Various stakeholders and reports have identified the importance of expanding telehealth and digital mental health to improve treatment access and navigation, bridge service gaps, and function as a key component of a national mental health system.
The Productivity Commission Inquiry Report on Mental Health (Productivity Commission Report) recommended the expansion of supported online treatment, group therapies and access to mental healthcare via telehealth.
The Productivity Commission stated that supported online treatment is a means to provide a convenient, clinically effective, low-cost way for individuals to manage mental illness, and called for the Australian Government to implement the following priority actions:
increase funding to expand supported online treatment for people with mental illness
instigate information campaigns for consumers and health professionals to increase the awareness of supported online treatment as an effective and convenient treatment option.
Similarly, in response to the Mental Health Reference Group Report, part of the Medicare Benefits Schedule (MBS) Review (2015-2020), the MBS Review Taskforce, recommended that the Australian Government promote and increase the awareness of digital mental health services and other low intensity options integrated with therapist support.
In addition, the MBS Review Taskforce Telehealth Recommendations 2020 report recommended the Australian Government ‘[e]stablish a National Strategy for Virtual Health Care, including telehealth, and an action plan for Australia.’
Responding to these reports, along with recommendations from the National Suicide Prevention Adviser to the Prime Minister, the Australian Government committed to ‘increasing the availability of services, including digital and telehealth services’ with an investment of $111.2 million in the 2021-22 Budget. This included:
$11.6 million to commence the transformation of the existing Head to Health gateway into a comprehensive national mental health platform. This will provide Australians with greater choice and access to high quality, free and low cost digital mental health services and treatment
$77.3 million to provide support to existing digital mental health services, including to manage the continuing increased demand due to the COVID-19 pandemic and the 2019–20 summer bushfires
$13.1 million to support ReachOut Australia to continue delivering free, high quality digital mental health services to young Australians aged 12–25, their parents, carers and schools …
With expansion underway, the Committee sought to consider the use, standards, safety and regulation of telehealth services and the role and regulation of digital and online mental health service providers in delivering safe and high quality care in Australia.
Accordingly, this chapter outlines the evidence the Committee has received in relation to telehealth and digital services, and then examines potential limitations of digital mental health and investment priorities.
Telehealth was discussed in Chapter 2 in reference to the positive outcomes driven by COVID-19 restrictions. While evidence strongly supported the increased availability of telehealth, there was broad agreement that it was most effective as part of a suite of mental health services.
The Productivity Commission Report identified a need to address healthcare gaps in community mental healthcare, recommending the Australian Government:
… make permanent the changes to expand access to psychological therapy and psychiatric treatment by videoconference and telephone introduced during the COVID-19 crisis.
On 26 April 2021, the Australian Government announced that it would invest more than $114 million to extend the telehealth services made available in response to COVID-19 in March 2020 until the end of 2021.
Referring to the significant uptake of the COVID-19-induced MBS telehealth items, the Hon Greg Hunt MP, Minister for Health and Aged Care, stated:
From 13 March 2020 to 21 April 2021, over 56 million COVID-19 MBS telehealth services have been delivered to 13.6 million patients, with $2.9 billion in Medicare benefits paid. More than 83,540 providers have used telehealth services.
The call to make the COVID-19 MBS telehealth item numbers permanent was widely supported by stakeholders.
A strong argument for extending or making permanent the COVID-19-introduced MBS telehealth item numbers has been the significant improvements to accessibility. The Black Dog Institute stated:
During COVID, we had a rapid expansion in the use of telehealth. There were over 2½ million MBS funded telehealth sessions between March and November last year. Within our own clinic, we saw the dramatic change that telehealth provided, where suddenly we were able to see patients who previously we wouldn't have been able to see, not just because of geographical challenges. We obviously want the extension of telehealth MBS numbers to continue beyond December this year, so that we can have certainty and plan treatment with patients.
The accessibility benefits derived from telehealth were acknowledged in the MBS Review Taskforce Telehealth Recommendations 2020 report:
Subject to clinical efficacy and clinical appropriateness, expand telehealth eligibility to patients in defined situations who may otherwise be unable to receive face-to-face care.
A number of stakeholders observed an increase in telehealth referrals beyond their regular client base. It was noted that this was largely driven by those in areas with service gaps – rural or remote areas or specialist services.
The Australian Rural Health Education Network (ARHEN) highlighted that from a rural community perspective, telehealth was very welcomed because ‘[w]e can’t always get services on the ground.’
The Women’s Mental Health Alliance advised that while telehealth was not for all users, having it available made a significant difference for isolated individuals to access compassionate care and other health practitioners besides general practitioners (GPs). The Alliance advocated for continuing the telehealth arrangements:
… sometimes it can also be hard to access a service or a support that's good around women's mental health if you're more isolated or in a more regional or rural area. So if you have the choice to log in with somebody … that also goes a long way. So I would advocate greatly for keeping telehealth alive. It has literally been a life saver for some people.
Amaze, the peak body for autistic people, stated that the increase in access to digital clinical interventions such as telehealth was positive.
Occupational Therapy Australia spoke about the benefits of telehealth services for regional, remote and rural Australia:
It certainly helps clinicians and clients and people across regional, remote and rural Australia, because it's so difficult to access qualified mental health practitioners. The distance is a factor, but there are not enough services, as you mentioned earlier on. So there is more I think evidence, and I suppose I'm talking from an associate professor perspective and thinking about generating robust evidence, that demonstrates that the results that we get from telehealth are as robust and significant and make an impact on the recovery of people with mental health conditions and their family members as well.
Speech Pathology Australia (SPA) also identified that the MBS telehealth item numbers have improved general access to specialist health professionals, which means that individuals can receive support and treatments better suited to their needs, regardless of their location.
The Australian Association of Psychologists Inc (AAPi) also recommended that the Australian Government retain all of the MBS telehealth items, ensuring access to both videoconferencing and telephone items:
… because we know that in rural and remote areas internet access is often problematic and that it excludes consumers that might have disabilities or financial constraints that would see them unable to have access to internet or smartphone technology …
ARHEN believed that telehealth's been a really good adjunct to enabling the delivery of services that may not have otherwise been available, but suggested it is a supplement to rather than a replacement for mental health services in many regions:
It supports the delivery of particular type of mental health services by particular professional groups rather than necessarily allowing the full spectrum of services that people may need in a rural and remote community.
The Royal Flying Doctor Service agreed with ARHEN’s view that telehealth worked as part of an integrated suite of services.
Engagement and outcomes
While the rapid expansion of telehealth was unexpected, it brought about a number of positive outcomes. Witnesses also acknowledged that further evaluation of consumer engagement and outcomes will be important for assessing its role post-pandemic.
The Australian Psychological Society (APS) advised that approximately 95 per cent of psychologists have been using telehealth for the last 18 months, recommending that the Australian Government permanently support telehealth services. APS further stated that:
Of course we want that to be high-quality care. We know video is one of the best forms, in that we can still reach connections. The outcomes are good. I would like to see that continue. I'd also like to see the provision of services supported by online integrated treatment. That's where a psychologist can work with programs they know are evidence based, trusted, supported, meet all the privacy quality controls, and they can refer out so that they're integrated within treatment as opposed to either doing an online program or one face to face. Overall, I'd like to see us broaden what we're doing there and how we're integrating it all.
Stride Mental Health found that telehealth has significantly improved appointment attendance:
… consumers that were coming into our headspace centres under the NDIS [National Disability Insurance Scheme] model were less likely to miss a telehealth appointment than what they would be to miss an appointment under normal circumstances where they were actually coming in. So the engagement there is higher. Whether or not they would … receive that depends on age groups and people's own technical capabilities and whether or not they would even accept technology as a part of their day to day. Generally, it's actually quite good.
Similarly, the National Aboriginal Community Controlled Health Organisation (NACCHO) noted that while initially unsure how successful telehealth would be, the reality was pleasing:
… when we had to lock down under the Biosecurity Act, in partnership with the Commonwealth and the state and territory governments, particularly in the remote areas we embraced telehealth with some trepidation, but it was proven to be highly successful. The people in the communities that we to contact for their chronic care management and to have telehealth consultations embraced it warmly, and we were very pleased with that uptake and we want that to continue.
The Black Dog Institute advised that it is currently completing a research study into the quality of care and engagement provided through telehealth services. On interim anecdotal evidence, the Institute noted that while there are some patients who struggle to therapeutically connect over telehealth, others found it to be preferable:
I have a number of patients who have said to me that they feel much more comfortable speaking via videoconference than they used to coming into a clinic. They said that they felt very anxious sitting in the clinic. They were often quite flustered by having to travel across Sydney to get there, and to be able to sit at home in their own surrounds they feel more comfortable and more able to engage. The other thing which I've had a number of patients say to me is that they are able to continue treatment while continuing working, which is exactly what we want.
SPA emphasised the importance of adaptability in therapy and engagement over telehealth, commending the work of speech pathologists in finding ways to make telehealth therapy engaging. SPA also noted that performing some aspects of therapy over telehealth can be exceptionally difficult:
There are some things we have had to change. For example, it's really hard to do an autism assessment completely online, so we have had to add in some other things because we couldn't stop doing autism assessments altogether. We have some of the trickiest kids in the state, so we need to still do them. So we have been adding in extra things that are helpful—extra questionnaires for different people to get collaborative background and information about the young person.
The Committee acknowledges the significant increase to service accessibility for individuals as a result of the COVID-19 introduced-MBS telehealth items, and the strong support for retention.
Access to telehealth numbers should be patient-oriented and based on patient need rather than geographical location.
The Committee supports Recommendations 3 and 4 of the MBS Review Taskforce’s Telehealth Recommendations 2020 report, which advised the Australian Government to ‘[e]valuate, research and review models of telehealth and virtual health care to ensure the MBS item structures are appropriate for the Australian setting’ and ‘[e]stablish a process to review all MBS telehealth items on a regular basis.’
Noting the evidence received in relation to extending funding cycles to five years (see Chapter 6 for details), the Committee suggests that the Australian Government implement a complementary review cycle for telehealth. In addition to regular reviews of individual items, a five yearly review would ensure that telehealth MBS items meet the principles of providing high-value care and that any risks or perverse incentives are managed and mitigated.
The Department of Health has commissioned PricewaterhouseCoopers to develop the National Digital Mental Health Framework, including a review of the current digital mental health service landscape, and challenges and barriers being experienced. The project is currently in progress and will contribute to implementation of future strategic directions in digital mental health, in line with the Fifth National Mental Health and Suicide Prevention Plan.
While strongly endorsing ‘the use of technology as a tool for increasing the accessibility, efficiency and quality of mental health care’, MindSpot stressed:
… technology should be seen as a tool for delivering mental health care and not as a replacement for safe and effective care. We note that successful use of technology requires not only secure infrastructure, but also changes to how healthcare is delivered, training and upskilling staff, profound cultural shifts in practice, and additional governance.
SANE Australia recommended the urgent expansion of supported online treatment, especially to individuals experiencing trauma or distress, as well as lower prevalence mental health issues. SANE Australia drew attention to the Productivity Commission Report, which stated that:
… people with more complex mental illness can also benefit from supported online treatment. There is some evidence that specifically designed supported online therapy may be effective in complementing specialist mental health treatment for severe and less prevalent disorders, such as schizophrenia, bipolar disorder and bulimia nervosa.
The transition towards digital health will also enable greater engagement options for allied health professionals in improving treatment and care. Referencing a report by the Australian Digital Health Agency and the Allied Health Professions Australia, Exercise and Sports Science Australia (ESSA), advised that the majority of exercise physiologists were already using electronic record systems for patient notes. ESSA further noted that digital channels for coaching, support and patient review had been quite reasonable for that level of treatment to be delivered.
Digital services improving access
Earlier chapters outlined issues around accessibility for consumers, workforce shortages and the compounding impact of COVID-19 on demand. Various stakeholders highlighted the possibilities digital services provide for increasing access for individuals who are unable to utilise face-to-face mental health services, including due to distance, cost, stigma or illness.
In August 2021, the Australian Government announced the launch of #ChatStarter, an online mental health communication program that incorporates social media to promote the benefits of having supportive conversations with young people and children who might be struggling. The program links to resources available through the Australian Government’s Head to Health website.
Describing the purpose of #ChatStarter, the National Mental Health Commission explained:
… talking may not necessarily be the best way to ‘start a conversation’. Sometimes engaging in fun, creative, and productive activities together can transcend barriers to conversation, build trust and help create safe spaces for people to talk about how they’re feeling, and the kind of support they need.
yourtown highlighted that its services have evolved in response to changing needs and preferences of its clients, particularly children and young people:
Digital platforms and tools provide a range of benefits to children and young people seeking mental health support, and young people tell us that they turn to Kids Helpline as it helps them overcome the barriers to access, such as stigma, discrimination, cost, and transport.
We understand that's why webchat is becoming the preferred modality for contact, and it's interesting to note that particularly for mental health conditions and young people expressing suicidal ideation, webchat affords them a level of confidentiality and privacy and safety that they may not otherwise have with phone or other modalities of contact.
The appeal of digital services is not limited to young people, or determined by other demographic or geographic indicators. Evidencing the wide reach and improved access of digital services, MindSpot identified the demographics that engage with its online services, which:
… are almost a representation of Australian national demographics, except for general. So we have more females than males who use the service. Approximately 70 per cent of the users are female. The age range is quite significant. It ranges from 18 to about 98. And I know it's surprising to a lot of people, but we have an increasing number of older adults using our services. About 40 per cent of people who use MindSpot report that they live outside of major metropolitan areas. When we look at postcodes, we see that there is quite an even distribution across the country. About four per cent of people who use MindSpot report that they have an Indigenous background—they are Aboriginal and Torres Strait Islanders—and about 12 per cent of people report that they are unemployed.
Smiling Mind suggested that on a stepped model of care, the low intensity digital services are an extremely affordable channel for reaching large numbers of people. Smiling Mind noted that while there are discrepancies in access to digital resources in communities, including access to devices and the internet:
… there are absolutely opportunities to integrate those into the way we deliver services. For example, having access to digital resources within community settings, where people can access a computer or a device when they come in to a service, can overcome some of those barriers.
Mind Australia outlined its experience with digital services in response to the COVID-19 pandemic. While similarly identifying challenges with devices and internet access, Mind Australia found that:
… as we provided in particular a whole range of group programs online, that some of the participation improved because people could access the group program and could participate without leaving home. Now, there were many reasons people were reluctant to leave home and not all were related to the pandemic.
Blended service delivery
The Black Dog Institute stressed that the use of technology in mental health and suicide prevention has to go beyond the use of telehealth, and needs to be blended into service delivery:
Australia has said it wants to be a leader in terms of digital health. We've got some of the world's leaders in terms of digital mental health. But at the moment it's very fragmented and it's an either/or situation, where individuals use either digital health or face to face. We don't have an ecosystem or a funding system that encourages blended care where people can see psychologists as well as use some of the new technology.
For a blended service delivery model to work, Transforming Australia’s Mental Health Service Systems identified two critical components to consider:
First of all, it's about getting an optimal balance between telehealth and face-to-face care. The second issue is about ensuring that telehealth practitioners communicate routinely and regularly, particularly in crises, with the designated care coordinators or case managers on the ground, families and the referring general practitioner. As that's not paid for in the payment for telehealth practitioners, a number of them will not adhere to communicating with the referring agents or with the people they know on the ground who will attend to crises.
Blended service delivery requires digital services to be able to build therapeutic relationships and ensure therapeutic outcomes. Appearing before the Committee, MindSpot explained that:
… a relationship with consumers and between consumers and service providers is critical for establishing engagement and maintaining engagement during treatment, which, of course, can be quite challenging. We have looked at this through therapist engagements and anecdotes, as well as testing this empirically. We've measured therapeutic outcomes online compared with face to face. What we've learned—surprisingly—is that consumers do engage very powerfully. In fact, there's no difference in the level of therapeutic engagement consumers had with MindSpot compared with what we would expect from face-to-face care. That's actually the result of an enormous amount of co-design with consumers and really thinking through the consumer journey—walking the walk with them.
Smiling Mind proposed that digital services are also a very powerful adjunct to face-to-face clinical services:
We know a large number of clinicians will recommend their patients use a program like Smiling Mind in the interim periods between those clinical visits, particularly when there is a significant time delay between appointments, as a tool to look after their wellbeing.
Wesley Mission highlighted the importance of incorporating digital approaches to care in a community-tailored approach. Throughout the COVID-19 pandemic, Wesley Mission noted that:
… some communities jump in and work well in participating in community network meetings online, whereas some other communities, particularly rural and remote communities and some of the First Nations communities, there is not such a preference for engaging online.
For at-risk communities
The Committee heard that digital resources and services can improve access and provide safe spaces for at-risk populations. ReachOut advised that huge numbers of young people who are LGBTIQ+ or sex and/or gender diverse individuals use its online mental health service. It argued that:
Often that can be because we're so well placed as an entry point for young people to begin exploring things. Often we are able to provide validation around their experience, help them to feel that they're not alone, help them to understand that if they are finding these types of questions confronting or challenging then there are other services as well that can provide really specific support. One of the things we focus on doing is almost helping young people to become more help-ready and then, ideally, helping to introduce them to services that can provide additional layers of support to what ReachOut provides. For instance, we wouldn't say that we are a specialist organisation that is purely focused on that demographic. But, that said, 30 per cent of young people who come to ReachOut identify as gender or sexually diverse. We have done a lot in making the service fit for them as well.
Appearing before the Committee, the Trans Health Research Group argued the value in developing novel strategies, including digital, to support transgender people all over Australia:
… whether that be having mental health services or case management remotely using videoconference or perhaps outreach after contact with a crisis support service or ongoing mental health support remotely, or whether that be through video meetings or text-messaging based interventions, with funding I think such strategies using remote technology can be delivered to trans people regardless of their location of residence and help connect people to community.
Similarly, yourtown identified that a significant portion of its digital mental health service users come from culturally and linguistically diverse communities. yourtown explained that:
Kids Helpline is currently accessed by children and young people of all ages and of all cultural backgrounds. Five per cent of our counselling contacts are Indigenous children and young people; 34 per cent identify as coming from culturally and linguistically diverse backgrounds; and they come from a whole range of areas urban, regional, rural and remote in line with geographic demographics.
In terms of Indigenous communities, the Kimberley Aboriginal Law and Cultural Centre (KALACC) indicated that in general the young people within its communities are ‘switched in digitally’ through their phones. KALACC explained that:
It can be fairly haphazard in terms of any number of things from changing phone numbers, lack of follow-through, prepaid accounts not having reach. So they are not necessarily as reliable a source in any way as a research agency on the ground with people knowing their patch. But certainly younger people are more engaged with technology now than they ever have been, which is why KALACC has gone down the route of Mabu Jila as a way of engaging young people in culture.
Mabu Jila, KALACC explained, is a digital service that it developed as a method of maintaining and sharing culture within Kimberley communities:
The state government of Western Australia through an entity called Lotterywest has provided KALACC with a substantial amount of money for a program we are calling Mabu Jila, which means 'good water'. What we are doing through Mabu Jila is creating an app that will enable young people—teenagers—in their communities to pull out their phone or whatever technology they have on hand so that they are empowered to capture the important cultural knowledge that their grandmother or grandfather has and to then store, document and share all of that. What we need to be doing is investing in cultural practice, those things that build the resilience and wellbeing within communities.
However, KALACC confirmed that for certain Aboriginal communities:
… while young people will engage to some degree in digital platforms, there is nothing that beats word of mouth. There is nothing that beats actual on-the-ground programs that people do sign up for, do join in on, that come to their communities wherever possible. So even though it may well be that taking the digital approach is certainly a quicker approach and useful to have as a back-up, it is certainly not going to be the main approach, which is face-to-face.
Managing system efficiencies and overcoming limitations
The Committee heard the use of digital services in the delivery of virtual mental health care has enabled services to overcome particular pain points intrinsic to physical services in addition to increasing broader system efficiency.
Investment in a state-wide digital service has enabled the WA Primary Health Alliance to bridge some of its workforce gaps and deliver an evidence-based service:
… built on the MindSpot model [it] is a GP referred system. It has greatest efficacy because we can effectively really guarantee not only the outcomes that are achieved but also the quality.
Appearing before the Committee, yourtown highlighted the benefit of digital services in managing surge demands:
We have found that mental health services, particularly during times of crises, need to be integrated, scalable and able to adapt very quickly during crises, and our experience with Kids Helpline is that virtual services are highly scalable and complementary.
ReachOut stated that its digital service has not only been able to bridge service gaps and meet demands caused by the capacity constraints on traditional mental health settings, but also meet growing service preferences for services like peer support:
ReachOut's been providing an aspect of that [peer support] for more than 10 years through our online community forums, which you can conceptualise almost like a chat room. Someone can come in, create an account and share their experiences, ask questions and interact with other young people. In that setting, all of that's very well and tightly managed by ReachOut's team, who have skills across youth work, social work and mental health work.
Professor Ian Hickie, from the University of Sydney’s Brain and Mind Centre, emphasised the importance of information technology (IT) coordinated care – to achieve the right care the first time. However, Professor Hickie was critical that there was still not widespread adoption of smart healthcare technologies:
We see apps and we see the Australian government continue to support many different organisations to develop very simplistic record systems and tracking systems. They're very inefficient and there's a lack of cross-talk and a lack of coordination. Many people will need to move across many organisations and many different professionals will effectively need to be involved in the care of the same individual over time. So despite the degree of innovation we've had in Australia, despite the great work done by many people here—we've been a real leader, and that was recognised by previous governments and reports—we have not moved the fundamentals to actually support the power of IT to support better care at scale.
ReachOut contended that consideration needs to be given to the development of connections between systems, and how digital tools and data can be used to overcome pain points that other service models cannot:
I think a lot of the conversations we might have had are in the past, but there's a really important difference with taking an existing or traditional kind of service model and just making it available online. What that does is solve a really important piece around access, but it's not necessarily speaking to the nuance or the potential to really think about how you use online data technology and blend all of those things together to create a new or different style of service that's actually addressing more than just access.
Online referral, connectivity and triage
The Productivity Commission recommended the development of an independent assessment and referral process associated with a digital platform. Appearing before the Committee, the Productivity Commission explained:
That's very similar to the Victorian royal commission recommendation. A difference is that I think the Victorian recommendation still had the GP as being the required gateway through which the consumer can access that; whereas we said there should also be just simply the ability for a consumer who needs help to go to that platform and receive moderated help, rather than perhaps relying on Dr Google or other internet searches to try to gain that information.
The Committee heard that there is already capacity for treatment referral and triage to be delivered via digital services and it is already being facilitated. MindSpot outlined its process:
By virtue of registering, we know who they are. They then get asked a series of questions about symptoms and about life circumstances, and we automatically generate a report, which is immediately available. With their approval and consent, we'll send a copy of that report to a general practitioner or another health professional. At that point, we also invite people to speak to us. We encourage people to do that, to have a consultation with one of our mental health professionals. The aim of that consultation is to talk through the results, to talk through their life experience, to start to tailor and personalise the recommendations and to make some recommendations about things which might help. It might be treatment with us, it might be some self-help strategies, it might be a referral to another service. At that point we're really hoping to help people make an informed decision about their treatment future.
Additionally, yourtown’s digital services support user navigation of the mental health system, as well as facilitate ‘soft’ referral and service collaboration. yourtown stated:
We are currently going through a major digital transformation, and with the use of new technology I think we will be moving towards much greater integrated support where we can have much better developed case planning that can look at a whole range of factors impacting on family dynamics.
ReachOut drew attention to the pilot that it is currently completing with Lifeline Australia. The pilot focusses on how its service can use data it receives to understand a person’s thoughts and triage accordingly, without needing to know the end-user:
We'll look at things like what search terms they come in at through Google, and which parts of ReachOut they're accessing: are they accessing suicide content? Are they accessing content that we would consider could be suggestive of imminent risk or higher risk?
… we'll piece together a profile, and where it meets enough of the criteria we'll do a pop-up that says: 'Hey, we want to check. How are you going? Would you like to speak to someone right now?' If they say yes, then that moves straight into the Lifeline service, so they're actually dealing in real time with Lifeline—digitally, through their web chat functionality. They then have a feedback loop. So, when that session ends they can provide us with feedback to close that out.
ReachOut identified this as an example of digital services working together to bring aspects of mental health support together in a seamless way. It continued, stating that:
It's more than just saying, 'Here's a number to call' or 'You should know about this other service.' You're actually seeking to take the step of them stopping their journey with us and starting it with someone else out of it for the person who is seeking help, and that's actually possible through tech these days. We've been running these kinds of pilots because we see a lot more potential if we're willing to be bold around the use of data and if services are willing to think outside of their traditional service boundaries to do a lot more of this heavy lifting on behalf of consumers.
Safety, quality and standardisation
Various stakeholders recognised the importance of having national digital mental health standards to ensure safety and quality in service delivery.
In November 2020, the Australian Commission on Safety and Quality in Health Care (ACSQHC) released the National Safety and Quality Digital Mental Health Standards (NSQDMH Standards), to improve the quality of digital mental health services and protect users.
Appearing before the Committee, ACSQHC advised that:
… there needs to be a whole range of measures in place around governance of these systems. That's a huge area and part of the standards we've looked at. Governance and leadership includes having systems around incident management and complaints, and it includes having really clear and transparent policies around how your data is used. I think that is one of the keys.
It obviously has to have very strong consent mechanisms and look at patient rights. That's very important. Usability and accessibility are very, very important elements that, I think, still need to be looked at and worked on and that are part of our standards. And, obviously, risk assessment and responding to deterioration are important. They're all key considerations as part of the proliferation of telehealth and digital mental health over the last little while, particularly during COVID.
Within the 2021-22 Budget, the Australian Government announced that it would be investing ‘$2.8 million to support the implementation of the NSQDMH Standards to improve the quality of digital mental health service provision, and protect service users and their support people’.
Dr Kristy Goodwin recommended wider standardisation of digital practices:
I think young people are demonstrating their preference through their use of online mental support tools. Kids Helpline data indicates that they have a preference towards seeking help in a digital space. So I think we definitely need consistency in service deliverables and best practice.
ReachOut explained that it ensures safety and quality in its service delivery through recruitment, its duty-of-care requirements and its technology. It has a clinical lead that oversees its organisation-wide approach, in addition to a clinical advisory group to support multidisciplinary approaches and follow trends, and uses technology to help keep the forums safe:
We use a tool that we developed with UTS [University of Technology Sydney] around triaging. We use natural language processing to detect posts and conversations that might be a high risk and those immediately get escalated to our team, who intervene. That can include things like imminent suicide or the need to make reports around keeping young people safe.
Additionally, ReachOut contended that its duty-of-care guidelines ensure that when there is escalated risk approvals are required, which guarantees that multiple individuals are working on any one matter. It also advised that where there is an imminent suicide risk, its system design ensures end-user safety:
… to post in ReachOut's forums you need to create an account. You can use a pseudonym, but we will have your IP [Internet Protocol] address, and we're really clear about the fact that we will step in where there is imminent risk. What that ultimately looks like is the team working with that individual to make all the clinical assessments around their safety and whether this is an imminent risk or, to your point, another type of risk. Where it's imminent, we will try to work with that person to get them safe, but if we don't feel that that's possible and it's not meeting our threshold then we will escalate to emergency services. We will provide an IP address and the team can go to the particular location. On the other range of issues, whether incidence of violence or sexual assault, we have a mandatory reporting obligation. So, we will always let someone know that we have an obligation to report and then seek to provide them with mental health support through what is also a very difficult stage.
The Committee has heard extensive evidence from some of the largest mental health and suicide support services about the increasing role and value of digital mental health services, and how these are being used to improve treatment accessibility through blended-care models, particularly for at-risk communities.
The Committee recognises the importance of digital services and systems for overcoming challenges across the mental health sector in workforce shortages, coordination and collaboration.
The Committee recommends that the Australian Government review available digital technologies to identify and promote best practice options for mental health and suicide prevention professionals to:
increase access to rapid assessment for self-harm
coordinate with other service providers to reduce administrative pressures on professionals and improve the user experience
track outcomes of care to ensure that the right care is being offered.
The Committee supports the development of the NSQDMH Standards for promoting safety and quality in the delivery of digital mental health services, but considers that implementation of the standards should be at a minimum mandatory for government funded services.
The Committee also supports Action 11.1 of the Productivity Commission Report, which recommends the Australian Government consider commissioning an evaluation of the performance of online treatment services, to facilitate ongoing service improvement.
The Committee recommends that the Australian Government make compliance with the National Safety and Quality Digital Mental Health Standards mandatory for all digital mental health service providers who receive Commonwealth funding.
Limitations of virtual mental health care
Evidence received from stakeholders identified two critical barriers to the implementation of digital mental health services and solutions: digital literacy and digital access.
Other barriers to the provision of digital mental health services identified by stakeholders included:
The lack of privacy individuals had when trying to engage with mental health services from home, due to a limited capacity to control their environment or have a private discussion.
The inability of children to focus for long durations online which needs to be factored into service design.
According to Jean Hailes, certain demographics, particularly older people, may not be compatible with a blended or digital service delivery:
I mentioned also that some older people are not as computer literate as many of us are, so telehealth, while it's a great offering, is sometimes quite difficult. What we know is that our older patients prefer a straight phone call. The first lot of statistics that came out about the use of telehealth was that 90 per cent of those consults were done on the phone. That is what suits older people. Asking them to log on and fire up their computer is just a bridge too far for most of them, and it actually undermines their sense of independence and capacity to cope with this abnormal situation [COVID-19].
This was observed by AAPi who experienced difficulties with telehealth for certain consumers:
A lot of people who were elderly or had intellectual impairments or were homeless had difficulty accessing telehealth because of the multiple steps that were required to connect to a service.
Stride Mental Health outlined the need for governments to action consistent and clear investment in services to support consumers:
… I think most people, the larger part of our population, are quite comfortable with technology and how to use it. It is about making sure that everybody knows what to use. An example is the apps that we use to scan QR codes when we walk in the front door. If you remember, right at the start of the pandemic it was a free-for-all. Everybody was doing their own thing. Slowly the state governments decided to invest in particular ones, and now everybody's fine with them. They are comfortable using them and understand them. It makes the education piece simple.
Despite observing low digital uptake within construction industries, MATES in Construction still saw a role for digital mental health solutions:
They've all got mobile devices. Even doing it through this forum is better than not. Anything that actually connects people in a way that makes them feel that they are closer to another individual, we know, does work.
Mental health professionals and service providers
Appearing before the Committee, Mind Australia noted the importance of investing in the digital capability of health practitioners, carers and administrative staff:
It is not automatic that staff can move from delivering services face to face to being able to use devices effectively. There is still a staff skilling up and capability issue to be aware of as we probably move to a more hybrid world of service delivery.
This was further supported by Stride Mental Health, contending that:
Telehealth is a technical solution. It requires skill. It requires change. It requires understanding how to pivot your organisation and how to get technology in place. We are lucky we've got a very strong IT team behind us, but not all organisations have that and the experience to actually make that change to telehealth.
MindSpot’s submission affirmed the importance of workforce in digital health transition:
We endorse investment in ongoing training and support of the mental health workforce. The change agenda described in the strategic reviews clearly indicate the future clinical workforce will require skills and support to seamlessly integrate measurement and technology into everyday practice.
In September 2020, the Australian Digital Health Agency published the National Digital Health Workforce and Education Roadmap, a policy document that identifies a plan for supporting the health workforce transition to the use of digital supports and systems through training and education. This builds upon the National Digital Health Strategy published in 2016.
Various stakeholders identified that a barrier to digital mental health and telehealth solutions for certain demographics was a lack of access to internet or devices, due to remoteness or affordability constraints.
Appearing before the Committee, yourtown recognised the importance of acknowledging the digital divide for certain individuals:
… we know from our own experiences with our digital modalities many children drop out of waitlists, when they are trying to connect with our service, due to poor internet coverage. We know young people from disadvantaged areas have maintained that they may not have access to a laptop, tablet or PC [personal computer], and that's why landlines still remain a key part of our service modality for those with poor internet connection and some families who don't have access to appropriate technology.
Stride Mental Health advised that digital mental health services need to be something that is cheap and easily accessible:
… because not everybody has availability of wi-fi or the NBN [National Broadband Network], for that matter. It isn't that simple. The more rural and the more isolated people are, the harder it actually is. So, making sure that there's a simple way for people to engage with technology will actually go a very far way.
Mental Health Carers NSW similarly recognised there are ‘significant digital deficits in different parts of the community that render online support difficult to access,’ suggesting that:
… this would invite us … to focus delivery of online supports to people who can access them and find them appropriate for their needs and to use the resources freed up to provide other supports, either bridging the digital divide by direct grant of equipment and data or offering face-to-face supports in appropriate sanitary settings as an alternative.
To address the ‘digital divide’ in rural and remote communities, the Australian Association of Social Workers recommended ‘[t]hat government sets a priority to guarantee reliable telephone and internet connections to all rural and remote communities as an aspect of mental health service delivery.’
Fostering digital literacy and digital capabilities across the Australian population is essential for the transition to a future of blended-care models, virtual mental health care, and improved mental health systems.
The Committee commends the Australian Government for the development of the National Digital Health Workforce and Education Roadmap, and for investing in upskilling the digital literacy of health workers.
A key concern is that certain communities and individuals will not be able to partake in the increased access of mental health services due to low access to quality Internet services or digital devices.
Therefore, it is critical that mental health services continue to be supported and operate offline and in physical locations, to ensure that the delivery of digital services does not reduce access.
The Committee recommends that the Australian Government ensure the next National Digital Health Strategy (2022-27) explicitly addresses barriers to digital access, and includes specific actions for reducing the ‘digital divide’.
On 25 August 2021, the Australia Digital Health Agency announced a nationwide online survey on digital health in preparation for the next iteration of the National Digital Health Strategy (2022-27), which will be delivered by mid-2022.
Stride Mental Health identified that a key focus of investment needs to be in consumer digital infrastructure, ensuring that individuals have a device, stable Wi-Fi and the additional supports that enable service access.
This focus was further supported by NACCHO, who stated that:
The COVID-19 pandemic has highlighted the urgent need to develop and invest heavily in telehealth and digital social and emotional wellbeing supports and services for Aboriginal and Torres Strait Islander communities. Opportunities for telehealth expansion should be supported but not at the expense of further development of the local workforce.
… It is essential that the infrastructure funding allocations are equitably spread across the country, future focused and enable tele- and digital health services into the future.
Additionally, yourtown advised that mental health services need to be underpinned by stable, long-term funding in addition to foundational infrastructure, clarifying that:
When I talk about foundational infrastructure to be able to scale up mental health services in times of need, this includes having an existing, stable and skilled workforce who are versed in a range of service modalities, particularly digital online service modalities …
It is also important to have high-quality digital practice models and training available to staff, quality assurance and supervisory structures for a digital service model which can be replicated or expanded upon. It is also important that funding is made available quickly and it's accessible to organisations to manage those spikes.
The Australian Physiotherapy Association acknowledged the disjointed nature of current online systems:
It's very hard for our allied health professionals to actually access the digital health records effectively, because there are some barriers with software access and the investment that hasn't been there from the government to allow us to access that efficiently and effectively, so that's one thing.
Another gap within digital health infrastructure, raised by Stride Mental Health, is that a lot of organisations struggle with the concept of what a professional and appropriate platform to use in service delivery looks like:
... we would commonly use three or four different platforms in any given day as part of our normal operations. They are not really suitable for clinical environments where we are talking to people. It would be a tremendous help to sift through all of the providers that are there and say: 'Here's something that is actually appropriate. It's been cleared. It is useful.' Also the ability for different technology platforms to actually integrate would be helpful. It really needs foresight, a bit of strategy and a bit of vision from the government to say, 'This is actually something that we could possibly invest in and here's an easy way for you and your workforce to actually use it.'
Smiling Mind noted that Australians are proactively engaging with digital tools and services to support their mental health, and that this needs to be supported with funding and investment. It further noted that:
The pandemic has resulted in significant demand for our services at Smiling Mind. In 2020, we saw 1.25 million new people sign up to the Smiling Mind app. This is a 350 per cent increase in kids under 12, a 224 per cent increase in teachers and a 150 per cent increase in parents. The challenge is that we just can't keep up with this demand. While technology based approaches allow significant efficiency, great reach and access wherever it's needed, these approaches also require funding, and the mental health system as it currently stands does not value these services as an integral part of the mental health system.
On 16 September 2021, the Australian Government announced its investment of $10 million in research projects using the latest digital and mobile technology to improve primary health care delivery. Grants are available to Australian researchers to undertake this critical research through the landmark Medical Research Future Fund.
Mind Australia stressed the urgency for research into telehealth and digital services, before these tools become overused or over-embedded in our mental health supports and responses:
I think understanding when you can use digital services—as an initial assessment; as a crisis response; as supplementary and re-enforcing to other forms of services or treatments; as services that build strong participation, but only with certain other services in place at the same time, particularly when we're talking about the mix of clinical and psychosocial support and self-re-enforcing services—from a research point of view, before we overdesign our policy responses based on something we did because we had to, is absolutely critical.
Similarly, Smiling Mind suggested that research is required to demonstrate ‘for who, for when and for what presenting problems it's [telehealth] best suited’. While supporting the call for further research, Occupational Therapy Australia also noted the need to ‘understand that it doesn't necessarily work for everyone’.
The calls from stakeholders for further research into telehealth and digital mental health services were supported by Recommendation 3 of the MBS Review Taskforce’s Telehealth Recommendations 2020 report which recommended the Australian Government:
Evaluate, research and review models of telehealth and virtual health care to ensure the MBS item structures are appropriate for the Australian setting.
Further discussion on the importance of data collection, monitoring and evaluation, and research to support innovation is included in Chapter 7.
The Committee commends the Australian Government for its recent investment into digital health research, and encourages a continued focus on both identifying innovations and solutions to barriers to ensure equitable access to mental health and suicide prevention services.
The Committee recommends that the Australian Government commit ongoing funding for digital mental health research, considering the increased prevalence of mental health problems and rapid expansion of virtual mental health care.
The Committee supports Recommendation 3 of the MBS Review Taskforce’s Telehealth Recommendations 2020 report for the Australian Government to invest in an evaluation of telehealth and virtual health care to ensure that its delivery through the MBS is best suited for both virtual mental health and the Australian context.
The Committee also supports the Australian Government’s continued investment in digital health capabilities, and supports any action that further strengthens virtual mental health care, data use and information sharing systems, to maximise system efficiencies.
The Committee recommends that the Australian Government embed and expand virtual mental health care in the next National Digital Health Strategy (2022-27).