suicide watch is a mental health term that says nothing about the person who is doing the watching, about their ability to undertake 24/7 surveillance, about the toll this takes and about what it does to relationships. Currently there is patchy follow-up at best when someone is discharged to a family, and little consideration is given to the emotions and the economic or social circumstances of those families or carers or how isolated they are in rural or regional locations. This means that carers and families are left scrambling to do the best they can and bear the burden of guilt for poor outcomes … Without support, carers and families can quickly reach breaking point. This has a flow-on effect across the community, leading to cost blow-outs for federal, state and territory governments in health, justice, housing and homelessness.
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HelpingMinds highlighted a University of Queensland study, commissioned by Mind Australia, that placed the value of unpaid informal carer support work to the community in Australia at about $13.2 billion a year.
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Despite the important role that carers play, Mental Health Carers Australia raised concerns that ‘families and carers are often left out of discussions about how to best support the person that they're caring for’.
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Carers, family and friends also need nationally recognised training available to empower them to provide skilled intervention. Suicide prevention training organisation, LivingWorks highlighted the need to ‘skill up those around vulnerable people’ through programs such as Applied Suicide Intervention Skills Training (ASIST). LivingWorks explained they need:
… practical abilities to be able to respond early to someone in distress through seeing the warning signs, listening with compassion, looking for turning points to live, and then onto safety plans for referral to the right service at the right time.
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The Productivity Commission Report considered in detail the role, support services and income support for carers and proposed actions to improve access to funding supports and income support payments, and to improve how families and carers are included by mental health services. It noted that as a priority:
All mental health services should be required to consider family and carer needs, and their role in contributing to the recovery of individuals with mental illness …
State and Territory Governments should ensure the workforce capacity exists in each region to implement family- and carer-inclusive practices within their mental healthcare services.
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NMHCCF contended that the Productivity Commission Report recommendation to consider the family and carer needs and their role would not lead to any significant changes. Instead, NMHCCF advocated for the development and implementation of family and carer inclusive practices, where the carer is an equal member of the team and it is not negotiable that services link with carers.
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Similarly Carers Australia called for strategies that support inclusive relationships between carers and service providers, ensuring carers are treated with respect and considered as partners in care.
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Carers Australia noted that the introduction of the Carer Recognition Act 2010 (Cth) acknowledged ‘the valuable social and economic contribution of carers in Australia’. However, it raised concerns that ‘the last National Carers Strategy lapsed in 2014’, and called for a new ‘national carer strategy that covers all carers regardless of their situation and circumstances’.
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Mind Australia suggested that ‘a new national carer strategy would demonstrate a real commitment to the needs of carers and ensure they are prioritised in future government policy’.
Peak body representation
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MHA advocated for the implementation of the Productivity Commission Report recommendations related to ‘designing a person-led mental health system including but not limited to Action 22.4, the establishment of peak bodies to represent mental health consumers and carers’.
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There were differing opinions across carers and consumer representatives as to whether there should be combined or separate carer and consumer bodies.
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Mental Health Carers NSW and the National Mental Health Consumer Alliance contended that the different perspectives and types of experiences of each group need to be represented. Mental Health Carers NSW suggested that advocating for their own role and position is ‘appropriately empowering and respectful’.
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Supporting the separation of peaks, Carers ACT advised that ‘carers report more often than anything else feeling incredibly invisible’, and raised concerns that a merged body may result in further reducing the carer voice.
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However, NMHCCF supported the ‘continued funding of a combined consumer carer and family lived experience voice’, and stressed the need for a fully inclusive and diverse membership:
… this type of an organisation offers the opportunity for ongoing shared understanding, discussion and debate on the intersectionality of issues, and co-design opportunities that will be missed if the combined voice is not established ... We also ask that the government ensures that the combined voice has representation from all jurisdictions and diverse population groups, such as Aboriginal and Torres Strait Islanders and the culturally and linguistically diverse, and reach into the communities they represent.
Caring for the carer – wellbeing and respite
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Evidence indicated that carers are deprioritising their own health and participation in the paid workforce due to the demands being placed on them in the role of carer. In addition witnesses raised concerns that mental health respite carer support had been removed without a suitable replacement.
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Mental Health Carers Australia suggested that ‘the biggest determinant of carer wellbeing is a functioning mental health system’, noting a functioning system would enable carers to engage in employment and other pursuits.
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Tandem Carers called for consistent and accountable carer-friendly policies in the workplace to boost carers’ ability to ‘juggle all their responsibilities’.
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PACFA suggested counselling be made available for carers, providing them an opportunity to prioritise their own self-care, talk about their situation and receive support in ‘a confidential and safe space’.
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When it comes to respite, Carers ACT explained that there is not a national standard and ‘respite for mental health carers looks very different than respite for people who care for aged or disabled people’:
For respite to work effectively for mental health carers it needs to be flexible, it needs to be responsive and it needs to be trauma-informed. We need to set up facilities that are non-clinical and that are welcoming and inviting for people with mental health concerns to want to be at in order to get proper respite.
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Having trialled various different models with different communities around Western Australia, HelpingMinds highlighted high demand for its current respite program that builds in a range of supports tailored to mental health carers:
The supports that we are evaluating at the moment are around a retreat-type approach, so it has an educational component but there is also the ability to rest and revise and build up your—resilience seems to be an overused word at the moment, but your energy levels so that you can then go back to that role. With these retreats, we actually don't need to advertise them ... It's about trying to build smart outcomes that communities can offer for themselves.
Committee comment
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First and foremost, the Committee wants to acknowledge all the people who have taken on the role of carer, and the family and friends who have stepped up to provide support.
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In parliamentary roles, representing communities across Australia, the members of the Committee have heard the frustrations experienced by many Australians as they try to navigate the mental health or suicide aftercare system on behalf of a loved one.
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There are also members of the Committee themselves who have brought their lived experience as mental health carers of family members to this inquiry.
5.347
As with lived experience (peer) workers, the Committee wants to ensure that carers have a voice at the table, and that the experience of carers is treated with respect and valued, recognising the contribution they can make to improving systems and individual outcomes. However while the Committee supports the views of carers being formally represented, based on the evidence heard the Committee was unable to reach a conclusion on whether the representative association should be a combined carer and consumer body or a discrete carer entity.
5.348
The Committee endorses the Productivity Commission Report recommendation for all mental health services to consider family and carer needs, and their role in contributing to the recovery of individuals with mental illness.
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In recognising the rights of consumers, and acknowledging that not all persons may want a carer or family member involved in their treatment, the Committee calls for the Productivity Commission’s recommendation to be strengthened to require carer or family inclusive practices only where the carer or family member has guardianship responsibilities (for example parents of younger children), or the consumer has expressed a wish for the carer or family member to be involved.
5.350
To support the implementation of improved recognition and support for mental health and suicide aftercare carers, the Committee calls for a renewed national strategy for carers that explicitly recognises these unique roles, the specialist support they provide and respite requirements. This work should take into account best practice from states and territories that have current strategies.
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Carers also need funded access to nationally recognised training to upskill them to provide safe, evidence-based interventions. A priority should be the development of training modules for carers (unpaid carers, family members and friends) that support carers to be suicide aware and suicide safe. Training developed on the LivingWorks ASIST type model and targeted at carers would benefit carers themselves and people living with mental health issues.
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The Committee recommends that the Department of Social Services, in consultation with the Department of Health, National Mental Health Commission and National Suicide Prevention Office, develop a national carer strategy that includes:
details on how and when unpaid carers are to be integrated into care teams
access to national standardised training for suicide awareness, risk and prevention for all carers
a clear pathway for engagement with carer representative bodies.
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The Committee recommends that the Department of Social Services implement a fit-for-purpose respite care program that is flexible and includes access to educational components, counselling services and other supports to boost resilience.
Workforce wellbeing
5.354
Chapter 2 explored in detail the impacts felt across communities as a result of the COVID-19 pandemic, bushfires and other recent natural disasters. However, these crises have undoubtedly impacted Australia’s health and mental health professionals who have been thrust into the spotlight and faced extraordinary levels of demand of their services.
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As ReachOut noted, those working to support others have also been affected by the same factors:
… you've seen the circumstances that are driving a lot of the service access from the community also affecting the team in a similar way. That almost amplifies the fatigue, because you're helping others through it as you, yourself, are navigating through it as well.
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To help its team cope, ReachOut implemented a number of adjustments, including adding resources, amending rosters to recognise the increased intensity, emphasising trauma informed training, and providing mechanisms for informal and formal debriefs.
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The Mountains Youth Services Team (MYST), a small NGO, experienced a massive spike in demand. In addition to structural adjustments, the team increased its focus on wellbeing, adding some light-hearted activities to counter-balance the intensity, and increased access to clinical supervision. However, MYST also recognised that additional resources would be helpful to support youth workers:
Youth workers don't have the same kind of training that our counsellors have, so, when they're dealing with young people disclosing plans to suicide, even though they've done additional training in suicide prevention, just being able to have additional staff—… other counsellors that have that special crisis training—would be really helpful to take that load off.
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There was general consensus that stressors including waiting lists, waiting times, lack of in-patient beds and shortages of clinicians were resulting in burnout and driving health and mental health professionals to leave the sector or work elsewhere.
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Noting the workforce shortages, the Australasian College for Emergency Medicine said that the pressure was being felt across all staff in emergency as they try to deal with a ‘supply-and-demand mismatch’:
Having to deal with those system failures that we know are contributing to poor patient care and worsening their outcome is incredibly stressful for physicians and nurses, and it is all those things that I think contribute to that level of stress and burnout.
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Likewise, consultant psychiatrist, Dr Emma Radford explained that ‘there is a large component of burnout that comes from never feeling you meet any need and feeling that you are constantly saying no or you are constantly not able to provide something for people’. Dr Radford suggested protective factors include engagement with professional peers and supervision, and valuing your own work.
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NMHC advocated for strengthening ‘supervision arrangements and arrangements around the care of mental health workers’, and looking more broadly for ways to avoid burnout:
… so looking at what the appropriate structures can be and perhaps utilising things such as our telehealth measures et cetera to expand the capacity for supervision, particularly for clinicians who might be in rural or remote areas.
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In terms of supporting specific fields, Professor Grenyer stressed the need for those in private practice to have access to support, advice and professional development. Professor Grenyer noted that annual conferences and online training are some of the ways to connect, but that supervision remains important:
Supervisors will say, 'I recommend you go and read something or go to one of these trainings.' That can be the turning point around practitioners getting the kinds of tips and strategies that will help keep them continuing to do good work when things get challenging and difficult.
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However concerns were raised about the cost of supervision, especially in private practice, where these costs would be borne either by the clinician or passed on to the consumer. NMHC called for a ‘conversation and investigation into funding models and funding mechanisms’ that take into account the intersection with existing supervision requirements.
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Not all supervision is equal according to Professor Rosen, who noted that:
It's patchy ... There are some beacons of very good supervision and mentorship. There is quite a huge wasteland between those beacons.
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Other suggestions to help mitigate burnout and improve wellbeing of the workforce included:
QNMU – implementing nurse-to-patient ratios in mental health units.
RACGP – reassuring doctors that they can get help for their mental health conditions without professional censure.
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AMA acknowledged that the greater stigma around mental health in the medical profession, and concerns about being reported to the regulator, remain barriers to help-seeking.
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AMA advised that there have been some programs developed for doctors' mental health, including by Beyond Blue, the DRS4DRS system, and since COVID-19, a support portal, but noted there is more to be done:
… particularly, as you said, in that more preventative space, including things like debriefing after severe events or having an opportunity, like some other mental health specialities do, for some professional supervision, where you could talk things through without it necessarily having any impact on your own health record and health and life insurance down the track and those sorts of other impacts that worry doctors, as they do other professionals.
Committee comment
5.368
Health professionals have faced a sustained spike in demand for their services, including increased presentations of mental health issues and suicidal ideation. Mental health professionals have built-in pathways for supervision that provide opportunities for wellbeing check-ins. In addition and as noted above, a national workforce institute for mental health could be tasked with:
examining strategies to reduce burnout
development of supervision pathways for other health professionals, who may benefit from the introduction of a process to facilitate regular debriefings with mental health professionals.
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In addition to normalising help-seeking, these actions could also help health professionals build their mental health skills and gain valuable second opinions on clinical judgements.