Mental health and suicide prevention is a broad topic that intersects with most areas of public policy. However, this inquiry seeks to focus on mental health and suicide prevention policy and matters arising, as a result of events such as the 2019 bushfires and COVID-19 pandemic.
While it is too early for the Committee to draw conclusions or make recommendations at this stage, major themes have emerged which may be the subject of further investigation by the Committee as the inquiry progresses.
The major themes that have emerged as part of the inquiry to date are discussed in this chapter.
The terms of reference include inquiring into the roles, training and standards for all health and allied health professionals who contribute to mental health care, including peer workers, that are required to deliver quality care at different levels of severity and complexity, and across the spectrum of prevention, early intervention, treatment and recovery support.
A National Mental Health Workforce Strategy is being developed by the Department of Health and the National Mental Health Commission to consider the quality, supply, distribution and structure of the mental health workforce, and identify practical approaches for Australian governments to attract, train and retain the workforce needed to address demands of the future mental health system.
The Strategy is being overseen by an independent National Mental Health Workforce Strategy Taskforce. The Taskforce was due to provide initial recommendations to the Government by December 2020, with a final report due in June 2021; prior to endorsement by the Australian Health Ministers’ Advisory Council.
The National Mental Health Commission is developing a blueprint for the national direction of the mental health sector in Australia – ‘Vision 2030 for Mental Health and Suicide Prevention’. As part of the ‘Vision 2030’ project, focus areas for workforce improvement have been identified:
Supporting the multidisciplinary workforce, including peer and lived experience workers.
Enabling a multidisciplinary workforce to work to 'top of scope' through development of competency-based frameworks and standards, increases capacity, satisfaction and efficiency.
Improvements to mental health education and training, including the broader health and social service workforces and the mental health sector, starting with tertiary education.
Expanding the role of social services (including education, policing, justice, and drug and alcohol services) and addressing the social determinants of health (safe and secure housing, financial security, improving living standards, participation in education, and employment).
Taking an integrated and inclusive approach across all sectors and governments. Primary Health Services, Mental Health Services, Disability Services, Aged Care Services, and various social services all need to work collaboratively.
Improve staff safety and wellbeing to reduce stress and burnout.
Addressing culture, values, and attitudes in workforce development and training, standards and supports to reduce stigma and discrimination and increase early identification and compassionate support.
Focus on growing and sustaining the rural and remote workforce.
Look at opportunities to improve access to services and a broader range of allied health providers using technology and e-Health.
To ensure workforce strategies and plans are actioned in a coordinated, timely and consistent way with national oversight, the National Mental Health Commission also recommended the implementation of national leadership structures.
The Committee will consider the distribution of registered mental health professionals both geographically and across specialities, the role of professional bodies and recognition of the various mental health professions, and the drivers for workforce participation in the public and/or private sectors.
Capacity and shortages
The Royal Commission into Victoria’s Mental Health System report identified that for much of the mental health sector, demand has overtaken capacity. The Royal Commission acknowledged that:
The system is overwhelmed and cannot keep up with the number of people who seek treatment, care and support. This is evident at all levels, from individual mental health professionals to acute and emergency services.
The Productivity Commission suggested there were ‘multiple indicators of shortages’ in psychiatrists, particularly in the specialist areas of child, adolescent and old age. While it found no evidence of a shortage in psychologists, as with all clinicians, accessibility in remote and regional areas remained a concern.
The Productivity Commission’s report recommended that the Commonwealth, state and territory governments develop a national plan to increase the number and distribution of psychiatrists, with an emphasis on sub-specialities and rural and regional clinical practices.
Noting that general practitioners (GPs) are ‘often the key doorway’ for mental health, the Department of Health advised that it is trialling a range of innovative models to improve access to GP care in regional communities, for example:
…GP practices in regional communities linked with potentially state hospitals and different funding mechanisms—is MBS [Medicare Benefits Schedule] enough to actually attract people to those areas and provide those services?
The Victorian Royal Commission noted an under-supply of community-based resources, reporting a large gap between the number of hours of community-based services provided by public specialist mental health services and the estimated demand for those services.
Further, the National Mental Health Commission noted that supervision arrangements and arrangements for the care of mental health workers need to be strengthened to protect the existing workforce and prevent professional burnout.
The Committee remains concerned that in addition to identified workforce shortages in regional and remote Australia, there also appear to be acute shortages in fast growing population areas within Australia’s capital cities.
Training and education
The National Mental Health Commission, appearing before the Committee, noted that the inclusion of training in mental health across health professions may assist in addressing the gap in workforce capacity by enabling more individuals to contribute to the mental health sector. Examples included ensuring that mental health training for nurses and GPs is a core component of their education, instead of being optional.
The Department of Health highlighted work underway as part of the National Mental Health Workforce Strategy.
General practitioners remain the first point of contact for many people seeking support in relation to concerns around mental health. The Productivity Commission in its report recommended improving medical practitioners’ training both on medications and non-pharmacological interventions for people presenting with mental illness, to provide a wider breadth of options for care.
The Productivity Commission also recommended the development of a new curriculum standard for a three-year direct-entry undergraduate degree in mental health nursing, as well as a mental health unit to be included in all nurse training courses.
The Committee has received many submissions from members of the peak psychology associations concerning the distinction between clinical and non-clinical psychologists, and specifically training and professional accreditation. In addition to the discrepancy in Medicare Benefits Schedule (MBS) rebates, discussion centred on addressing qualifications to best serve client needs.
The Productivity Commission’s report noted a disproportional focus on clinical services, which led to the overlooking of other determinants of, and contributors to mental health – including the role of family, kinship groups and carers, and providers of social support services in enabling an individual’s recovery within their community.
The National Mental Health Commission, appearing before the Committee, stated that there are not a lot of mechanisms for supporting multi-disciplinary teams within the MBS rebate:
Under current MBS arrangements, there is not an ability to actually mandate [a multi-disciplinary team] and bring it together...probably the most effective way—and this is aspirational—you can drive clinicians in realising the importance of multidisciplinary approaches and what they can mean for somebody trying to manage their ill-health or illness is to bring in an incentive for a higher rebate if they will involve the consumer, or the consumer and carer, in that session, that rebate.
The Productivity Commission’s report found that co-located services can improve multi-disciplinary work by bringing together clinical and non-clinical services – i.e. co-locating physical health, mental health, drug and alcohol and/or vocational support services.
Within the 2019/20 Budget, the Australian Government announced that it would allocate $114.5 million over five years to fund the trial of eight walk-in community mental health centres, which will provide a range of mental health support services and integrate with other local community services.
The Committee has received a number of submissions calling for further review of the trend towards mental health ‘hubs’ (co-locating services) and specifically in relation to accessibility, the level of funding required to establish and maintain them, staff turnover, financial remuneration and funding model reliance on bulk-billed Medicare rebates.
The role of a peer worker is to complement the skills and expertise of mental health professionals. They are able to bring a level of understanding of what people using mental health services experience, assist with the navigation through what can be a complex system, and provide emotional and social support.
The Department of Health defined peer workers as those ‘with lived experience of mental ill-health or carers of people with mental ill-health’, and refer to the cohorts as consumer and carer peer workers, respectively.
The Department of Health, Productivity Commission and National Mental Health Commission have placed a strong emphasis on development of a peer workforce as part of multi-disciplinary teams.
The Department of Health recognised the risks related to a peer workforce operating with clients in isolation of trained clinical and non-clinical experts.
I think the peer workforce is an incredibly important and growing area of the mental health workforce. It's important they're part of a multidisciplinary team, have appropriate supervision and are dealing with the sorts of mental health issues that are appropriate for their experience and qualifications.
The Productivity Commission suggested that the Australian Government strengthen the peer workforce by providing once off, seed funding for a peer worker professional association, and collaborate with state and territory governments to develop a program educating health professionals about the role and value of peer workers in improving outcomes.
The Victorian Royal Commission recommended the establishment of a new agency at the state level:
…led by people with lived experience of mental illness or psychological distress, to support the development of organisations and services that are led by and for people with lived experience of mental illness or psychological distress.
Peer Workforce Development Guidelines are currently being developed by the National Mental Health Commission, under the Fifth National Mental Health and Suicide Prevention Plan.
Coordination and funding of services
The terms of reference include inquiring into the funding arrangements for all mental health services, including through the MBS and Primary Health Networks (PHNs), and whether they 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.
Responsibility for funding and regulating mental health services in Australia is shared between the Australian Government and state and territory governments.
According to the Australian Institute of Health and Welfare in 2018-19, $10.6 billion was spent on mental health-related services in Australia. While the amount spent on mental health continues to grow, the split in spending by the Australian Government, state and territory governments, and private health insurance has remained relatively stable at around 35 per cent; 60 per cent and five per cent respectively.
Noting that Australia has ‘a mixed model of public and private investment in health care and particularly mental health care’, the Department of Health advised:
…we’re working with the states and territories on how you provide more attractive interactions and connectivity in the system between the private and public system and how you make sure that professionals, in particular, can work across those systems at the appropriate levels and in the appropriate circumstances. So, at the broad level, absolutely we're looking at how to make the best use of the workforce that we currently have and the right ways of incentivising and working with them to make sure that, where they need to work in the public system, they have access to that.
In October 2020, the National Cabinet commissioned the Mental Health National Cabinet Reform Committee, and tasked it with advising the Cabinet on national coordination and implementation of the National Mental Health and Wellbeing Pandemic Response Plan, and delivering a new National Mental Health and Suicide Prevention Agreement by November 2021.
In December 2020, the National Federation Reform Council met, and through the National Mental Health and Suicide Prevention Agreement ‘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.’
Medicare Benefits Schedule and the Better Access initiative
The MBS covers a range of mental health services including those provided by GPs, psychiatrists, psychologists, and eligible social workers and occupational therapists.
The Better Access initiative gives MBS rebates to help people access mental health professionals and care, where and when needed.
According to the Department of Health, the Better Access initiative has substantially expanded the role of the MBS in the provision of mental health services, including most recently with the expansion from 10 to 20 MBS rebated sessions for people with diagnosed mental health conditions in response to the bushfires and COVID-19 pandemic.
The measure now provides 10 additional Medicare subsidised psychological therapy sessions for all eligible Australians experiencing a severe or enduring mental health response to the COVID-19 pandemic. This measure will be available until 30 June 2022.
A review of the MBS was released last year, which noted:
...a huge shift to longitudinal care of multi-morbidities including mental health. Many patients routinely require complex integrated care over time and across multiple providers.
The Committee is interested in hearing more about further MBS evaluations the Department of Health has underway, and will be looking how the MBS impacts the public-private nexus and whether MBS rebates incentivise mental health professionals to move from the public sector into private practice.
The Commonwealth, state and territory divide
A gap has been identified in coordination, funding and communication between Commonwealth, state and territory governments relating to mental health services.
The Royal Commission into Victoria’s Mental Health System report found that often the ambiguity regarding responsibilities and accountabilities between the state and the Commonwealth governments had negatively affected consumers through gaps and poor coordination of mental health services.
The Victorian Royal Commission recommended encouraging national partnerships and delineation of responsibilities of the Commonwealth and state governments. In addition, the Royal Commission recommended establishing a co-commissioning approach for Commonwealth and state-funded mental health and wellbeing services that ‘builds on joint Commonwealth-state planning approaches to mental health and wellbeing service delivery’.
Similarly, the Productivity Commission recommended a whole-of-government approach to mental health, including a new National Mental Health Strategy that integrates services across the state, territory and Commonwealth levels, and both health and non-health sectors. This included clear identification of the body in charge of and responsible for consumer outcomes.
The Productivity Commission, in its evidence before the Committee, highlighted that the starting point would be a Commonwealth-state and territory agreement:
‘I think the key starting point needs to be the agreement between federal and state/territory governments as to who's responsible for what and who's paying for what. If we can move rapidly towards that and get agreement on it, [the agreement] would really underpin all of the reforms going forward.’
The Department of Health, noting the importance of connectivity and clarity of roles for the Commonwealth and state and territory governments, explained its role in pulling together evidence from various reviews including the Productivity Commission and the Victorian Royal Commission reports:
…we're actually taking the benefits of that evidence and that review and looking at: What is the role of the Commonwealth? How do we work better with the states and territories? How do we work better with the professions and the consumers and the carers to try and implement an integrated system?
The Committee notes the extensive work underway on government coordination. For the purposes of the inquiry, the Committee will focus on the outcomes and whether the needs of consumers across whole-of-population are being met, rather than high-level jurisdictional arrangements.
Measuring mental health outcomes was raised by the Department of Health, the Productivity Commission, the Victorian Royal Commission and the National Mental Health Commission.
Appearing before the Committee, the Department of Health explained that ‘measuring outcomes in mental health over the long term, particularly with people’s episodic care, is not easy.’ However, the Department confirmed that it ‘continues to be a key pursuit, both at the Commonwealth and the state level.’
The Department advised that there were a number of evaluations into mental health programs, including of the MBS system and the headspace program, and referred to a recently completed evaluation of the Early Psychosis Youth Services program. At the request of the Committee, the Department subsequently provided a list of evaluations underway and recently completed. This is available at Appendix B.
The Productivity Commission recommended a national body to lead Australia’s mental health and suicide prevention system in developing an evaluative culture, which would include evaluations of policies and programs of national significance. The national body would:
Promote a culture of evidence-based policy and program development;
Commission transparent and robust program evaluations, with rigorous evaluation quality control processes;
Develop evaluation capacity and capabilities based on internationally recognised best practice approaches;
Build partnerships with stakeholders, particularly consumers and carers, research institutes, government departments, state and territory bodies and providers; and
Report on findings and evidence to enable practical policy and program improvements.
Rather than establishing a new body, the Productivity Commission proposed an expansion of the National Mental Health Commission’s role to incorporate evaluation, noting the synergies with its existing monitoring and reporting functions.
Further, the Productivity Commission recommended that the National Mental Health Commission ‘be afforded statutory authority status as an interjurisdictional body’ to strengthen ‘[n]ational leadership, guidance and coordination of the mental health system’ as a priority reform.
This would align with the state level recommendation of the Victorian Royal Commission to establish a new independent and statutory Mental Health and Wellbeing Commission ‘to hold the Victorian Government to account for the performance of the mental health and wellbeing system and the implementation of the Commission’s recommendations.’
Accessibility and affordability
Accessibility and affordability of mental health services has been identified as a concern, particularly with demand for services increasing.
The National Mental Health Commission identified accessibility as the most commonly raised concern during its Vision 2030 consultations, with affordability being the most common barrier raised. The Commission found those that ‘do access care often experience financial hardship to do so’. Further, people with mental illness were found to be disproportionally represented among the unemployed and those on low incomes.
In relation to affordability, there have been suggestions that the MBS rebates are not high enough, resulting in large gap payments for certain mental health services. The National Mental Health Commission stated:
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.
The Department of Health, appearing before the Committee, noted that while there may need to be MBS reform, it is not the only scheme that can fund mental health services:
I wouldn't want to suggest that MBS is the only funding mechanism for mental health services. We have used a range of different funding mechanisms, including commissioning grants through the PHN, to ensure that you can provide services particularly to lower-income, lower-SES [socioeconomic status], lower-intensity services that are available free to people.
The Department of Health noted that it has implemented mixed funding models within headspace and the eight mental health centres across Australia, where some staff are salaried and others are MBS-rebated staff, to ensure operation and access to stepped services.
The Committee considers affordability to be a significant and ongoing barrier to accessing mental health services in Australia.
Beyond cost, the Royal Commission into Victoria’s Mental Health System found that accessibility was hampered by poorly integrated services, that made it difficult for people living with mental illness and other conditions to gain access to services that met their needs and preferences.
Appearing before the Committee, the Productivity Commission noted that often limited accessibility is due to a lack of community services, and that this is exacerbated by short funding cycles. This in-turn impacts on the availability of long-term and consistent community supports.
The Productivity Commission identified as a priority, reform that goes beyond the direct provision of mental health services. The aim is to improve the quality of life for individuals with mental illness while reducing demand for more intensive and expensive health services over the longer-term. Examples include: expanding community support services to meet demand; improving the mental health assistance in place for police and first responders; and, increasing access to legal representation for people facing mental health tribunals.
The National Mental Health Commission suggested that innovative and responsive funding mechanisms covering all components of care, including ‘clinical intervention, coordination, consultation and support’ should be used to improve accessibility.
Private health insurance
Private health insurance can cover treatment by mental health professionals in private hospitals, public hospitals and out of hospital services. However, as noted above, private health insurance covers only a small portion of the overall spend on mental health in Australia.
In 2018, the Australian Government announced private health insurance reforms to increase access to mental health services. Limits on the number of mental health sessions accessible under policies were removed and those with basic or medium level hospital cover products were able to upgrade their cover and immediately access in-hospital mental health services.
However, the Australian Prudential Regulation Authority has noted a continuing longer term trend of decline in private health insurance coverage for younger people.
Commenting on affordability of access to mental health services and the possibility of funding coming from private insurance, the Productivity Commission stated:
The feedback that we had from the private health insurers and the life insurance companies is that they feel that the current restrictions on their ability to offer services to their members means that they're unable to, in a sense, get in early enough and prevent the deterioration of the relevant consumers. And, yes, it's only going to be dealing with those who can afford private health insurance. I don't know if it's still a majority of Australians; I'm not sure where the numbers are now, but there are many people who can't afford it. But there’s still a potential gain there.
The terms of reference include inquiring into emerging evidence-based approaches to effective early detection, diagnosis, treatment and recovery across the general population and at-risk groups, including drawing on international experience and directions.
In December 2020, the National Federation Reform Committee agreed a vision and set of principles to underpin improvements to Australia’s mental health system which include to, amongst other things, ‘[e]stablish structures and mechanisms as required to jointly drive planning and reform that supports a stepped care model, addresses the ‘missing middle’ and supports effective early intervention’.
Stepped care recognises that there is ‘no one-size fits all’ approach. It is a staged system with a hierarchy of interventions from least to most intensive, matched with an individual’s needs.
In 2019, the Department of Health published guidance for implementing a stepped care approach through the PHNs, which provided strategic advice on managing mental health cases as they move between different intensities of care.
Despite this, recent reports and reviews still indicate that the Australian mental health system has a ‘missing middle’. The Victorian Royal Commission described the people impacted by the missing middle as:
A large and growing group of people [that] have needs that are too ‘complex’, too ‘severe’ and/or too ‘enduring’ to be supported through primary care alone, but not ‘severe’ enough to meet the strict criteria for entry into specialist mental health services. As a result, people receive inadequate treatment, care and support, or none at all.
Prevention and early intervention, early in life and early in the development of mental health, has been identified as an ongoing reform priority across a number of reports and reviews. It is critical to reducing the number of people caught without suitable mental health support. According to the Productivity Commission:
…you can think of there being two gaps in the broader health system for people with mental ill health, at the moment. One is at the low-intensity end, many people with mild anxiety or depression where the only gateway is the GP. That often leads to medication. The only other gateway they have is Dr Google, so we're trying to fill that gap and provide more support. Then you've got the missing middle gap, which is the people with more severe mental ill health who need a lot more support to be able to recover in community.
According to the Productivity Commission, reform is needed to ‘[help] people to maintain their mental health and reduce their need for future clinical intervention, including by tackling early mental health problems and suicide risks.’
The Productivity Commission advocated for the creation of a person-centred mental health system that focused on prevention and early help – early in life and early in illness.
The mental health of children and families should be a priority, starting from help for new parents and continuing through a child’s life. Schools should have a clearly defined role in supporting the social and emotional wellbeing of students, with effective pathways to care. Prevention and early intervention should continue through tertiary education and employment.
The National Mental Health Commission explained that there was broad agreement that when talking about the importance of prevention and early intervention, it is predominantly about looking at how to keep people mentally well:
There is a strong emphasis in each of those reports on the importance of moving away from how much we are spending on mental illness to how much we are investing in mental health and wellbeing.
The Department of Health advised that the Commonwealth is ‘predominately responsible for early intervention, prevention and primary care activities’. Australian Government early intervention and prevention initiatives include:
National Suicide Prevention Leadership and Support Program - providing funding for regional and national projects to reduce deaths by suicide and suicidal behaviour.
headspace – a program for provision of services to young people aged 12-25 experiencing, or at risk, of mental illness.
Adult mental health centres – a trial to establish one centre in each state and territory, which will ‘provide a welcoming, low stigma, ‘no wrong door’ entry point for adults to access mental health information, services and supports through a multidisciplinary team’.
Linked to early intervention is the availability of low-intensity mental health options. These are evidence-based psychological services, targeting people with, or at risk of, mild mental illness within a stepped care approach, and designed to be accessed quickly, easily and efficiently.
The Productivity Commission describes low-intensity options as ‘low cost, low risk, and easy to access services’. In its report, the Productivity Commission identified a large gap in the utilisation of these services, and concluded that:
…the low intensity gap exists primarily because of under-provision of low cost, low risk and easy to access services, and because of a lack of information — for referring clinicians and for consumers — about the existence of such services and their clinical and cost effectiveness.
Further, noted by the National Mental Health Commission, early intervention is important:
…many Australians do not or are not able to access supports when they first begin to struggle with their mental health, which can result in problems becoming more severe and less responsive to low-intensity treatments.
For the individual, the Productivity Commission suggested that having access to low-intensity options, for example in relation to anxiety and depression, may be empowering:
There's a whole cohort of people who, if they were given the sort of information that they could access themselves, could do more. And I don't say that in a pejorative way; they would be empowered to do more about their own mental health.
In an example of integrating low-intensity services into communities, the Productivity Commission recommended that ‘universities put in place an overarching strategy for the mental health of their students and then make sure the services are there’. This may be through partnerships with outside organisations such as headspace, but ultimately the universities must take responsibility for the mental health of their students.
The Committee will consider further the gaps in low-intensity services in Australia, and how particular services could assist, such as digital and telehealth services, group therapy, and community-based mental health care.
Children 0-12 years
Appearing before the Committee, the Department of Health acknowledged that there was a gap in the funding of mental health services aimed at the 0-12 year old age group, and identified it as an area of focus. The Department noted that this is an area where schools play a role, and therefore an area that requires coordination with states.
The Productivity Commission raised the importance of assisting teachers in the classroom and ensuring that schools have access to knowledge about local services. In addition, the Commission encouraged sharing information with principals in regard to successful evidence-based programmes operating in other schools that could be implemented.
The Victorian Royal Commission recommended the development of a digital platform that contains a validated list of evidence-informed initiatives, including for ‘anti-stigma and anti-bullying programs, to assist schools in supporting students’ mental health and wellbeing’.
Subsequent to appearing before the Committee, the Department of Health provided additional information outlining a range of programs that are being funded by the Australian Government to support the mental health and wellbeing of children up to 12 years of age, including:
Be You (delivered by Beyond Blue) which promotes mental health and wellbeing for children and young people by offering educators in early learning services and schools evidence-based online professional learning, complemented by a range of practical tools and resources.
The National Workforce Centre in Child Mental Health initiative (delivered by Emerging Minds) which assists professionals and organisations who work with children and/or parents/families to have the skills to identify, assess and support children at risk of mental health conditions.
The National Mental Health Commission’s submission advised that it is working on a National Children’s Mental Health and Wellbeing Strategy to guide action for supporting children’s mental health and wellbeing. On 15 February 2021 the Commission’s consultation for the draft Strategy concluded, and the final Strategy is due to be released later in the year.
The Productivity Commission Inquiry Report into Mental Health recommended nationally consistent screening for mental ill-health of new parents and prioritising the social and emotional development of children in early childhood and school.
The Department of Health highlighted Australian Government initiatives that aim to support the mental health of parents during the perinatal period (from conception to the end of the first year after birth), which include:
The Perinatal Mental Health and Wellbeing Program which is designed to improve the range of services supporting the mental health and wellbeing of expecting and new parents, and deliver support to parents and families experiencing distress after birth trauma, miscarriage, stillbirth or infant death to help prevent mental ill health.
The National Perinatal Mental Health Check which is designed to improve access to perinatal mental health screening and strengthen electronic capture of screening data by states and territories.
The Committee has received contributions from a number of individuals raising concerns that increased screening for infants (0-3 years old) might lead to overprescribing medication.
Telehealth and digital health services
The terms of reference include inquiring into the use, standards, safety and regulation of telehealth services and the role and regulation of domestic and international digital and online mental health service providers in delivering safe and high quality care in Australia. This is particularly relevant in light of the events of the last year, including the COVID-19 pandemic.
COVID-19 has had a significant effect on the mental health of Australians, with many seeking help for the first time. COVID-19 restrictions saw a move away from face-to-face mental health services, to increased use of telephone support and digital platforms.
The Department of Health reported that the Australian Government’s investment into a whole-of-population telehealth model enabled mental health professionals to continue to engage with clients, where COVID-19 or proximity barriers may have otherwise limited access.
In December 2020, the Medicare Benefits Schedule Review Taskforce, informed by the Telehealth Working Group, released its report Telehealth Recommendations 2020, finding that:
Telehealth services have been effective for the bushfire and COVID-19 response items, and the Australian community is receptive to telehealth consultations being provided more broadly.
However, the report also cautioned that the change to increased use of non-face-to-face services and especially those without video, posed additional risks, such as:
…commercialisation of high throughput low value telehealth services that have no intention to provide face-to-face services or to ensure holistic care of the patient.
On 14 March 2021, the Prime Minister, the Hon Scott Morrison MP, announced the extension of the telehealth Medicare rebate until 30 June 2021. The Prime Minister noted that the Government would continue to review the ongoing role of COVID telehealth to support the pandemic in the short term, while planning for permanent post-pandemic telehealth.
In relation to the uptake of telehealth services, the Productivity Commission noted:
One aspect of that where we were lacking information was the community willingness to participate in telehealth. Subsequently, with COVID-19 and the uptake of telehealth, I think we have an answer to that. We've seen considerable uptake of telehealth by both health professionals and by the community. In that sense there is now data available that we didn't have at the time of the inquiry.
While acknowledging the increased use of telehealth, the Committee is interested in hearing more at public hearings regarding the efficacy of telehealth, and exploring the options of mixed mode delivery of mental health services.
Digital health services
The Department of Health’s submission outlined government funding for a variety of free or low-cost digital mental health services, and noted the increasing demand for webchat and text services.
The Productivity Commission recommended increased digital mental health service engagement, noting a national digital mental health platform should be a key component of the mental health system. The Productivity Commission envisaged a platform that would be accessible to consumers, GPs and other clinicians through a website, and include:
A tool for person-centred assessment and referral, which would be used by GPs, and by individuals who could access online assessment and referral, supported by an experienced mental health clinician;
Access to evidence-based digital low-intensity services that are low cost and accessible to consumers;
A gateway to other digital and face-to-face treatment and support services, and in time, draw on the recommended navigation portals in each region as a source of local information on service availability and capacity.
The Victorian Royal Commission recommended that the Victorian Government:
…promote, and co-produce with people with lived experience, a website that provides clear, up-to-date information about Victoria’s mental health and wellbeing system that helps users to understand their mental health needs; identify services and supports across all relevant provider types; and access online self-help resources.
In addition to targeting resources to stage of life and type of supports or services needed, the Victorian Royal Commission also recommended the ‘development of digital technologies to support the delivery of language services that assist access to and engagement with mental health and wellbeing services’ for diverse communities.
While supportive of digital mental health services, the National Mental Health Commission’s submission identified concerns around:
compatibility issues in matching the user’s actual need and the service offering;
privacy and confidentiality; and
the digital divide or digital poverty – where those who often need the support most are also those least likely to be able to access digital options.
For example, the National Mental Health Commission identified that while digital mental health services enable equal outcomes for Aboriginal and Torres Strait Islander people, this demographic may also be particularly impacted by the digital divide or digital poverty, and health inequalities.
In addition, the National Mental Health Commission noted that as yet ‘[n]o single view has emerged on what constitutes best practice in this field’, and there are significant legal and ethical challenges for digital health services spanning international boundaries, including differences in professional standards and regulations across jurisdictions.
The Australian Government has funded the Australian Commission on Safety and Quality in Health Care’s development of National Safety and Quality Digital Mental Health Standards to address safety and quality in digital mental health services and products. The standards were launched on 30 November 2020.
The Department of Health’s submission noted that the uptake of the Standards is currently voluntary and they are slowly being introduced to the sector.
The inquiry’s terms of reference include inquiring into effective system-wide strategies for encouraging emotional resilience building, improving mental health literacy and capacity across the community, reducing stigma, increasing consumer understanding of the mental health services, and improving community engagement with mental health services.
While each one of these areas warrants attention, stigma and its inherent link to discrimination has emerged as a major theme from the inquiry to date, and is the focus here. Reducing stigma underpins willingness to seek help, being open to learning about mental illness and building community support.
The Productivity Commission identified stigma and discrimination as one of the ‘key gaps and barriers that lead to poor outcomes for people’, and an area that needs to be addressed in reform of Australia’s mental health system. This would include:
…how people view themselves, and how people with mental illness and those who support them are viewed by the community and service providers.
The ever-presence of stigma and discrimination was also one of the major themes that emerged and shaped the Victorian Royal Commission’s recommendations. The Royal Commission explained:
It can prevent people living with mental illness or psychological distress from seeking support, can make social isolation and loneliness worse, and can be a barrier to gaining and retaining employment. Ultimately, it can be an obstacle to recovery that keeps people from fully and effectively participating in society. Discrimination is widespread and presents in many ways, such as difficulties accessing health care or being unsupported in the workplace, leaving people socially and economically excluded from society.
Likewise, the Productivity Commission found that most people with mental illness had experienced stigma, ‘although the degree, nature and experience of stigma and consequent discrimination varies with the type of mental illness, and with the person’s age, gender and culture’. Further, the Productivity Commission suggested that significant economic benefits could be realised through the instigation of a national campaign for stigma reduction.
Stigma can be broken down into three main types:
Self-stigma – the lens of shame
Social stigma – community attitudes, overt or perceived
Structural stigma – policies and social organisation that result in negative consequences for people when they seek help or are treated for mental ill health.
In relation to stigma as a barrier to seeking help, the National Mental Health Commission suggested that the COVID-19 pandemic had led to many more people experiencing mental ill health and it had been ‘somewhat normalised’.
However, the National Mental Health Commission explained that while it had a ‘relatively strong evidence base’ around self-stigma and social stigma, ‘[o]ne of the areas that really requires deep investigation is the reality of structural stigma’.
The National Mental Health Commission’s submission identified nine areas of immediate focus to address structural stigma and discrimination:
Community and social services including all aspects of policing and justice systems, employment, housing and child protection
Education and training settings
Taxation, banking, and finance industry
Retail and customer service contact points
Religious and spiritual organisations, systems, and workforce
Cultural communities, community and sporting institutions.
The Victorian Royal Commission noted that in addition to addressing stigma through system reform and anti-stigma programs, people need to have improved access to legal protection from mental health discrimination. The Royal Commission recommended a series of reforms to ensure protections and provide support for consumers to exercise their rights.
The Productivity Commission highlighted the need for ‘ongoing commitment over a long time period in order to ensure that reductions in stigma persist’, and recommended that as a priority:
…the National Mental Health Commission (NMHC) should develop and drive the implementation of a renewed national long-term stigma reduction strategy that: targets stigma reduction messages for different audiences (such as health professionals); focuses on the experiences of people with those mental illnesses that are poorly understood by the community; addresses different aspects of stigma including perceptions of danger and unpredictability; and identifies and draws on a small number of national ambassadors for mental health.
On 11 December 2020, the Prime Minister announced that the National Federation Reform Council agreed to the development of a National Stigma Reduction Strategy, led by the National Mental Health Commission, in consultation with all levels of government. The Strategy is due for delivery by the end of 2022.
The Committee has received a number of submissions that comment on structural stigma and will delve into this area through upcoming public hearings. The Committee is interested in understanding more about how this is impacting the most vulnerable communities.
Dr Fiona Martin MP
14 April 2021