6.1
The Australian Government’s 2021-22 Budget made the largest Commonwealth mental health investment to date, allocating $2.3 billion to the National Mental Health and Suicide Prevention Plan.
6.2
States and territories have also made a series of record breaking investments in mental health and wellbeing. For example:
Responding to the Royal Commission into Victoria’s Mental Health System, the Victorian Government invested $3.8 billion to ‘transform the state’s mental health and wellbeing system’.
The New South Wales (NSW) Government allocated $10.9 billion over the next four years across the state to support mental health and wellbeing.
Western Australia provided ‘$1.114 billion in 2021-22 to the Mental Health Commission to boost mental health, alcohol and other drug services’.
6.3
These substantial investments across Australia reinforce the need to ensure that funding arrangements for mental health services, including through the Medicare Benefits Schedule (MBS) and Primary Health Networks (PHNs), are structured in a way that supports safe, high quality and effective care in line with the qualifications of practitioners and needs of consumers across whole of population.
6.4
This chapter first reviews the Commonwealth, state and territory funding coordination and reform priorities, and then examines the role of PHNs, the MBS and other non-government organisations (NGOs) providing services. Finally, the chapter considers implementation priorities.
The National Agreement and Commonwealth-state and territory funding coordination
6.5
On 11 December 2020, the Prime Minister announced that the National Federation Reform Council (NFRC) had agreed to the development of a new National Agreement on Mental Health and Suicide Prevention (National Agreement):
The NFRC agreed to collaborate on systemic, whole-of-governments reform to deliver a comprehensive, coordinated, consumer-focussed and compassionate mental health and suicide prevention system to benefit all Australians. This will be achieved through a new National Agreement on Mental Health and Suicide Prevention to be negotiated through the Health National Cabinet Reform Committee by the end of November 2021.
Defining roles and responsibilities
6.6
Mental Health Australia’s (MHA) submission recommended that:
The Australian, state, and territory governments should clarify funding roles and responsibilities through the National Agreement on Mental Health and Suicide Prevention, currently being developed.
The Australian, state, and territory governments should ensure lines of funding for mental health are clear and transparent enough to enable consumer-focussed accountability.
6.7
Appearing before the Committee, headspace called for the National Agreement to incorporate a whole-of-life, whole-of-government and whole-of-community approach that positions mental health and suicide prevention as everyone's responsibility:
This needs to be cross-portfolio, cross-jurisdictional and not confined to mental health. It needs to be accountable to first ministers and incorporate clear roles and responsibilities across all levels of government. It also calls for a whole-of-sector effort in collaboration that's incentivised and supported by governments.
6.8
The Black Dog Institute contended that successful negotiation of the National Agreement would be critical in resolving jurisdictional fragmentation, and reinforced the importance of leadership and cross-portfolio engagement:
… mental health goes well beyond the healthcare system—the role of education and of social support in mental health. Our view is consistent with Mental Health Australia's advice that, even if health ministers are going to be tasked with that, there needs to be a mechanism through which health ministers can request … other ministerial portfolios to document that activity, and that there is oversight of that.
6.9
Any reform to funding responsibilities requires an appreciation of the types of services delivered by Commonwealth and state and territory governments, and their respective intensities and costs. The Australian Institute of Health and Welfare explained:
… if you look at spending, there's a lot more spending on the state and territory services because they're more intensive services. Often, if somebody stays in hospital for several days or in residential mental health, the costs are a lot higher than the MBS data. In terms of sheer numbers, there are more people using MBS mental health services than the state and territory services.
6.10
headspace identified the National Agreement as the starting place for effective reform to the mental health sector, noting that:
The disparity between a state system and a federal system or a primary care system, if they're not connected in a policy sense, in a funding sense, plays out on the ground … Shared systems, shared electronic records and a real consumer focus has to be at the forefront of any reform, and that starts with this very challenge that's before this committee and governments around having an agreed position on who is responsible for what.
6.11
The Royal Australian and New Zealand College of Psychiatrists (RANZCP) also recommended ‘that any Commonwealth funding work very closely with the state based services’:
I say that because, if we create more and more doors for accessing services, it confuses the person who needs to access that service … That's where I think the integration of Commonwealth and state based services is very important. We should not be rolling out services that do not interface with other existing services correctly. An example is headspace. There are headspaces that work very well because they work in connection with a state based service and there are headspaces that are not working in connection with the state based services … They work less better than the other ones.
6.12
Concerns were raised about the lack of consultation with peak bodies and service providers during the National Agreement development process. The Western Australian Association for Mental Health (WAAMH) stated:
We had a chance to make a submission to Mental Health Australia, who are the peak non-government body for mental health at a national level. They asked for submissions from their members, of which we are one, with the advice to us that Mental Health Australia are not represented on the expert advisory committee overseeing the development of the agreement and that they hadn't been asked to undertake any consultation with the sector in relation to its content … According to Mental Health Australia, that was not something that anyone had actually instigated; that was something that they had to instigate themselves. In the spirit of getting perspectives from the entire sector, I'd say that's maybe something to take back and consider about how we actually get genuine input from different parts of the mental health sector and the community around these processes and make them easy to understand and easy to engage with.
Committee comment
6.13
Noting that the development of the National Agreement should be almost finalised, the Committee hopes that it clearly outlines the specific funding responsibilities, governance structures and reporting requirements of the Commonwealth, states and territories. This will be fundamental for resolving current service and workforce gaps, and the fragmentation of the sector’s systems.
6.14
Recognising the significant impact that the National Agreement will have on the mental health sector, the Committee calls for the Australian Government to include stakeholder consultation in any future funding negotiations.
Primary Health Networks
6.15
Australia’s 31 PHNs are independent organisations that operate as regional commissioning bodies, working to streamline health services and coordinate care.
6.16
In early 2017 the Department of Health commissioned an evaluation of PHN’s, the Primary Health Network Mental Health Reform Lead Site Project, which was conducted by the University of Melbourne. It was established to provide the Department of Health with an evidence base on effective approaches to planning, integration and delivery of mental health services. In December 2020 this report was completed, but is not publicly available.
6.17
The Productivity Commission Inquiry Report on Mental Health (Productivity Commission Report) recommended reform to funding arrangements with PHNs to support efficient and equitable service provision:
The Australian Government Department of Health should reform the way that it allocates funding to PHNs (or RCAs [regional commissioning authorities]) to support greater regional equity and remove incentives to engage in cost shifting.
6.18
The Productivity Commission Report also recommended the Department of Health provide guidance on the evidence base behind interventions and require PHNs to demonstrate evidence-based service delivery.
Coordinated, joint regional approaches
6.19
Various witnesses highlighted the importance and the need for coordinated, joint regional approaches to commissioning mental health and suicide prevention services. Professor Ian Hickie from the University of Sydney’s Brain and Mind Centre stated:
The inequity tends to grow under systems that are not well structured and in which the agreements between the Commonwealth, the states and, I must say, increasingly the non-government sector are poorly coordinated.
I am therefore a strong advocate of regionalisation—that these things can be regionally organised. I was a strong advocate on the Mental Health Commission for PHNs taking that role on behalf of the Commonwealth, but they cannot act in isolation. Regional planning requires cooperation between the federally funded services, organised through the PHN, state-run services and the non-government sector. It also requires strong action by the Commonwealth with regard to supporting the private health sector to be a productive member of this discussion.
6.20
MATES in Construction explained that through PHN support and regional coordination, it has been able to effectively address service gaps, trial its services in broader-community approaches, and reach more diverse regional areas.
6.21
WAAMH suggested that as a peak body it had the capacity to support workforce planning objectives, but requires clarity from governments and PHNs on what it should be planning for, and what the regional priorities are:
I think one of the things that's also important … is taking into account that whatever's going to be done at a national level, replicated in states and territories, really needs to be done in a way that can take account of the local infrastructure and state funded service systems that are already in existence. Again, that's one of the reasons why we had a strong preference for the notion of regional commissioning that the Productivity Commission spoke to.
6.22
The PHN Cooperative referred to the Productivity Commission Report findings that identified a ‘lack of system integration across the mental health system’, and ‘the challenge of the blame game, or cost shifting between funders’. The Cooperative argued that:
… the reality is that the Commonwealth is going to continue to fund primary care, and the states are going to continue to fund hospital care. While those two things are continuing, they both need to work together to address mental health issues … So it's by PHNs and LHNs [Local Health Networks] working together that we can understand the needs of communities, plan and commission services.
6.23
Healthy North Coast highlighted its work around developing a joint regional approach to address duplication of investment in certain areas and funded programs that had not been delivering on outcomes:
At its pinnacle—and I think it's got a long way to go around that—we started to make investment decisions at a portfolio level, and saying, 'Actually, we're investing all of this money here like we always have, but if we shifted investment focused on outcomes we could probably get much better outcomes for our region.' But those things can't be done unless you're working collectively together towards a joint set of goals. Importantly, you really need to understand not only what you invest but the outcomes of what you invest.
6.24
Brisbane North PHN noted the benefits of a health alliance with the Local Health Network (LHN), explaining that the alliance provides a mutual space for strategic work in joint planning and co-commissioning of services:
… where PHNs are really well positioned is to have an understanding of the service profile across our particular region and how consumers might access that. From our perspective we have a mental health service navigator line that really is consumer facing. It can also support our GPs [general practitioners] and other primary healthcare providers to think about what services are in the community that can meet people's needs and how people might navigate to those.
6.25
The Productivity Commission Report recommended reform to PHN funding arrangements to support efficient and equitable service provision. To achieve this, the report recommended that governments strengthen the cooperation between PHNs and LHNs by requiring comprehensive joint regional planning. It recommended that:
The National Mental Health Commission should independently monitor and report on compliance by PHNs and LHNs against their commitments. (Action 23.1)
6.26
Action 23.4 of the Productivity Commission Report recommended federal support for the state and territory governments that choose to establish regional commissioning authorities (RCAs) to administer mental health funding as an alternative to PHN-LHN groupings.
6.27
The Brisbane South PHN and Metro South Addictions and Mental Health Services (MSAMHS) submission identified concerns with this recommendation in the Productivity Commission Report. The submission argued that while not all PHN-LHN relationships are as collaborative as the Brisbane South PHN-MSAMHS relationship, federal and state governments might erase all progress achieved over the last five years by moving to a new commissioning model. It contended that:
We would support strengthened guidelines/requirements for, and oversight of, the PHN-LHN working relationship but see the creation of new commissioning agencies or bodies as a duplication of resources and effort.
6.28
Appearing before the Committee, Brisbane South PHN further explained this concern:
Systems change takes time, and the systems and our communities can't afford another reset in the system. I don't think that there is a single agency that can be the panacea, and any new iteration would need to integrate into the broader health and social systems, just as we're doing, and will have the disadvantage of needing to gain trust from stakeholders that this next solution will stick.
6.29
Wesley Mission also expressed concern with the suggestion of changing the regional commissioning model, noting that:
The reason why we recommended continuing to build the PHN capability is that there are significant inroads made in terms of the relationship of trust between community members and the commissioning authority … There's obviously quite a lot of workforce capability that's been developed there.
Multidisciplinary care
6.30
Various reports and witnesses have raised the importance of investing in multidisciplinary models of service delivery outside of the MBS, to give the Australian population access to holistic healthcare and remove the current siloing approach that causes discipline friction.
6.31
The PHN Cooperative contended that current funding models lead to the siloing of professions and do not effectively accommodate individuals who present with other concurring health challenges, co-morbidities, or life situation concerns:
So PHNs receive funding to fund psychology. We receive funding for mental health nursing. So we receive these little pots of money each with their own guidelines attached to them, which are about funding professions. But what we don't get is a pot of money that's about funding the services that people need. What people say they want and need is often a multidisciplinary integrated service.
6.32
Similarly, Professor Alan Rosen from Transforming Australia's Mental Health Service Systems argued that:
The dual disorder is in the services, not in the service users. In fact, it's not just dual; it can be up to a quintuple whammy that includes mental health problems, drug and alcohol, forensic, alienation of youth and all the social determinant factors such as poverty. That's just a simplified version.
6.33
The Women’s Mental Health Service at the Royal Women’s Hospital highlighted the success of its multidisciplinary approach within its delivery of perinatal care, improving patient navigation of the public healthcare system:
… the Royal Women's Hospital recently established an innovative approach called the social model of health, which combines mental health, sexual violence and trauma counselling, social work, housing, and alcohol and drug services for our most vulnerable. The social model of health is underpinned by a strong multidisciplinary team approach based on close clinical collaboration, providing perinatal women, in particular, with greater integration and continuity of care as they journey through the inpatient, outpatient, antenatal and postnatal aspects of their care, which can be extremely fragmenting. Such a multidisciplinary team approach also allows for enhanced capacity building and cross-fertilisation of ideas amongst clinician[s].
6.34
However, the Committee heard that successful multidisciplinary teams require reliable funding and adequate staffing. Exercise and Sports Science Australia (ESSA) noted that exercise physiologists (EPs) are often based in community facilities or hospitals and are unreliably funded through a combination of compensable schemes or state PHNs:
… in terms of hospital models of care there are some really great examples. For example, in Brisbane it's located in the community care unit, our Coorparoo residential service, and they predominantly treat those who are suffering with schizophrenia … So it's delivered by a multidisciplinary team which includes a dietitian, and the programs are led by the psychiatrist there. Unfortunately their EP is funded inconsistently, so they have to reapply for their funding.
6.35
Likewise, Professor Perminder Sachdev contended that multidisciplinary approaches to service delivery effectively support the complex treatment of eating disorders, but are often not sustainably funded:
The best treatment is offered by a unit that specialises in eating disorders, because you need dietitians, social workers, psychologists, psychiatrists and general physicians working together, and only a specialised unit can offer that kind of treatment. We have very limited, specialised units for eating disorders, especially in the public sector. There are a few in the private sector, but there are very few in the public sector.
6.36
The Black Dog Institute raised concerns in relation to the staffing of multidisciplinary centres:
There's no point opening up a new multidisciplinary centre if the only way to staff that is to pull mental health professionals out of other services, and we've certainly seen that before where new centres and initiatives have been opened.
Referral and connectivity
6.37
According to SANE Australia, in order to develop an integrated systems approach to reform there needs to be thought given to the level of investment actually required for NGOs in the mental health sector, in addition to other social services, to improve connection-building and data sharing.
6.38
The Mountains Youth Services Team (MYST) advised that its relationship-based, ‘warm referral’ model was improving connectivity with other community services. The model includes ‘drop-in’ workers from drug and alcohol and accommodation services to build relationships and support consumer transfer between services.
6.39
Appearing before the Committee, the Queensland Nurses and Midwives’ Union (QNMU) discussed the benefits of the discontinued mental health nurse incentive program. The federal program funded providers to engage credentialed mental health nurses to deliver coordinated clinical mental health care in the community. QNMU identified that:
Unfortunately this funding arrangement has ceased, with the primary health networks now given a flexible funding pool which means mental health services are commissioned to local providers, which are not necessarily provided by mental health nurses or mental health-trained health practitioners.
Regional commissioning flexibility and funding cycles
Funding flexibility
6.40
Various contributors to the inquiry identified concerns with tight constraints on funding and an inability to respond or adapt to the significant increases in demand as a result of the COVID-19 pandemic and recent natural disasters.
6.41
Noting systemic affordability issues within the mental health sector, Mind Australia stated:
Our workforce, on the whole, is probably less expensive than a clinical workforce, but all of our services are funded directly by government, so there's not a lot of give for us in what we can do if we're not specifically contracted to do that … Our capacity to solve the affordability issue is constrained by the ways in which services are commissioned.
6.42
Brisbane North PHN argued that through the development of regional plans it is able to improve community accessibility and affordability issues. These plans provide the priorities of commissioning decisions and identify service gaps, but it argued that the capacity for implementation is currently limited by PHN budgets.
6.43
Surge funding for capacity building over time, and as community demands increase, is becoming increasingly important. MYST contended that the inflexibility of funding contracts provided to community organisations has restricted options to expand to meet demand and presentation complexity. MYST identified that:
… because of the crisis [COVID-19 pandemic] we have a contract with our state funders for five years, but it's the same amount of funding from years 1 to 5, and we're seeing this huge increase, and no additional resources. It would be really helpful to have a few additional counsellors who have clinical training in crisis to help us through this gap.
6.44
Appearing before the Committee, yourtown highlighted the benefits of not needing to depend on government or PHN funding, and not being constrained by granular funding agreement clauses:
… we are able to redesign our theories and change to engage with them [different client demographics] to understand their needs and preferences, develop new program logics for our programs and bring in staff with the relevant skills needed to address their needs. So our lesson learnt has been that you have to be quite flexible and responsive to do this and you have to be agile to the changing needs of your clients, and they do change over time. Particularly with COVID we have had very different cohorts of people coming into our services with very different needs that we haven't anticipated.
6.45
The Consumers Health Forum of Australia and the Royal Flying Doctor Service (RFDS) also stressed the importance of flexibility within regional commissioning structures, including funding arrangements, to support effective regional commissioning, service planning, and to ensure that service profiles can be properly integrated into the community.
6.46
The Committee heard that one of the key benefits of regional commissioning of mental health and suicide prevention services is the capacity for PHNs to commission to meet the unique demand profiles of their communities and take steps towards resolving service gaps. SANE Australia proposed that this required some degree of flexibility in regional commissioning and funding:
… we've heard support from the Productivity Commission and the royal commission for regionally based commissioning … it's about getting the state and territory governments and the Commonwealth to fund in a way that leads to system cohesion while retaining that local flexibility through the regional commissioning.
6.47
The Brisbane North PHN and Metro North Hospital and Health Service (HHS) submission noted:
A flexible funding pool at the regional level, made up of state and federal funds, would facilitate better co-commissioning and reduce administrative burdens on providers. This integrated approach to the health system, at the regional level, is the best way to drive system improvements and achieve health outcomes for local communities.
6.48
The Metro South HHS indicated that flexible COVID-19 response funding enabled the HHS to support place-based, local decisions:
In discussion with the PHN and in discussion with local communities we had three areas that we wanted to work on, and one of the things we did really well I think is PHN leveraging the HHS. We've implemented dialectical behavioural therapy training [DBT] for the whole sector, so our staff at the HHS are training up GPs, NGOs and our own staff to allow the confidence to deliver some DBT, with the aim of increasing the resilience of our community.
6.49
The Metro North HHS admitted that the highly-targeted nature of PHN budgets acts as a significant commissioning restriction, largely limiting the implementation of regional commissioning plans:
… it's a little bit arbitrary to have these decisions about joint commissioning because, as I say, most, 99 per cent, of the funding is targeted to a specific program such as headspace or Way Back. Effectively the Commonwealth and the state make a decision that they are going to give money for a specific program, so it is in some ways a waste of time having a regional plan if no one is prepared to give us funding to actually do something about it.
6.50
This was further explained by Metro North HHS:
For example, in the budget that the PHN gets there's money for headspace, there are a whole range of $2 million blocks of money, and basically there is very little discretionary funding. In the new money coming from the Commonwealth, the largest bucket of money is the Head to Health programs. Again that's not going to give us a lot of ability to deliver areas of planning that we see as important. So I would, if I were saying something to the federal government and the opposition, the need for non-targeted funding. Unless you give us that, we're not going to be able to roll out our plans.
Funding cycles
6.51
Short government funding cycles and PHN contracts and the flow-on impacts that they have on proper co-design, the stability and sustainability of service delivery, and the recruitment and retainment of mental health professionals within NGOs were raised as areas of concern.
6.52
While noting that extending the funding cycle would require a change in approach to how governments and PHNs embed accountability and monitoring mechanisms within commissioned services, RFDS explained it was not ‘talking about removing accountability’:
… I am saying we should not use the retendering of services and programs as our fundamental accountability mechanism, because there are others. We can sit down, as we do each year, with the Commonwealth and we can assess our progress against a set of KPIs [key performance indicators] … That process can be an ongoing process over many, many years. It doesn't require this arbitrary cut-off of saying, 'In order to test efficiencies, we're going to go back to the market.’
6.53
The Aboriginal Health and Medical Research Council of NSW (AHMRC) highlighted the impact of truncated funding cycles on being able to demonstrate service impact, and complete an effective evaluation of services. The Council advocated for a transition from 12 month contract terms to three to five year contract terms, noting this resolution could solve workforce attraction issues as well as the current lack of outcome data collection.
6.54
Appearing before the Committee, Lifeline Australia also emphasised the importance of longer-term funding cycles, noting particularly their impact on its workforce:
I think absolutely the longer the term, the better. Of course, like many other organisations, whether they be private, commercial, not for profit or profit for purpose, I guess it's allowing for longer-term planning and staff engagement, particularly for our members who run a lot of community based services. It's very difficult to keep staff engaged, let alone volunteers we were talking about before, when it's a year-on-year contract scenario.
6.55
SANE Australia similarly noted the role that funding insecurity has on recruitment and an NGO’s capacity to attract mental health professionals:
People might spend a bit of time in an NGO, but it's quite common for them to then to head to a state or Commonwealth government funded position. We can't offer the same length of permanency with funding contracts that are only two to three years in length.
6.56
Beyond Blue advised that a three-year minimum contract length is critical for NGOs to meet community demands and for sector reforms to be effective in meeting their objectives.
6.57
Witness comments align with findings of earlier reports. Action 17.1 of the Productivity Commission Report recommended the extension of minimum contract terms to improve the availability of psychosocial supports:
As contracts come up for renewal, commissioning agencies should extend the length of the funding cycle for psychosocial supports from a one-year term to a minimum of five years. Commissioning agencies should ensure that the outcome for each subsequent funding cycle is known by providers at least six months prior to the end of the previous cycle.
6.58
Recommendation 3 of the Report of the PHN Advisory Panel on Mental Health (PHN Advisory Panel report) – which was formed to develop advice to the Minister for Health – similarly recommended this extension of minimum contract terms to PHN contracts:
As a matter of priority, provide PHNs with contract certainty (5 years) to allow more considered and timely planning, workforce development, and more appropriate commissioning cycles.
Provisions should include a mandatory 12 month notice period if PHNs will be discontinued in order to avoid ‘end of contract’ uncertainty, which invariably affects service stability.
Reviewing the Primary Health Network-model, its commissioned services and national standards
6.59
Various stakeholders have called for a review of PHN commissioning focusses, as they can introduce unnecessary complexity into the commissioning of national programs and fragment evidence-based practice.
6.60
StandBy petitioned for a continuation of its single funding agreement with the Commonwealth in light of the National Agreement, identifying, before the Committee, several concerns with a proposed PHN-commissioned arrangement:
StandBy, with the national expansion that we have been funded to deliver over the last several months, have developed a comprehensive national architecture which ensures that there is consistency, uniformity and fidelity across the country, no matter where you live, to the evidence based StandBy model that we base all of our services on. We're concerned that that will be lost through separate commissioning processes around the country in each Primary Health Network.
6.61
StandBy also raised general concerns with requiring national programs – like Beyond Blue’s postvention program (The Way Back program) – to be commissioned across 31 PHNs, identifying that:
… it creates inefficiency due to excessive commissioning activities, inconsistencies in approaches across PHNs, and fragmentation of the national coordination StandBy has developed.
6.62
This criticism of the PHN model as it applied to mental health was reinforced by Professor Patrick McGorry, appearing before the Committee on behalf of Orygen. Professor McGorry labelled the approach as being ‘deeply flawed’, due to an inability to guarantee standards of care with a devolved commissioning structure. Professor McGorry contended that:
There is an argument for local provision of services. I've said it's more like an 80-20 rule, 20 percent variation. But, basically, the needs of people around the country are very similar, and services have to be based on the best available evidence and team based care. We have those models, but PHNs have currently got the ability to mess with them, and many of them actually have … We need to … have a much more centrally commissioned mental health system. I note that New Zealand has been taking that step in recent months, to recentralise the commissioning of mental health care and health care more generally. That's not to say there isn't a role for PHNs, but it certainly can't be the role, in my view, that they've currently got.
6.63
These criticisms are not new. In 2018, the PHN Advisory Panel report identified some of these issues, recommending that government, in consultation with PHNs, review the types of services and activities that would be more efficiently and effectively managed nationally, rather than by PHNs individually.
6.64
Further, the PHN Advisory Panel report recognised the need to manage regional disparities in evidence-based care, recommending that government:
Commission the development and implementation of minimum standards for evidence-based practice which include guidelines for trialling new service models. This could foster and support the important role of PHNs to develop innovative service models and ensure that clinical risks are managed.
6.65
Contrary to the evidence heard from stakeholders during the inquiry, Action 23.6 of the Productivity Commission Report recommended more funding control for PHNs. The reform would permit PHNs to redirect funding hypothecated to particular providers to alternative services, where they are not meeting the service needs identified in regional plans.
6.66
Orygen’s submission raised significant concerns with Action 23.6:
Orygen strongly disagrees with this recommended action. In our feedback to the draft report, Orygen stated that this approach ignored and contradicted the evidence base and global scale-up of youth early psychosis programs and models of care and would put the future of these programs at considerable risk. As a result, there would be a gradual erosion and fragmentation of these models, replacing them with disparate elements of service provision and components of care being delivered by different providers. This would leave young people and their families with the impossible task of negotiating services, exacerbate service and geographic gaps and deliver an inconsistent quality of care.
6.67
Jesuit Social Services highlighted issues from having fragmented funding sources, including increased administrative complexity, workloads and costs, as well as onerous reporting obligations:
… dealing with four funding bodies is very bureaucratic. We're funded across much of Victoria. We used to be funded directly from the Commonwealth. Now we are funded by four. In the first year of the primary health networks I was doing two reports. The next year I was doing 22 reports. There are different reporting regimes and different templates. There are budgets, activity work plans, reporting and financial acquittals for four funding bodies now, rather than one. That is actually the challenge. A lot more time has needed to go into that administration. It would even be better if there was some uniformity in terms of the reporting and the templates et cetera, but there isn't. They're each developing their own identity, which probably has its own strengths. But, for a service provider, it has challenges.
6.68
Jesuit Social Services further outlined that as its budget amount for management expenses is a fixed percentage (10 per cent), any broader administration, evaluation or management outside of that funding threshold simply does not happen.
6.69
The Pharmacy Guild of Australia called for clearer lines of organisation in PHN’s commissioning, stating that the devolved funding structure has created disparate levels of commissioning quality, and that it is unclear where some of the funding that is directed at mental health goes. The Guild further outlined that:
Without picking on PHNs, some pharmacies have a good relationship in a PHN, but there would be pharmacists in other PHNs that could not tell you what they do. It's unclear where a lot of the funding and channelling through PHNs goes. I think there has been a bit of streamlining into some of the GP related professions in PHNs. It's marginalised some of the pharmacies in primary care and also in the allied health space as well.
Committee comment
6.70
While many examples of collegial PHN-LHN relations and effective alliances were provided to the Committee, it is clear that this is not the case for every jurisdiction. Collaborative efforts between PHNs and LHNs are required to achieve desirable regional outcomes.
6.71
Effective oversight is essential for enabling a degree of PHN funding flexibility, while also reducing regional outcome disparities and ensuring proper commissioning activity.
6.72
The Committee recognises the importance of oversight, and supports both stakeholder recommendations and Action 23.1 of the Productivity Commission Report, for the National Mental Health Commission (NMHC) to take on oversight responsibilities of PHN-LHN collaboration.
6.73
The Committee recommends that the Australian Government provide legislative authority to strengthen the independence of the National Mental Health Commission, with a designated task being to monitor and report on compliance by Primary Health Networks and Local Health Networks against their commitments.
6.74
The importance of regional commissioning flexibility links directly with regional services being able to immediately respond to regional needs, as they change with demographics and the impacts of national and natural disasters.
6.75
PHNs can be supported to effectively complete this work through the development of flexible funding pools to ensure the effective implementation of regional plans.
6.76
However, the Committee is concerned that too much flexibility in commissioning may be detrimental, leading to quality and evidence-based inconsistencies between regions, so these funding pools must have reporting and approval requirements.
6.77
The Committee recommends that the Australian Government review the commissioning constraints on Primary Health Networks to ensure that the implementation of regional plans providing for regional mental health and suicide prevention services can reasonably be delivered.
6.78
The relationships between contract length and sustainable service delivery, the capacity for evaluation and reporting, service quality, and workforce attraction, are interconnected. Therefore, there is an identifiable need to improve the minimum contract length for mental health and suicide prevention services.
6.79
A transition to longer contract lengths should see the addition of equivalent longer term reporting and accountability measures factored into funding agreements to improve data collection and outcome evaluation.
6.80
The Committee recommends that, in line with stakeholder and the Productivity Commission Report recommendations, the Australian Government:
fund Primary Health Networks (PHNs) for mental health and suicide prevention services on five year cycles
transition mental health and suicide prevention services provided by non-government organisations to five year funding contracts
require PHNs to commission mental health and suicide prevention services on five year contracts
strengthen long- and short-term outcome reporting requirements to enable continuous service evaluation in response to increasing the length of contracts and funding cycles.
6.81
The Committee does not support Action 23.4 of the Productivity Commission Report that suggests the consideration of new commissioning models, noting the threat that this poses to another system reset.
6.82
Nationally coordinated and delivered services with high levels of national standardisation and shared evidence bases, like the Way Back Support, StandBy and headspace services, should retain their singular contract arrangements with the Commonwealth to avoid discrepancies in the delivery of care, and to avoid unnecessary complexity in service commissioning.
6.83
Therefore, the Committee supports Recommendation 16 of the Report of the PHN Advisory Panel on Mental Health for a review of the decision to devolve commissioning for previously nationally-coordinated, single contract services.
6.84
The Committee recommends that the Australian Government review the types of mental health and suicide prevention services that would be better delivered nationally, noting the importance of having strong national standards of care, quality, and evidence-based practice in service delivery, as well as reducing the burdens of unnecessary commissioning complexity.
The Medicare Benefits Schedule and the Better Access initiative
6.85
The MBS is a listing of the Medicare services subsidised by the Australian Government, and the Better Access initiative gives Medicare rebates to improve access to mental health professionals and care.
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The Department of Health has commissioned the University of Melbourne to evaluate the Better Access initiative. The University of Melbourne will partner with the University of Queensland, Deakin University, the Australian National University, LaTrobe University, Monash University and NovoPsych to complete the evaluation. The evaluation will start in August 2021 and it is expected to be completed in June 2022.
Reform to address access barriers
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Various stakeholders identified a range of barriers that have limited individual access to mental health and suicide prevention services that are funded through the MBS rebate system.
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Affordability of services was an identified barrier to care, with NMHC contending that:
Probably one of the most challenging realities for people in Australia is the significant gap payment that is associated with any MBS rebate. I don't believe there's a simplistic answer to that in the form of just changing the payments. I think much deeper analysis is required. That certainly affects affordability.
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The Australian Counselling Association (ACA) referenced the Productivity Commission Report findings, evidencing that:
Essentially, there is a mismatch between the provision of mental health services under the Better Access initiative, which goes disproportionately to higher-income areas, and mental health problems, which occur disproportionately in lower socioeconomic and regional and rural areas.
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Affordability and access issues were raised in the Australian Psychological Society’s (APS) submission, recommending the government introduce bulk-billing incentives for consumers facing financial hardship, and incentivise telehealth service provision in rural, regional and remote locations.
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APS further elaborated on these concerns, contending that:
Currently within the medical streams of the MBS there are actually systems that allow for bulk-billing incentives. That would mean that those who are low socioeconomic and can't necessarily afford gap payments are supported within the system broadly across all those who can provide service within the MBS. They're supported by bulk-billing incentives to allow them to afford that gap and provide it to those in need. It allows for a connection between the group that is most vulnerable and in need and the capacity of the system to provide that service. The second element of it is rural incentive programs. We know that that works very well within the medical sphere to actually allow for the delivery of services in those locations and to encourage and incentivise them. Currently those types of things have not been applied within the current MBS system to do with mental health. I think that that would be a huge change that would actually increase access.
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MBS reform for increasing access to allied health professionals was raised by ESSA, Dietitians Australia and Speech Pathology Australia (SPA), who identified that a lack of MBS items prevents exercise and sports scientists, accredited practicing dietitians and speech pathologists from privately treating individuals and groups with mental health disorders, unless via chronic disease management plans.
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Dietitians Australia also argued that:
… only five visits per year are Medicare rebatable for those on chronic disease management plans, and these visits are shared amongst 14 different allied health professions. This allowance is vastly inadequate to provide meaningful treatment outcomes.
The two-tier MBS rebate system
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Currently the MBS system for accessing psychologists is provided through two rebate tiers (the two-tier system). It maintains a higher rebate for psychologists with clinical endorsement and a lower rebate for registered psychologists, including psychologists with qualifications in the other endorsed areas. For example, a session of psychological assessment or therapy of at least 50 minutes would see:
Clinical psychologists claim under MBS item 80010 with the service valued by Medicare at $152.40, this carries an 85 per cent benefit so the MBS rebate available is $129.55.
All other registered psychologists claim under MBS item 80110 with the service valued by Medicare at $103.80, this carries an 85 per cent benefit so the MBS rebate available is $88.25.
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The Australian Association for Psychologists Inc (AAPi), argued that there should be a raised, one-tier, $150 rebate for clients of all registered psychologists, identifying that:
… the current system, which has psychologists and clinical psychologists on two different rebate levels, is financially affecting the public, consumers, and making services unaffordable for many.
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AAPi calculated that, given the significant costs for registration, insurance, professional development, supervision, equipment and administration required, the hourly income of a registered psychologist seeing five or six bulk-billing clients per day is approximately $23 per hour. This reiterates that the capacity for psychologists to bulk-bill services without an increase in rebate or additional financial support is low.
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AAPi also identified that having a two-tier system has led to professional discrimination across the MBS, employment opportunities, scope of practice and funding. AAPi further contended that:
We see this played out in places like Centrelink, where you need a report from a clinical psychologist to open up a disability support application. We're restricting consumers with a disability to the 30 per cent of psychologists who have clinical endorsement. Rather than allowing them to see someone who might have been treating them for five years to try to overcome their disability and get back into the workforce, we're asking people to go and see a clinical psychologist or psychiatrist for a few sessions and get a report for Centrelink. We see this is as inappropriate, and the best evidence would come from someone who's actively been trying to support them to overcome their issues.
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Dr Catriona Davis-McCabe argued that despite having advanced training and competencies in psychological therapy, counselling psychologists and other psychologists with areas of practice endorsement have been restricted by the Better Access initiative to provide focused psychological strategies and offer a lower rebate to clients. Dr Davis-McCabe recommended that:
… whilst the public absolutely needs access to clinical psychology, all areas of practice endorsement have a role in the delivery of advanced mental health services to the community. There needs to be a broadening of the higher rebates within Better Access to include areas of practice endorsement who do work with complex mental health.
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This perspective was supported by APS:
The APS's position has always been that a broader range of psychologists than those with clinical endorsement, particularly those who have additional training and expertise, should be recognised and included within the higher rebate. Adding other areas of practice endorsement to that higher tier would ensure that the public could have access to the expertise of the full diversity.
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Conversely, the Australian Clinical Psychology Association’s (ACPA) submission argued that clinical psychologists have high levels of expertise in mental health and that the rebate discrepancy was justified by clinician outcomes. ACPA supported its position with evidence from an American journal article published in 1995 by David M Stein and Michael J Lambert. According to ACPA, the research shows that practitioners with credentials have improved mental health outcomes. ACPA’s submission also contended that:
Paramount to effective service delivery is protection of the public through recognition of accredited training and allocation of expertise to the right level of intervention for patient needs, supported by the regulatory framework under which we work and upon which the National Law (2009) is founded. Compelling research evidence shows that experience alone does not make practitioners better therapists (e.g., Blow et al., 2016; Goldberg et al., 2016).
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Responding to a question by the Committee, the Department of Health explained that the two-tier rebate system for clinical psychologists and registered psychologists under the MBS was initially implemented on advice from the psychology profession, as referenced in the 2011 final report of the Commonwealth Parliament’s Senate Community Affairs Reference Committee's Inquiry into Commonwealth Funding and Administration of Mental Health Services.
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In 2012, the then government advised, in response to the Senate report, that it was committed to ensuring that patients have access to the most appropriate practitioners with relevant competencies. It stated that:
The issue of the two-tier Medicare rebate for psychologists under the Better Access program reflects the international benchmarks regarding qualifications, skills and experience in delivering psychological therapy services.
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The Department of Health further submitted that:
The Medicare Benefits Schedule (MBS) recognises different types of practitioner training in setting schedule fees. For example, medical practitioners working in general practice can also claim different rebate amounts for preparing a mental health treatment plan for treatment through the Better Access to Psychiatrists, Psychologists and General Practitioners through the MBS initiative (Better Access) according to whether or not they have completed accredited mental health skills training.
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APS identified that at present there are not any Australian studies available that compare the outcomes between psychologists with clinical endorsement and other psychologists. It further noted a lack of any outcome data collected on psychologists, recommending:
… the inclusion of outcome measures to get at some of the data. That certainly would be of interest when we're doing a mental health system change.
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NMHC’s submission affirmed a lack of outcome collection and outcome-based policy on mental health-related MBS decisions, outlining that:
The Commission shares concerns raised in reform reviews, including the Productivity Commission Inquiry and Victorian Royal Commission, that the availability of MBS items for psychology and psychiatry is not clearly linked to evidence on their outcomes, effectiveness, and successful 'dosage' of treatment.
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Further discussion on the importance of data collection to support decision making is included in Chapter 7.
The 10 session cap
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In response to the increased rates of mental health problems as a result of COVID-19, the Australian Government doubled the number of MBS-rebated psychological therapy sessions from 10 to 20 for eligible patients. Many stakeholders recommended this increase be permanently available under the MBS. AAPi outlined that:
It's also our position that more sessions need to be allowed under the MBS. We've seen that recommended across so many different inquiries. The review of the MBS, the Productivity Commission—they have all recommended that session numbers be increased. If we actually treat people with the amount of treatment they need then they won't be presenting back year after year, needing more access to the system and remaining unwell.
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This was further supported by APS , which also noted that the existing limit was not evidence-based:
The 10-session model does not allow for the delivery of evidence based care so those with higher needs are able to access curative treatment and therefore exit the system. We know that some people need 10 but also that there are others who need 20 and, for a small but really important few, up to 40 sessions in a year. We would never, ever cut access to evidence based levels of medication or cancer care the way that we do for mental health care.
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APS explained how this session cap has translated into conflicting service delivery objectives:
I have to say, practising on the ground is one of the hardest things when I am trying to pace out sessions and see people once a month or when you're dealing with a child case and you want to consult the parent and none of that is allowable within the system. I can't see a strong reason for it. The data presented within some of the MBS forums has very clearly shown that the funding decision around it seems to be at conflict with what is actually in the best interests of the patient. Not everyone needs all of those sessions, absolutely, but, for those that do, creating an artificial limitation within the system is not the best idea.
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SAGE Australia referred to the 10 session cap as a ‘sticking plaster approach’ to mental health and suicidality treatment.
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The ACA suggested that some individuals may transfer to counsellors because there is no gap fee, a consistent price and the capacity to see a mental health professional without the restriction of 10 or 20 sessions.
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Professor Brin Grenyer advised that for individuals with complex disorders, such as personality disorders, there are access issues caused by having a limit of 10 MBS-rebated sessions and reliance on MBS-funded mental health professionals:
The No. 1 complaint of people with personality disorders is getting access to trained and skilled practitioners. Unfortunately, state funded health services and community mental health services can only go so far with programs … for this particular disorder, we need 40 sessions a year and that 10 sessions or even 20 sessions are a challenge. For lots of the patients that we consult, it's now August and they've run out of sessions, so they're facing quite a few challenging months without their psychologist.
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APS raised concerns about the requirement in mental health plans to complete a rebate review by returning to the general practitioner (GP) at session six, as well as session 10, suggesting these act as a friction point and result in treatment drop out. APS’s submission recommended ‘changing the requirement for GP reviews from six sessions to ten sessions’:
Psychologists are experts in the assessment, diagnosis and treatment of mental health disorders, and are able to determine the needs of their patients and make appropriate recommendations to referring GPs. Reviews after six sessions are often administrative, rather than clinically necessary, and place an additional financial burden on the MBS and are a misuse of GP's time.
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Metro North HHS observed that despite the Commonwealth’s pandemic response doubling the number of sessions available through the MBS, access to private providers actually became worse during COVID-19:
… whilst it is good if you've got those 20 sessions, [it] effectively halved the access for people, because the number of psychologists, for example, hasn't gone up. We will have waits in our health service, whether it is in the public system or the private system, of six to nine months unless you are very acute, so there is a whole systemic issue of availability and access. It is just not there.
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This was reiterated by Brisbane South PHN and headspace. headspace explained that:
Perhaps one of the unintended consequences has been that—we were talking about the same supply of the workforce—one person having 15 to 20 sessions means that you're spending less time seeing those who come into the system, so it's a double-edged sword in some ways. It's a hard one because it was absolutely the right decision to extend the sessions, but the supply of the workforce means that people who are now coming into the services may not have access to the same numbers of workforce who are able to see new clients.
Better Access for counsellors and psychotherapists
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Chapter 5 discussed the training and regulatory requirements for mental health professionals, and noted that counsellor and psychotherapist are not legally regulated titles in Australia. Appearing before the Committee, the ACA noted that despite counsellors and psychotherapists being tertiary qualified and accredited, the services that they deliver are not recognised under the MBS. The ACA recommended:
… that an item number be either added to the Better Access scheme at the tier 1 rate or created outside the Better Access scheme within MBS for counsellors to deliver psychological therapies independently from Better Access.
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This recommendation was supported by the Psychotherapy and Counselling Federation of Australia, who argued that if qualified counsellors were given Medicare item numbers, the profession would be able to greater support the mental health of the Australian community, workforce shortages and telehealth delivered care:
… before Better Access in Australia, GPs would refer to counsellors or refer to psychotherapists. Since Better Access for our psychologist colleagues, that suddenly equals mental health, and counsellors and psychotherapists, albeit equivalent parallel training, seem to have been kind of left off the list. But, internationally, counsellors are standing alongside psychologists. Psychotherapists internationally are standing alongside psychologists.
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The ACA contended that a large proportion of its members had indicated that they would look at bulk-billing were they to be given Medicare rebates, particularly in low socio-economic regions.
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The capacity for accredited counsellors to increase the access for at-risk populations to supportive mental health care was also recognised. SAGE Australia outlined that equipping the 14,000 qualified counsellors and psychotherapists in Australia with MBS numbers would contribute to the scaffolding approach required to support sex and/or gender diverse (SGD) mental health. SAGE Australia’s submission further contended that:
This will allow for greater immediate early intervention for suicide prevention in sex and/or gender diverse groups of people. Members of those registers who are from SGD groups can create quicker and greater rapport with those clients, offering faster suicide prevention.
Reform to general practitioners and general practice
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In response to concerns that mental health treatments plans prepared by GPs were being completed to a low standard, the Royal Australian College of General Practitioners (RACGP) argued the issue stems from the low remuneration value of their completion. RACGP identified that the remuneration is approximately half that of a chronic disease management plan, providing a low incentive given the work involved in assessment and treatment planning.
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This was also recognised by the Australian Medical Association (AMA), which recommended that:
… government should also think about the fact that mental health consultations with GPs are actually funded at a lower level than physical health consultations of a similar complexity. That seems rather difficult to understand, if you acknowledge the burden of disease that is present in mental health …
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To improve patient rebates to support mental health care, and coordination of mental health and physical healthcare by GPs, RACGP recommended within its pre-Budget submission 2021-22 an improvement to MBS funding, outlining that:
As a first step, patient rebates for mental health care and physical healthcare should be aligned … For example, unlike general consultation items, there is currently no unrestricted item for patients to spend more than 40 minutes with their GP discussing their mental health.
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Another factor identified as hampering quality mental health treatment by GPs is that Medicare does not permit multiple treatment items to be used on the same day. As a result, GPs are either required to complete the work with no remuneration or request that the patient return on another day:
This is because, understandably, the government is trying to exclude inappropriate use of Medicare. But what they inadvertently do is disadvantage doctors who are trying to do the right thing. They design a system to protect against misuse but, in so doing, punish doctors who are trying really hard to meet a group of very vulnerable patients who otherwise would not get the care.
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Appearing before the Committee, AMA explained the ramifications of a model that is primarily funded for episodic care:
In fact, the funding mechanism directs GPs to frequent low-complexity care as being more financially rewarding and therefore more sustainable for a bulk-billing practice than dealing with patients with various chronic diseases, including, of course, mental health. So we need to work a way for our system to change—to actually support GPs, both financially but also in all the other ways that have just been described, to actually deliver the care the patient needs, rather than what the system wants to pay.
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RACGP identified that while there is an opportunity to expand mental health services with GPs delivering focused psychological strategies, the structure of Medicare funding does not support this. RACGP explained that GP delivery of focussed psychological strategies cuts into the 10 counselling sessions available to patients via the Better Access initiative with other providers:
This is actually counter-intuitive, in terms of the stepped care model. The stepped care model is meant to be that the GP offers some more simple interventions—lower intensity things like the ones I just described—and then has the option of referring patients on to more intense psychological interventions if the patient isn't making progress … So, most of us who are trained in this are reluctant to use the item numbers, even though we're trained to do so and even though it seems, on paper, that there's an incentive to do this training.
Reform to funding for case conferencing and multidisciplinary approaches
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APS recognised the importance of an integrated approach to mental health care, noting that current limitations within the Better Access program have resulted in mental health remaining the poor cousin of physical health:
We would like to ensure telehealth, digital and online services, as well as multidisciplinary case conferencing, are integrated within the system. The current one-size-fits-all approach is hugely problematic.
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The Committee heard the capacity to effectively and sustainably implement multidisciplinary teams is strongly tied to how funding mechanisms incentivise multidisciplinary approaches and case conferencing. NMHC identified this, stating that:
The MBS rebate system, whilst it will rebate different disciplines and whilst it will rebate where there has been case conferencing, that is purely at the election of those professions who may be claiming those rebates. Multidisciplinary approaches—coordinated, integrated approaches—shouldn't be optional. They actually need to be a core component of how services are delivered. Unless you have a funding mechanism which requires that, you are not really matching your funding mechanism to what you are fundamentally trying to do in terms of your service delivery.
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Similarly, the Back Dog Institute argued that the Australian mental health system does not support multidisciplinary approaches:
We know from international studies that works, but the Australian system incentivises away from that style of collaborative care … For psychiatrists and clinical psychologists, the incentive is really to keep seeing patients they already have rather than to take on new patients and to genuinely share the care with GPs.
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The Black Dog Institute advised that it has been developing a model of collaborative care that would suit the Australian system, which has just begun its pilot. However, the same funding concerns remain:
… the reality is that's not going to be able to be used at scale without changes to the way in which MBS numbers work, so I think one of the solutions is going to have to be to look at the MBS numbers and to have new numbers that encourage collaborative care.
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The Consumers Health Forum of Australia were of the view that general practices should be funded to fully manage and coordinate mental health care, by being able to offer, negotiate and manage consumer movement between lower- and higher-level treatment options.
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RANZCP asserted that the MBS could assist in the connection of multidisciplinary practices and virtual care. RANZCP stated that:
If you were establishing a private practice, there would be incentives available to you if you had other professionals come and work with you. I think that is something worth exploring. I think it is possible to have substantial opportunities for new as well as existing practices, to say, 'If you have another professional work with you, there are some incentives available to you.' This will encourage that.
The other thing that needs to happen is virtual multidisciplinary care, allowing reimbursement for case conferences and discussions between those professionals who provide that multidisciplinary care for the person who is at the higher end of complexity and challenges that they are experiencing. We refer to multidisciplinary care. There are a lot of people who would benefit from seeing their professionals and having regular communication with their professionals, but there are some who need to go to that next level for a truly integrated multidisciplinary care.
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APS argued that it is difficult for mental health professionals to work in a multidisciplinary manner for the benefit of a patient when there is no system support:
That's particularly problematic for child and family cases, where you really want to work with the system around a child to get the kind of change that you'd like to see. At present, our MBS system doesn't support proper consultation. I think that's integral to getting a system that works together, to get the best outcome for the patient.
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SPA highlighted that most clinicians are willing to take part in case consultations, but the current lack of funding through the MBS for mental health treatment case conferencing is a barrier.
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The Pharmaceutical Society of Australia advised that:
There's a positive recommendation from the MBS Review Taskforce to incorporate pharmacists as allied healthcare professionals who could be reimbursed through MBS for their involvement in mental health care. The Better Access program excludes pharmacist participation in a funded manner within case conferencing. One recommendation would be to make sure that pharmacists' participation and their legitimised role within the case conference are more recognised.
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The National Mental Health Consumer and Carer Forum (NMHCCF) recommended dedicated MBS items for all health professionals to engage families and carers in case conferencing:
… currently there is no financial incentive, I would say, for the inclusion of family members in discussions, even around the planning of treatment. So, for there to be an incentive for the inclusion of family members, even to have those meetings without the consumer present to obtain the family perspective, currently there is no mechanism for that to happen. So, as a family member, you are at the will of the clinicians to engage with you.
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The Independent Private Psychiatrists Group’s submission queried specifically who the multidisciplinary team model should include, arguing for further clarification of the key participants, and how often a multidisciplinary focus should be embedded in ongoing treatment.
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The Independent Private Psychiatrists Group suggested a flexible model of multidisciplinary collaboration with investment in a strong clinical governance structure, and psychiatrists to lead the complex treatment with clear handover points. The Group further outlined that:
At an appropriate stage in treatment, the ongoing care would be handed over to another team member, who could be the GP, a mental health nurse, a psychologist, or other allied health worker - but with ongoing input via consultations for the consumer, with the psychiatrist. At times, two or three members of the multidisciplinary team may be actively consulting with the consumer. But mostly, the consumer would see just one team member predominantly. These teams would be bound together with local ties of trust from working with each other over time, and by regular consumer focused team meetings, but on a less frequent schedule than in institutional teams.
Committee comment
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There are significant concerns about the trend outlined within various reports that the lowest access to MBS item numbers also correlates with the lowest socio-economic demographics. The Committee recognises that this is at odds with the purpose of the MBS system in supporting broad access to health services.
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APS’s recommendation to expand bulk billing incentives, like those available to rural and remote working GPs, to support individuals experiencing financial hardship was particularly persuasive.
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The Committee agrees with NMHC that coordinated, integrated approaches need to be the standard rather than be optional, and need to be core to multidisciplinary service delivery. In addition to identifying and promoting best practice for digital services, the MBS should support the use of these tools by all professionals involved in treatment. Chapter 4 refers to the importance of integrating digital services to support coordinated care.
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The Committee is also concerned by the lack of patient outcome data and outcome evaluation for psychologists, psychiatrists and GPs in the delivery of mental health care, to guide policy decision-making and MBS rebate amounts. The lack of any recent Australian study proving an outcome disparity, and thus justifying the rebate distinction between clinical psychologists and other psychologists, is a concern.
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While acknowledging the call for counsellors and psychotherapists to be recognised under the MBS, the Committee considers there is a need to address the regulatory framework in which these professions operate before making any additional recommendations in this regard. See the discussion on regulation in Chapter 5.
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The current annual cap on MBS-funded sessions with a psychologist does not support the effective delivery of evidence-based care for complex presentations. This can prevent individuals from receiving sufficient treatment and instead see them exit the system. This increases long-term costs for the individual, for the sector and for governments.
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The current cap also results in drop-outs by requiring excessive GP review of patients, impacting the delivery of treatment by psychologists, and reducing the quality of treatment for complex mental illnesses. Reform should ensure treatment is patient-oriented, with the number of sessions to be determined by a mental health professional, such as a GP, psychologist or psychiatrist in the interests of the patient’s health.
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The Committee calls for a change to the GP referral system for psychological services to match that of other health professionals, with a 12 month referral. This should be supported by digital services to track patient outcomes and reduce the need for patient/ GP review sessions. This will improve patient outcomes, communication between referrer and referee, and efficiency and reduce administrative burden. This will also prevent interruptions to treatment, and reduce the risk of the patients dropping out.
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The Committee recommends that the Australian Government’s evaluation of Better Access, and reform of the system, focus specifically on:
the viability of bulk-billing incentives available to general practitioners (GPs) being similarly made available to mental health practitioners for the treatment of mental illness, where there are patient affordability constraints
the two-tier system impacts on treatment access, appropriateness and affordability of psychological care
including psychologists with other areas of endorsement (non-clinical endorsement) on the higher rebate tier, noting that this will increase access to specialists, address non-clinical endorsement disincentives and support the diversity of the psychological workforce
the value of extending the annual cap on psychologist sessions, to ensure evidence-based delivery of care for complex presentations to increase affordability for people experiencing serious and/or complex mental illness
the GP referral system for psychological services, including a valid 12 month referral:
utilising digital services for treatment to track patient outcomes
with a limit of two GP review sessions – an initial Better Access assessment/ referral and another after session 10 (to assess if another 10 sessions with the current provider is appropriate).
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The Committee supports the recommendation within RACGP’s pre-Budget 2021-22 submission, for mental health care rebates to be equated with the rebates for physical health, and recommends that rebates for mental health treatment plans be valued at the same rate that chronic disease treatment plans are.
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The Committee recommends that the Australian Government reform the Medicare Benefits Schedule to ensure that the completion of mental health treatment plans and consultations by general practitioners for the management of mental illnesses have the same rebate value as chronic disease management plans and physical health consultations.
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In September 2021, it was announced that MBS items 10955, 10957, 10959, 82001, 82002 and 82003 will be added to the MBS, in accordance with the Health Insurance Legislation Amendment (Section 3C General Medical Services – Allied Health Case Conference) Determination 2021. Available from 1 November 2021, these items will provide rebates for allied health participation in chronic disease management and autism, pervasive developmental disorder and disability case conferences.
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The Committee commends the Australian Government’s decision to expand case conferencing MBS items for allied health professionals to chronic disease management and autism, pervasive developmental disorder and disability case conferences.
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The Committee recommends that the Australian Government add Medicare Benefits Schedule items to support case conferencing in the treatment of mental illness for:
allied health professional attendance, for example psychologists, pharmacists, social workers, occupational therapists, exercise physiologists, and speech pathologists
health professional attendance, for example general practitioners, mental health nurses, and psychiatrists
mental health professionals to support the attendance of carers and families.
Community and culturally-based services and programs
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The importance of sufficiently funding community and culturally-centred initiatives and organisations, particularly for at-risk communities, was raised by various stakeholders.
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Appearing before the Committee, the Australian Rural Health Education Network recommended that governments invest in the social infrastructure of rural and remote communities:
While people will often present to their GP in the first instance, it's the local sporting clubs, the other community facilities or the strength of the school where often they will find support or advice which may connect them or may assist them to support themselves during a period where they may not entirely be well.
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RFDS raised concerns about gaps in commissioning pathways for community and cultural initiatives, where the portfolio of responsibility is not clearly defined. This was identified within the context of RFDS’ Guiding Rural Outback Wellbeing (GROW) program:
Is it an education program? Is it an economic development program? Is it a social connectedness program? Is it a mental health program? Is it something else? That's the great strength; it's also the great weakness because, when you look to fund a program like that, who's going to fund it? Is it really education or are they going to say it's mental—I think that those integrated programs on the ground are probably some of the most productive and some of the most challenging in terms of ongoing funding.
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There was broad agreement amongst stakeholders on the importance of funding public community services and grassroots NGOs in supporting multidisciplinary, evidence-based, and ongoing mental health care in a way that private MBS services cannot. According to WAAMH:
The focus of all levels of government is very much on current implementation of clinically based supports. The need for community based supports around providing recovery is really the area that we think needs to be given attention in new areas of reform. Evidence on this is very clear that we need new funding to be injected in this. It's not possible for us to remove funding from other parts of the system, because of the levels of crisis that are currently presenting.
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Professor Sachdev affirmed the importance of appropriately investing in community services, noting that people who have been hospitalised for mental illness are often discharged quickly and hospitals are not structured to deliver ongoing care in the community.
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Appearing before the Committee, MYST outlined the impacts that COVID-19 has had on the capacity of grassroots organisations to meet the increased demand within the constraints of funding:
The young people we provide support to have been experiencing an increase in suicidal ideation since the pandemic began. Sixty-two per cent of our individual clients had suicidal ideation in 2019, which increased to 92 per cent in 2020. We have also seen an increase in young people contacting our service—on average, seven new referrals a week. Worryingly, given MYST's resourcing levels, we are having to turn young people away. This, coupled with the increase in suicidal ideation, may have significant impacts for our local community.
Culturally and linguistically diverse community organisations
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Despite higher vulnerability, culturally and linguistically diverse (CALD) communities can be supported to improve mental health and suicide prevention through funded community solutions and organisations, and by investing in programs for cultural engagement.
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Within the 2021-22 Budget, the Australian Government announced a $16.9 million investment in mental health early intervention supports and preventative measures for migrants and multicultural communities, and initiatives to improve the cultural competence of the broader health workforce:
This includes continued funding in 2021-22 for the Program of Assistance for Survivors of Torture and Trauma, and support for Mental Health Australia to promote mental health among culturally and linguistically diverse (CALD) communities.
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To address mental health barriers like stigma, the Centre for Multicultural Youth (CMY) explained that the Australian Government can best support CALD communities by directing funding to local literacy programs and ‘empower the local organisations and the community members and work alongside them’ to reach desired outcomes.
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CMY’s submission identified the importance of a culturally-responsive local mental health system with staff professional development and transcultural approaches, a multicultural workforce, interpreter services, and engagement with young people, families and communities from multicultural backgrounds that they trust.
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NMHCCF’s submission highlighted a lack of workforce and funding support for CALD community carer organisations, identifying that:
Some of the Community Managed Organisations (CMOs) employ a few bilingual workers to work with some high number CaLD populations but they are barely able to address the issues. In some Local Health Districts/Local Health Networks with more than 40% of their populations from CaLD backgrounds covering several hundred languages and cultures – the service provision unfortunately doesn’t reflect that.
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NMHCCF’s submission recommended that government fund Local Health Districts to provision services to train and coordinate multi-lingual or multicultural carers, who can be shared state-wide between Local Health Districts to maximise talent and address demand.
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In its submission, CMY recommended that government:
Promote the mental health and wellbeing of young people from refugee and migrant backgrounds through significant investment in accessible sports, recreation, arts, youth support, leadership development and employment – opportunities that strengthen young people’s connections, social capital, ability to access support, and increase a sense of belonging.
Invest in co-designed youth suicide prevention programs that specifically target communities from migrant and refugee backgrounds.
Resource recurrent, co-designed mental health literacy programs with young people and communities from migrant and refugee backgrounds to reduce stigma and promote help seeking.
LGBTIQ+ and SGD community organisations
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SAGE Australia highlighted community funding as a key component of the ‘scaffolding approach’ required to improve mental health and suicidality rates within the SGD community. It noted that:
It has been the community support that has helped people, so the government needs to give money to community groups to help people with depression and suicidation.
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LGBTIQ+ Health Australia argued that continued investment into large-scale, generalist mental health services has meant that community-controlled LGBTIQ+ health organisations that desperately need investment to meet current demand and expand are struggling. LGBTIQ+ Health stated:
Now I've often said previously that you can judge our health by the health of our community-controlled organisations, and they're not in good health … So at the structural level I suppose what I'm wanting to get across is that we need a really cohesive process where we can see national investment. I mean, we don't get peak funding; we have a bid in at the moment, as do all those other organisations that are seeking that precious funding, but we need jurisdictional joined-up approaches so that we can see our organisations flourish across the country, because only when these organisations flourish will our communities flourish.
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Similarly, SAGE Australia noted the importance of providing grants and funding to community groups in conjunction with mainstream services, to avoid the reality of social ostracism and build local supports for SGD individuals who are suffering from suicidal ideation:
The danger zone when somebody is suicidal is 28 days after the first incident, when the brain begins to repattern itself. They need daily support for those 28 days, and only small local community groups can do that.
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The Trans Health Research Group explained that the mental health needs of the transgender community are not being met by mainstream services, with most relying on LGBTIQ+ organisations that cannot keep up with this demand. The Trans Health Research Group stressed an urgent need to expand and consider novel approaches for co-designed services:
… our vision and I think that of most people would be that trans people can turn up to their local GP or any psychologist or any mainstream service to access care, and ideally, trans people would be in a society where they can live, work, rent a house and go to the supermarket without any fear of discrimination or abuse. But we're not there yet, and so because we're not there yet, right now it's the community-controlled organisations that can work to prevent suicide and improve mental health and provide that peer support where people can go and get help and they know they'll be understood and be included and feel safe.
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Mind Australia in its submission explained that a lack of funding led to the closure of its Mind Equality Centre, a specialist counselling and support service, established to address the disproportionately high rates of mental illness in LGBTIQ+ communities and the lack of specialist mental health support for LGBTIQ+ people in Victoria:
The Equality Centre was funded almost entirely by Mind. Demand for the centre (approximately 95%) came from the general community through mental health treatment plans funded through the Medicare Benefits Schedule (MBS). However, 85% of clients were not able to afford the gap payment.
In August 2020, the operations of the Equality Centre ceased. This was due to a lack of government and other external funding, coupled with the complexity and vulnerability of the people accessing the service, making the model unsustainable.
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However, Mind Australia continues to operate Mind Equality services through the delivery of an aftercare program, funded by the North Western Melbourne PHN. The results of the aftercare program pilot evaluation (March 2020 - December 2020) showed the success of the program and the gap it could fill in the mental health system.
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Despite this, Mind Australia confirmed that the aftercare program is subject to the same funding uncertainty as many other mental health services.
Aboriginal Community Controlled Health Organisations
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The Kimberley Aboriginal Law and Cultural Centre (KALACC) underscored the criticality of funding culture within Aboriginal communities, identifying a need for long-term, sustainable funding and sufficient investment.
That's the biggest challenge for our communities. This is why we continue to have these gaps, I reckon, because, when you have good practice you have to keep it going, but they say, 'We're termed for only three years …’ whereas they could continue programs that have benefit and could evaluate them to keep them up to date with the latest information, but do it in the cultural context, including the elders and the young people, because that's the healing component coming in.
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KALACC also highlighted the importance of having appropriately funded cultural programs that connect to community directly in a co-design approach, noting the profound impact of the Yiriman Project for offending juveniles:
They took them out on camps, 10-day camps, and these young people that attended never reoffended. We all go back and say that we had a lot of gaps in program delivery. In my term of coming on KALACC, I've had some of the elders say, 'Well, if you didn't stop the funding then, we wouldn't have what we have now, where crime has just totally escalated and they're much harder to have to work with.' To me this two-year funding isn't enough. I would say have five-year funding and then do evaluations on it and then continue to build on that best practice to go forward.
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In its evidence, KALACC outlined that there is significant evidence identifying Aboriginal suicidality as a cultural issue not a health issue, referencing a number of publications including:
Culture wounds require cultural medicines, written by Professor Michael J Chandler in 2012
Learnings from the message stick report, published by the Western Australian Parliament’s Standing Committee on Health and Education in November 2016
My life, my lead report, published by the Department of Health in December 2017
Country can’t hear English, written by Kerry Arabena in June 2020
Culture is key, published by the Lowitja Institute in early 2021.
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KALACC acknowledged that despite this evidence-base, there are still no commissioning pathways for services in the social and cultural determinants of health. KALACC stated that:
‘If we are serious about reducing the suicide rate, we need to get serious about investing in language programs, we need to get serious about investing in ceremony, we need to get serious about investing in Aboriginal empowerment of their own culture.’ We don't want to turn this phenomenon of suicide. This is not a health issue. This is a cultural issue.
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AHMRC identified that in response to growing antenatal depression presentations within its member services, it has been building social and emotional wellbeing strategies and additional programs to support parents in health and culture. AHMRC highlighted that:
… the issue for us is that we don't get extra funding for those programs. Our services utilise their own self-generated income to develop these community based programs that are targeted for young women.
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Similarly, the National Aboriginal Community Controlled Health Organisation (NACCHO) stated that mental health, and social and emotional wellbeing funding is poorly coordinated and sits within different federal departments. NACCHO recommended:
… social and emotional wellbeing funding be moved to the Commonwealth Department of Health from the National Indigenous Australians Agency to ensure a more integrated approach to funding proposals.
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Further, Gayaa Dhuwi (Proud Spirit) Australia argued the importance of Aboriginal and Torres Strait Islander leadership across all parts of the Australian mental health system, including for funding arrangements, in order to achieve the highest attainable standard of care. Gayaa Dhuwi recommended:
Implementing The Gayaa Dhuwi (Proud Spirit) Declaration in all departments and importantly the Health Department and PHN service contracts/schedules, with KPIs that ensure Aboriginal and Torres Strait Islander people have access to clinical and cultural responses - the ‘best of both worlds’.
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The Royal Commission into Victoria’s Mental Health System acknowledged the need to support Aboriginal social and emotional wellbeing and recommended that the Victorian Government:
1
build on the interim report’s recommendation 4 to support Aboriginal social and emotional wellbeing, and resource the Social and Emotional Wellbeing Centre to establish two co-designed healing centres.
2
resource Infant, Child and Youth Area Mental Health and Wellbeing Services to support Aboriginal community-controlled health organisations by providing primary consultation, secondary consultation and shared care.
3
resource Aboriginal community-controlled health organisations to commission the delivery of culturally appropriate, family-oriented, social and emotional wellbeing services for children and young people.
4
resource the Victorian Aboriginal Community Controlled Health Organisation, in partnership with an Infant, Child and Youth Area Mental Health and Wellbeing Service, to design and establish a culturally appropriate, family-oriented service for infants and children who require intensive social and emotional wellbeing supports.
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The Australian Government announced in the 2021-22 Budget, a $79 million investment to address the devastating and disproportionate impact of suicide and ill-mental health on Aboriginal and Torres Strait Islander Australians. Key initiatives include funding for aftercare, regional suicide prevention networks, suicide prevention leadership, the Gayaa Dhuwi-Lifeline crisis line, and sector reviews, under a renewed Indigenous-led National Aboriginal and Torres Strait Islander Suicide Prevention Strategy.
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Appearing before the Committee, NACCHO acknowledged the Australian Government funding for Aboriginal and Torres Strait Islander suicide prevention and after-care services in the 2021-22 Budget. However, NACCHO noted that:
… there is no funding set aside for Aboriginal and Torres Strait Islander-specific prevention and early intervention services. NACCHO must play a lead role in identifying how this funding, as well as programs and services, will be rolled out across the country to ensure culturally competent access for Aboriginal and Torres Strait Islander people.
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In addition, NACCHO identified that social and emotional wellbeing teams within Aboriginal Community Controlled Health Organisations (ACCHOs) struggle to attract adequate and sustained funding, which results in individuals missing critical early interventions. NACCHO argued that often this progresses to individuals requiring more complex treatment, generally within hospital settings, resulting in worse health outcomes and increased costs to governments.
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In its submission NACCHO further argued that an integrated funding approach to Aboriginal mental health, suicide prevention, and social and emotional wellbeing would be beneficial for:
minimising staff costs and duplication
streamlining reporting and decreasing the reporting burden for ACCHOs
better coordination and integration of health and community services
maximising funding for service delivery.
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AHMRC explained that funding services through ACCHOs allows support services to be tailored to the needs of each community and reduces the disjointed care pathway:
A great example of this is the adequately governed project of the Building on Resilience initiative funded by the New South Wales government, in which activities are delivered directly to Aboriginal community controlled services, who create their own community controlled suicide prevention projects. There is a strong evidence base to indicate that Aboriginal communities respond better to suicide prevention activities that incorporate culture as a critical component.
Committee comment
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The Committee commends the Australia Government for the 2021-22 Budget’s investment in the mental health and suicide prevention services of Australia’s CALD and Aboriginal and Torres Strait Islander communities.
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LGBTIQ+ and SGD communities face significant mental health and suicide disparities when compared to the general population, and there is an apparent incapacity for mainstream services to meet this demand.
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The Committee is concerned by the closures of, and the lack of funding given to, LGBTIQ+ and SGD community-controlled organisations who currently struggle with funding instability and competitive tendering processes against large mainstream services.
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The Committee recommends that the Australian Government direct specific funding for LGBTIQ+ and sex and/or gender diverse community-controlled health services, community groups and programs to provide mental health and suicide prevention services that meet community needs.
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The importance of culture and cultural community programs to Aboriginal and Torres Strait Islander communities are significant factors that underwrite Aboriginal and Torres Strait Islander mental and physical health.
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The Committee is particularly concerned by continued investment in mental and suicide prevention health that does not appropriately factor in the social and emotional wellbeing or cultural needs of Aboriginal and Torres Strait Islander communities.
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This is undoubtedly leading to variable returns on investment, and there is a clear gap in the commissioning model that does not sufficiently fund culture-oriented community programs.
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The Committee recommends that the Australian Government formalise commissioning pathways for Aboriginal cultural programs, noting the significant relationship between cultural connectedness and Aboriginal mental health, suicide prevention, and social and emotional wellbeing.
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The Committee commends the Australian Government for its $79 million investment into Aboriginal mental health and suicide prevention within the 2021-22 Budget.
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The Committee supports the ‘best of both worlds’ approach for providing clinical and cultural responses, and calls for the Australian Government to further invest in Aboriginal and Torres Strait Islander leadership within the mental health system through fully implementing the Gayaa Dhuwi (Proud Spirit) Declaration.
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Proactive investment in early interventions for Aboriginal communities plays a significant role in maintaining Aboriginal health, and in reducing hospitalisations and health system costs.
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Therefore, the Committee supports government action to address the funding gaps in Aboriginal mental illness prevention, early intervention, and social and emotional wellbeing programs through ACCHOs.
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The Committee also supports the recommendation within NACCHO’s submission that:
Funding for Aboriginal and Torres Strait Islander mental health and suicide prevention services should be redirected from Primary Health Networks (PHNs) to Aboriginal Community Controlled Health Organisations (ACCHOs).
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Further, the mental health, suicide prevention, and social and emotional wellbeing funding portfolios need to be integrated within ACCHOs to improve coordination, and minimise costs and duplication.
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The Committee recommends that the Australian Government:
consolidate its funding portfolios to Aboriginal Community Controlled Health Organisations (ACCHOs) within the Department of Health for Aboriginal mental health, suicide prevention, and social and emotional wellbeing
ensure that Commonwealth funding for Aboriginal services is redirected from Primary Health Networks to ACCHOs, where available
ensure funding is sufficient for the full and rapid implementation of the Gayaa Dhuwi (Proud Spirit) Declaration.
Implementation
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Appearing before the Committee, NMHC argued that:
It's a well-known maxim that you can have very well developed theories, processes, strategies et cetera but they are only as good as the implementation of them … we certainly will be proposing that this should be included in the national agreement between the states and territories and the Commonwealth. But it is something we need to put on the table: what mechanisms are needed, how do we ensure that the implementation process is recognised, resourced and reported, and are there measurable consequences if things are not being implemented?
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Additionally, stakeholders have identified the importance and urgency in the Australian Government implementing the recommendations identified and repeated through the significant history of government reports, parliamentary inquiries, research papers and evaluations. The Salvation Army outlined that:
… we'd like to stress that we need action, but, more importantly, we need action now. Across our services, particularly in the emergency relief space, we're seeing an increase and a heightening of behaviours that would indicate a mental health concern. We are preparing for it to get a lot worse before it gets better.
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MHA’s submission recommended that the Australian Government should prioritise:
The development of an implementation plan for the PC Report’s [Productivity Commission Report] recommendations including any gaps identified in the other reviews and well informed by mental health consumers, carers, and the broader sector.
The provision of an accompanying budgetary plan that identifies the key components of the future mental health system, clarifies which level/s of government will be responsible for delivering each of the components, and articulates the Australian, state and territory governments’ commitments to fund these recommendations over a number of funding cycles.
Immediate investment to fund the PC Report recommendations that can be implemented immediately, and to ensure continuity of funding for the psychosocial service sector.
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MHA welcomed the funding announced for mental health and suicide prevention in the Australian Government’s 2021-22 Budget and acknowledgment that this was the ‘first instalment of their response to the PC Report’. While noting that implementation details were still to be released, MHA stated:
It is imperative that they engage consumers and carers early in the design and delivery of these new services and that there is broader sector engagement to ensure service integration and to inform appropriate accountability and evaluation processes.
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Other stakeholders called for any investment in mental health and suicide prevention to be coupled with long-term funding plans, outcomes and activity, to ensure that investments make a difference and support the continuity and sustainability of services.
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Similarly, Gayaa Dhuwi (Proud Spirit) Australia advised that:
Implementing the system-wide reform process proposed in the three policies, comprehensively and with a long-term commitment, would begin to address the targets and outcomes of the National Agreement on Closing the Gap and all the critical, longstanding disparities listed in the Indigenous health performance framework, including the rate of suicide for all Indigenous Australians being twice that of the general population and that Aboriginal and Torres Strait Islander people are 2.5 times more likely than non-Aboriginal and Torres Strait Islander people to have high to very high levels of psychological distress.
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Beyond Blue suggested that the implementation of reform that has been recommended to the government needs to be approached differently, on an iterative basis:
This is a really big and complex reform agenda and it's not possible to do everything at once, so for many measures, government should embrace iterative design and a 'try, test and learn' approach where it makes sense to do so. This way new ideas and solutions can be incubated and proven in stages rather than being delayed by overinvestment in the design phases that are not informed in real-time by results, user feedback and analysis.
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Stakeholders also identified that there is an immediate capacity for government to ensure mental health and suicide prevention policies are implemented by embedding them through all ongoing government procurement processes. MATES in Construction argued that while there is progress within workplace health and safety policies, incorporating suicide prevention and mental health outcomes within contracts:
… would actually drive best practice across diverse settings and would be a relatively low-cost way for government to be able to make significant impacts. That's something we've already seen. We've been part of having that happen in some parts of our industry and we've seen the benefits it has actually delivered.
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Similarly, Ms Christine Morgan, the National Suicide Prevention Adviser to the Prime Minister, argued that procurement is also a strong lever for government to ensure ‘lived experience’ representation within the creation and delivery of services:
… [it] is really calling it out to say, 'Please don't go into a contract unless the organisation that you're giving this to has demonstrated experience in engaging with lived experience.' It's that simple. Don't experiment with it.
Committee comment
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The need to begin action on the implementation of the ideas within the major reports cannot be understated, and the Australian Government has already begun aspects of the needed reform.
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Despite this, the Committee has also recognised a real sense of urgency for the successful delivery of an improved mental health and suicide prevention system at the grassroots, and developing stakeholder fatigue.
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Clearly, implementation needs to have a whole-of-government approach and accountability, and the evidence across the inquiry has identified a number of immediately actionable recommendations that would deliver this result with immediate impact.
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In the implementation of system reform, one of these whole-of-government levers the Australian Government has to enact system change is the terms of federal contracts in service commissioning and procurement.
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The Committee recommends that the Australian Government ensure:
under the Commonwealth Procurement Rules it is a condition for participation that any potential supplier demonstrate minimum standards of mental health support and care in their workplace
mental health and suicide prevention service commissioning activity requires services to reasonably demonstrate the inclusion of lived experience in service design and delivery.