Chapter 1

Introduction

Referral of inquiry

1.1        On 22 June 2011, the Senate referred the following matter to the Community Affairs References Committees for inquiry and report:

The Government’s funding and administration of mental health services in Australia, with particular reference to:

a)      the Government’s 2011–12 Budget changes relating to mental health;

b)      changes to the Better Access Initiative, including:

i.        the rationalisation of general practitioner (GP) mental health services;

ii.       the rationalisation of allied health treatment sessions;

iii.      the impact of changes to the Medicare rebates and the two-tiered rebate structure for clinical assessment and preparation of a care plan by GPs; and

iv.      the impact of changes to the number of allied mental health treatment services for patients with mild or moderate mental illness under the Medicare Benefits Schedule;

c)      the impact and adequacy of services provided to people with mental illness through the Access to Allied Psychological Services program;

d)     services available for people with severe mental illness and the coordination of those services;

e)      mental health workforce issues, including:

i.       the two-tiered Medicare rebate system for psychologists,

ii.      workforce qualifications and training of psychologists, and

iii.     workforce shortages;

f)       the adequacy of mental health funding and services for disadvantaged groups, including:

i.       culturally and linguistically diverse communities,

ii.       Indigenous communities, and

iii.       people with disabilities;

g)      the delivery of a national mental health commission; and

h)      the impact of online services for people with a mental illness, with particular regard to those living in rural and remote locations and other hard to reach groups; and

i)        any other related matter.

1.2        The reporting date for the inquiry was originally set as 16 August 2011; this date was subsequently extended to 20 September 2011, and again until 20 October 2011. The committee tabled an interim report on 20 October, indicating that the final report would be tabled by 28 October. A second interim report was presented on 28 October 2011 to give the committee time to fully consider the evidence to the inquiry.

Conduct of inquiry

1.3        The inquiry was advertised in The Australian and on the internet. The committee also wrote directly to a number of organisations and individuals inviting submissions to the inquiry. The committee received over 1500 submissions as well as form letters, other correspondence and additional information. The committee held two public hearings, the first in Melbourne on 19 August 2011 and the second in Canberra on 5 September 2011.

1.4        The large volume of evidence provided to the committee has delayed completion of the processing of submissions. In a later sitting week there will be a supplementary tabling of evidence received.

Privilege matters

1.5        In mid-July 2011 the committee was considering the submissions that it had received. The committee noted that over ten submissions incorrectly stated that the committee had reached a conclusion:

The Senate Community Affairs Committee has concluded that there are no grounds for the two-tiered Medicare rebate system for psychologists and recommends the single lower rate for all psychologists including clinical psychologists.[1]

1.6        The committee established that these submissions had been prepared in response to a newsletter circulated via email by Mr Cichello from the Australian Psychological Society's College of Clinical Psychologists (CCP). This newsletter had presented a hypothetical scenario, intended to encourage CCP members to make submissions to the inquiry, but was widely misconstrued as implying that the committee had prejudged the issue.

1.7        Once the committee became aware of the source of this problem, it made contact with the Australian Psychological Society (APS) and was advised that there had already been clarification within the organisation to address the misconception. As the newsletter was by this time some days old, the committee took the view that there was no merit in trying to correct the record to the original email distribution list. While it meant that the committee received submissions that inaccurately described the committee's work, this did not actually interfere with that work. The committee decided to place on its submissions webpage a notice stating: 'The committee advises that, contrary to some submissions, it has made NO recommendation regarding the two-tiered rebates system'.[2]

1.8        On 24 July, the Australian Association of Psychologists Incorporated (AAPI) sent a newsletter by email to a distribution list that comprised a large number of psychologists (not only its own members), and placed the newsletter on its website. The email / newsletter included the following:

Reading the submissions already received by the Senate Inquiry, one can quickly and easily ascertain how many of our 'clinical colleagues' view the 86% of their non 'clinical' colleagues.

We will be presenting to our readers some of the more interesting comments over the next few weeks, along with the names of the people who have made such arbitrary and derogatory statements. Their comments and names are already publicly available on [the committee website]...

Treat yourself to their collective wisdom by reading their submissions on the above webpage. If you feel inspired to lodge complaints to the PBA about their unethical conduct, you may like to familiarise yourself with Sections C.1.2, C.2.1, C.2.3.a.b.d & f; as well as the expectations that psychologists conduct themselves in ways which respect the rights and dignity of all others, with propriety and integrity. You will get plenty of material from reading their submissions for ethics complaints. All such complaints need to be assessed by the PBA.

As most, if not all of these people are members of the APS; you might consider sending the same ethics complaints on to their professional body that developed the Code of Ethics...

...

AAPi will be naming the 'clinical' psychologists who denigrate most of Australia’s psychologists in their submissions to the Senate Inquiry, to assist you in deciding who you want your training funds to go to.

1.9        Within 48 hours of the emailed newsletter being distributed, the committee had received complaints about the newsletter from representatives of two different professional associations, including Mr Cichello. It also received complaints from individuals who believed the message was threatening them or their professional practice.

1.10      The issue was further complicated by the fact that the Mr Cichello had emailed members of the CCP on or around 25 July, drawing their attention to the AAPI newsletter and advising them that he had complained about it to the committee. Some of his organisation's members, concerned about the AAPI newsletter, then wrote to the committee asking that their names be withheld from their submissions, or that their submissions be made confidential.

1.11      On 26 July, the committee held a private meeting, at which it agreed to write immediately to the AAPI, asking them to email a message to their distribution list:

• Indicating that they have withdrawn their most recent newsletter as it may have led some psychologists to believe they were being threatened or attacked over evidence they had given to the Senate inquiry;
• Stating that it was not the AAPI's intention to make any such threat;
• Explaining the requirements of privilege resolution 6(10) and section 12 of the Parliamentary Privileges Act 1987; and
• Encouraging their members to make submissions to the inquiry should they so wish.

1.12      The committee also wrote to Mr Cichello, asking him to email his members:

• Indicating that the Community Affairs Committee had reminded all parties participating in its inquiries, including the Australian Association of Psychologists Inc, of the requirements of privilege resolution 6(10) and section 12 of the Parliamentary Privileges Act 1987; and
• Encouraging their members to make submissions to the inquiry should they so wish.

1.13      On the evening of 26 July, the AAPI complied with the committee's request both by issuing a corrective email and removing the 24 July newsletter from their website. Mr Cichello likewise immediately sent out an email in response to the committee's request.

1.14      Also on 26 July, the committee wrote a general letter to all four psychology associations it had been dealing with to that point: the AAPI, the CCP, the CCP's parent organisation the Australian Psychological Society (APS), and the Australian Clinical Psychology Association (ACPA). The letter stated in part:

The committee is taking this opportunity to draw to the attention of stakeholders the Senate Privilege Resolutions... Of most relevance are resolutions one and six, which concern procedural protection of witnesses, and matters constituting contempt.

If, at any stage, you have any concerns about the conduct of any party in relation to the committee's inquiry, you should bring these concerns directly to the attention of the committee, and let the committee deal with them.

1.15      Unfortunately, this did not represent the end of the matter. Over subsequent weeks the committee received a number of communications from psychologists, complaining about the conduct of members of their own and other organisations. Subjects of the complaints included representatives of the AAPI, the CCP, the APS, and some individuals. Some of this correspondence reflected professional disagreements and debates about submitters' evidence. These were generally accepted as supplementary submissions and answers to questions on notice, which have been published by the committee.

1.16      However, there were also complaints that individuals were being threatened with penalties as a result of their evidence to the committee. The threats included the possibility of loss of office within organisations. As a result of some of these complaints, the committee provided oral advice to a range of parties and on 12 August 2011 wrote to the Australian Psychological Society and to the chairs of its individual colleges, reiterating the importance of parliamentary privilege and the protection of witnesses. It wrote to the APS on a third occasion on 23 August 2011 for a similar purpose.

1.17      Despite the committee's swift response to several complaints, it continued to receive emails and phone calls, right up to the time of tabling the report, from submitters wanting their names withheld or removed from the committee's website, or for their submissions to be made confidential. A significant proportion of these emails and calls appeared to stem from disquiet over the actions of professional associations, particularly the AAPI.

1.18      The committee wishes to place on record that the actions of numerous parties within the psychology profession caused considerable frustration for the committee, anxiety for submitters, and reflected poorly on most of the professional bodies involved. The events above caused significant additional work for the committee without any benefit to its consideration of the terms of reference.

1.19      On balance the committee decided not to seek a referral of any of the above matters to the Senate Committee of Privileges because, while many of the actions involved may constitute potential contempts, the committee's main concer—the obtaining of evidence—as not significantly impeded. While large numbers of submitters sought a change in the status of their submissions (to name withheld or confidential) very few sought to withdraw from the process. On the contrary, several submitters appeared to have been provoked into making submissions because they were angry about the conduct of individuals or organisations.

1.20      The committee advises the professional associations that it remains vigilant regarding any penalties imposed on a witness as a result of evidence given to this inquiry.

Scope of inquiry

1.21      The Government's 2011–12 Federal Budget includes a commitment to National Mental Health Reform. Most of the Terms of Reference for the inquiry are related to, or affected by, funding changes made in the budget.[3] The Government explains in the budget papers that the major goal of the National Mental Health Reform is to address service gaps in the mental health care system, with a particular focus on early intervention and addressing the needs of priority groups. [4]

1.22      Priority groups identified in the budget papers include:

• People with a severe and persistent mental illness;
• Young people (under 25);
• Men;
• Indigenous people;
• People from Culturally and Linguistically Diverse (CALD) backgrounds;
• Carers of people with a mental illness;
• Residents of rural and remote areas;
• People living in low income areas; and
• People with a disability.[5]

1.23      As well as stating its immediate goals for mental health reform, the Government also plans to develop a ten year reform roadmap for mental health. This will be informed by the results of the current reform agenda, data analysis, research, and the advice of a National Mental Health Commission also established through funding provided in the 2011–12 budget.

1.24      The first of the two major programs affected by the budget changes is the Better Access Initiative.  This is a program designed to encourage patient referrals between GPs, psychologists, clinical psychologists, social workers and occupational therapists, and to promote mental health education and training for health professionals. [6]  The program expands services that attract a rebate under the Medicare Benefits Schedule (MBS), and like other MBS items often involves a co-contribution by the consumer.  The program is not capped by government.    

1.25      The second program is the Access to Allied Psychological Services (ATAPS) program.  This has been in existence since 2002 and was designed to fund 'short term psychology services for people with mental health disorders through a capped fundholding arrangement delivered through Divisions of General Practice'.[7]  The ATAPS projects enable GPs to refer patients with high prevalence disorders such as depression and anxiety to allied health professionals (predominantly psychologists).[8] The program is not funded through the MBS and does not generally attract a co-contribution from consumers.  

General views on the budget announcements

1.26      There was a mixed reaction for the budget announcements with broad support for the overall increase in the mental health budget, qualified by some stakeholders who objected to aspects of the detailed proposals.  Consumer organisations in particular welcomed the focus in improving mental health in Australia. The Mental Health Council of Australia expressed the view that the announcements were: 

...an important step towards improving the mental health system and the mental health of all Australians. They reflect a commitment by the Government to improving mental health and increasing the availability of mental health services in Australia.[9]  

1.27      The Consumer Health Forum agreed with the view that changes will have benefits for mental health consumers:

The Federal Government's 2011-12 Budget promised a range of new initiatives for mental health services that will result in improved outcomes for many Australians.[10]

1.28      The Public Health Association of Australia also concurred that the changes demonstrate a commitment to improving mental health:

The overall changes to the Federal Mental Health Budget are justified and the focus on mental health is welcomed by PHAA.[11]

1.29      The Australian College of Mental Health Nurses stated:

When the Government's mental health reform package was announced as part of the Budget in May 2011, the ACMHN welcomed and supported this investment in improving services and support for people with mental health issues.[12]

1.30      Similarly, the Australian Nursing Federation strongly endorsed the package:

The Australian Nursing Federation (ANF) has welcomed the Australian Government's additional $1.5 billion budgetary commitment to Australia's mental health services. The raft of new initiatives announced in the 2011/12 Budget will help provide much-needed social and clinical support for mental health across the country.[13]

1.31      The Australian Medical Association, the Royal Australian College of General Practitioners, as well as the Australian Psychologists Society all expressed concerns about the impact of the changes to the Better Access initiative.  The AMA requested that the committee:

...recommend that the Government reverse its 2011/12 Federal Budget decision to cut Medicare funding for mental health services delivered by GPs and psychologists under the Better Access Program.[14]

1.32      The Australian Psychological Society urged the committee to:

...focus its attention on the Federal Budget cuts to the Better Access initiative as these are due to come into effect on 1 November 2011 and will deny effective psychological treatment to an estimated 87,000 people per annum from this date.[15]

1.33      While the Royal Australian College of General Practitioners said that:

The College is gravely concerned regarding the proposed cuts to the Better Access program and the subsequent impact on mental health delivery for every patient age group, demographic, and geography throughout Australia.[16]

Consultation on mental health spending

1.34      In 2008, the Government established the National Advisory Council on Mental Health (NACMH). Granted $2.4 million over three years as part of a 2007 Federal Election commitment, the Council:

...provide[s] a formal mechanism for the Australian Government to gain independent advice from a wide range of experts to inform national mental health reform.[17]

1.35      The NACMH is chaired by the Hon Mark Butler MP, Minister for Mental Health and Ageing. Appointed members were:

Mr Michael Burge; Monsignor David Cappo AO, Deputy Chair; Associate Professor Neil Cole; Ms Adele Cox; Mr David Crosbie; Professor Allan Fels AO; Professor Ian Hickie AM; Professor Lyn Littlefield OAM; Adjunct Professor John Mendoza, former Chair;[18] Professor Helen Milroy; Ms Dawn O’Neil AM; Dr Rob Walters.[19]

1.36      In December 2010, the Mental Health Expert Working Group was established specifically to provide advice on mental health reform in the lead-up to the 2011–12 Federal Budget. Membership of this group comprised:

Dr Christine Bennett; Monsignor David Cappo AO; Dr Pat Dudgeon; Mr Anthony Falker; Mr Toby Hall; Professor Ian Hickie AM; Professor Lyn Littlefield OAM; Ms Janet Maher; Dr Christine McAuliffe; Professor Patrick McGorry; Professor Frank Oberklaid; Ms Sally Sinclair.[20]

1.37      The Terms of Reference for the expert group were determined as follows:

The Mental Health Expert Working Group (MHEWG) is being established as a time-limited working group to provide confidential, strategic and practical advice to the Australian Government to inform mental health reform directions and decisions.

The MHEWG will provide significant input to the Australian Government about how to achieve well coordinated, cost-effective and lasting reforms to mental health care across a broad range of clinical and non clinical service systems with the aim of developing a strong, sustainable system now and into the future.[21]

1.38      Questions were asked by some submitters during the inquiry as to why it was necessary to establish a new group to provide advice on the above matters rather than consult the NACMH. In response to a question about how the membership of the expert group was determined, the Department of Health and Ageing responded:

Twelve members were appointed by the Minister for Health and Ageing, as individual experts on broader social care and participation issues affecting people with mental illness. Membership was settled in consultation with other relevant Commonwealth Portfolios.[22]

1.39      However, other submitters were dissatisfied with its composition:

This submission refutes the defence that this group are independent and impartial including proffered explanation that the group are picked from a small academic mental health sector. There are nearly forty Australian Universities who could make solid contribution to a mental health policy expert panel...

This issue is considerably more significant than concerns about conflict of interest. The mental health reform agenda is intrinsically based in closed, non-consultative and exclusive process which is part of the larger imposed shift of health reform.... [23]

1.40      The Department rejected the suggestion that such a group could comprise members without any perceived conflict of interest:

Everyone here declared their conflict of interest. Let us be very clear. Mental health is not a large community. Everyone, in some way, is conflicted because everyone is involved in the delivery of service. All of these people are passionate advocates, and good on them, because they care about the delivery of service. What we did and what the minister did with this process was actually try to get a balanced view about how you deliver a balanced package to meet mental health needs, and the important thing that came out of this was an acknowledgement that mental health is not just a health issue. Mental health is an employment issue, a housing issue, an issue of income, an issue of social justice and I could go on.[24]

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