Chapter 1

Introduction

1.1        One in five Australians will experience mental illness in any given year, no matter where in Australia they live.[1] Over a lifetime, almost half of all Australians will experience a mental illness.[2]

1.2        However, Australians living in rural and remote communities are less likely to seek mental health treatment than their city dwelling counterparts.

1.3        In 2016–17, people living in remote areas accessed Medicare-subsidised mental health services at a rate of three times less than people living in major cities. In very remote areas the rate of access decreased even further, with people accessing services at a rate of six times less than in major cities.[3]

1.4        The reduced access to mental health services is reflected in the high rate of suicide in rural and remote communities. In 2016, 47 per cent of all suicides occurred outside capital cities, even though these areas account for only 32 per cent of Australia's total population.[4]

1.5        The Royal Flying Doctor Service (RFDS) released a major report in March 2017 which sparked a national conversation about the state of mental health in remote and rural communities.[5]

1.6        Mental Health in Remote and Rural Communities[6] described how even though Australians living in rural and remote areas are impacted by mental disorders at the same rate as people living in major cities, they experience unique barriers to receiving care.[7] The report outlined data about the mental health services provided by the RFDS, including mental health and social and emotional wellbeing programs and aeromedical retrievals, in order to describe the impact of mental disorders on rural and remote Australians receiving those services.[8]

1.7        In January 2018, the Chief Executive Officers of the RFDS, Dr Martin Laverty, and of Mental Health Australia, Mr Frank Quinlan, expressed the view that a lack of coordination and funding in the sector had led to rural and remote patients missing out on services. Dr Laverty described the low rate of people accessing mental health services in rural and remote areas as a crisis.[9] In response to this, the Minister for Health, the Hon. Greg Hunt MP, stated that he believed there to be a 'very significant challenge' for mental health services in regional areas.[10]

1.8        In March 2018, the Senate referred an inquiry into the accessibility and quality of mental health services in rural and remote Australia to the Senate Community Affairs References Committee (committee).[11] The terms of reference for the committee's inquiry are outlined below:

  1. the nature and underlying causes of rural and remote Australians accessing mental health services at a much lower rate;
  2. the higher rate of suicide in rural and remote Australia;
  3. the nature of the mental health workforce;
  4. the challenges of delivering mental health services in the regions;
  5. attitudes towards mental health services;
  6. opportunities that technology presents for improved service delivery; and
  7. any other related matters.[12]

Defining rural and remote

1.9        There are a number of classifications used by government health programs which seek to measure the remoteness of a particular community, such as the Australian Bureau of Statistics (ABS) Remoteness Areas, the Modified Monash Model (MMM) and the Accessibility and Remoteness Index of Australia (ARIA). A 'remoteness classification' refers to a set of geographic boundaries that define the areas contained within them and assigns them to a specific remoteness category.

1.10      Each of these remoteness classifications rely on data from the ABS and information collected during the five-yearly Census of Population and Housing. Effectively, each classification uses the distance from an urban centre as an indicator of whether an individual may or may not have access to particular services.

1.11      For example, the ABS Remoteness Areas classifies each area in Australia as:

Figure 1.1—Map of the 2016 ABS Remoteness Areas

Source: ABS.[14]

1.12      Remoteness classifications are used in a wide variety of settings, such as to determine a person's eligibility for telehealth, identify areas with a workforce shortage or to analyse statistical data.

1.13      The committee has not chosen to limit itself to one particular remoteness classification or to strictly enforce these definitions in the course of its inquiry. This report refers to particular remoteness classifications where relevant, and uses the term 'rural and remote' to refer generally to regional and remote communities.

1.14      The committee held public hearings in a number of locations which may be considered a regional town. This was in recognition of the fact that often mental health services for residents of rural and remote areas are located in regional hubs which have the population to sustain the services. These regional hubs can also act as a base for outreach services to smaller rural and remote communities.

Prevalence of mental illness and suicide in rural and remote Australia

1.15      Mental health is defined as 'a state of emotional and social wellbeing where the individual can cope with the normal stresses of life and achieve their life potential. It includes being able to work productively and contribute to community life'.[15]

1.16      Mental illness refers to a clinically diagnosable disorder which affects a person's cognitive, emotional and social abilities, and interferes with the lives and productivity of people.[16] Mental illness covers a spectrum of disorders that vary in severity and duration and include disorders such as anxiety, depression and addiction.[17]

1.17      The most recent National Survey of Mental Health and Wellbeing was conducted in 2007. The survey found that approximately 45 percent of Australians aged 16–85 years will experience a diagnosable mental illness in their lifetime.[18] The survey also found that the prevalence of mental illness outside capital cities and major urban areas was marginally lower than in capital cities.[19]

1.18      However, the same cannot be said for the prevalence of suicide in Australia's rural and remote communities. As remoteness increases, so too does the rate of suicide.

Figure 1.2—Percentage of avoidable deaths from suicide and self-inflicted injuries (persons aged 0–74 years), 2010–2014

Source: Department of Health.[20]

1.19      As shown above, between 2010 and 2017, the rate of suicide in remote areas was almost double that of major cities, while the rate in very remote regions was almost 2.5 times that of major cities.

1.20      The high rate of suicide in rural and remote communities is in part driven by the increased rate of suicide amongst Aboriginal and Torres Strait Islander peoples.[21]

1.21      Statistics show that Aboriginal and Torres Strait Islander peoples are 1.2 times as likely to die from mental illness as non-Indigenous Australians and 1.7 times as likely to be hospitalised for mental illness. Furthermore, Aboriginal and Torres Strait Islander peoples aged 12–24 years are three times as likely to be hospitalised with a mental illness as non-Indigenous young persons of the same age.[22]

1.22      While the prevalence of mental illness does not differ across Australia, the impact of mental illness is far greater in rural and remote communities.

Living in rural and remote communities

1.23      Approximately 10 per cent of Australia's population, or 2.6 million people, live in outer regional, remote and very remote areas.[23]

1.24      While people living in rural areas report high levels of civic participation, social cohesion, social capital, volunteering and informal support from friends, neighbours and the community, they experience unique circumstances such as flood, fire, drought, as well as economic variability and population downturn, which can impact on their health and wellbeing.[24]

1.25      Residents of rural and remote communities face a unique combination of factors which are believed to contribute to low rates of access to mental health services and the high rate of suicide. These include poor access to primary and acute health care, social and geographical isolation, limited mental health services, funding restrictions, ongoing stigma surrounding mental illness and the cost of travelling to and accessing mental health services.[25] In addition, Aboriginal and Torres Strait Islander peoples face cultural barriers and a lack of mental health services which are culturally appropriate.[26]

1.26      The barriers which impact upon the availability and accessibility of mental health services in rural and remote communities will be explored further throughout this report.

Aboriginal and Torres Strait Islander communities

1.27      Aboriginal and Torres Strait Islander peoples are more likely to live in rural and remote communities with approximately 20 per cent of all Aboriginal and Torres Strait Islander peoples living in remote or very remote areas, compared to only 1.7 percent of non-Indigenous Australians.[27]

1.28      Aboriginal and Torres Strait Islander peoples make up approximately three per cent of Australia's population but continue to be disproportionately represented on almost every indicator of social, health and wellbeing outcomes.[28]

1.29      Social determinants of health and historical factors such as intergenerational trauma, racism, social exclusion, and loss of land and culture are commonly recognised as factors which contribute to these ongoing disparities in health care.[29]

1.30      The level of psychological distress for Aboriginal and Torres Strait Islander peoples over 18 years old is nearly three times the rate of non-Indigenous people across Australia.[30]

1.31      The alarmingly high rate of suicide amongst Aboriginal and Torres Strait Islander peoples has led to the development of a number of state and national strategies which seek to address the over representation of Indigenous Australians in the mental health system as a priority.[31]

National framework for mental health

1.32      Mental health services, like most other health services in Australia, are funded through a combination of federal, state and territory, and private health insurance spending and delivered by a combination of public, private and non-government sector providers.

1.33      Public mental health services include psychiatric hospitals, psychiatric units in general hospitals, community residential units and community mental health services, which are funded by both the Commonwealth and state and territory governments.[32]

1.34      At a federal level, the Commonwealth Government has established 31 Primary Health Networks (PHNs) which are responsible for the coordination and commissioning of health care, including mental health services, in their local areas.[33] PHNs are expected to work with state and territory Local Hospital Networks to ensure that the national approach to mental health service delivery is effective at the local level.[34]

1.35      Mental health services are provided in the private sector by private psychiatrists, general practitioners, private psychiatric hospitals and private allied health professionals. However, the Commonwealth Government also contributes to these services through Medicare Benefits Schedule rebates and private health insurance rebates.[35]

1.36      Non-government organisations include not-for-profit and community managed organisations, which promote independence and mental wellbeing, provide support and advocacy, or provide specialised information, accommodation and rehabilitation services.[36]

Fifth National Mental Health and Suicide Prevention Plan

1.37      In 2014, the National Mental Health Commission conducted a review into mental health services and programs across Australia. The review found that Australia's mental health system was poorly planned, fragmented, badly integrated and lacked accountability.[37]

1.38      In response, the Council of Australian Governments (COAG) released the Fifth National Mental Health and Suicide Prevention Plan (Fifth National Plan) in August 2017. The Fifth National Plan aims to achieve reform and improved outcomes in eight identified priority areas:

1.39      Notably the Fifth National Plan is the first national mental health strategy to include a national suicide prevention plan.[39] Under the suicide prevention priority area, governments will establish a new Suicide Prevention Subcommittee which will develop a National Suicide Prevention Implementation Strategy.[40]

1.40      The National Suicide Prevention Implementation Strategy will include a focus on Aboriginal and Torres Strait Islander suicide prevention and a draft version of the strategy is expected to be released in mid-2019 for public consultation, prior to release of the final strategy by 2020.[41]

1.41      The Fifth National Plan committed all governments to work together to achieve integration in the planning and delivery of mental health services and placed consumers and carers at the centre of how services are planned, delivered and evaluated.[42]

Overview of state government services and strategies

1.42      State and territory governments provide funding for public sector and community services and set legislative, regulatory and policy frameworks for mental health service delivery within their jurisdiction.[43]

1.43      The main government bodies delivering mental health services to rural and remote areas in each state and territory and the key strategies for mental health in these areas are outlined below.

Western Australia

1.44      Public mental health services in rural and remote Western Australia (WA) are delivered by the WA Country Health Service, part of the WA Department of Health. Health services are organised by a hub and spoke model, with services based in larger regional and metropolitan centres, and specific rural services funded to address locational disadvantage.[44]

1.45      The WA Mental Health Commission is responsible for commissioning of state-government funded mental health services from government and non-government providers, and also provides and has responsibility for commissioning mental health, alcohol and other drug prevention and health promotion programs. Investment has been directed to the implementation of a comprehensive suicide prevention program (Suicide Prevention 2020), public education campaign initiatives, and the expansion of community-based bed and treatment services.

1.46      Mental health services in WA are guided by the Western Australian Mental Health, Alcohol and Other Drug Services Plan 2015–2025.[45]

1.47      The committee held five public hearings in WA, in recognition of the vast rurality of the state and high number of remote communities. WA encompasses 32 per cent of Australia's remote communities and 31 per cent of very remote communities.[46]

1.48      The committee held its first public hearing in the south-west regional town of Albany on 5 June 2018. The committee held its next four public hearings across the remote Kimberley region in northern WA, visiting Kununurra and Halls Creek on 5 July 2018 and Derby and Broome on 6 July 2018.

Northern Territory

1.49      The Northern Territory (NT) makes up approximately 18 per cent of Australia's land mass, but only one per cent of the total national population. Approximately 33 per cent of the NT population live in areas considered remote or very remote.[47]

1.50      Public health services in the NT, including mental health services, are delivered by the Top End Health Service (Darwin metropolitan and the northern part of the territory) and the Central Australia Health Service (Alice Springs and the southern part of the territory).[48]

1.51      Key strategies relating to mental health services and suicide prevention in the NT include the Northern Territory Suicide Prevention Strategic Framework 2018–2023, which was recently launched in September 2018, the Northern Territory Mental Health Strategic Plan 2015–2021 and the Northern Territory Health Aboriginal Cultural Security Framework 2016–2026.

1.52      Provision of funding to non-government organisations is managed by the Mental Health Alcohol and Other Drugs Branch of the NT Department of Health.[49] This funding supports services such as subacute care, mental health promotion, support and advocacy, primarily in Darwin and Alice Springs, with a small number of providers in Katherine and Tennant Creek.[50]

1.53      The committee held three public hearings in the NT: two on 9 July 2018 in Darwin and Katherine and a further hearing in Alice Springs on 10 July 2018.

South Australia

1.54      SA Health provides mental health services for South Australians through community health centres, public hospitals and in-home care.[51] SA Health is also responsible for implementation of the South Australian Suicide Prevention Plan 2017–2021.[52]

1.55      The South Australian Mental Health Commission was established in 2015 to strengthen mental health and wellbeing in the state.[53] Subsequently, the commission released the SA Mental Health Strategic Plan 2017–2022 which recognised the need to target support for rural and remote communities.[54]

1.56      The committee held one public hearing in South Australia in Whyalla on 20 July 2018.

Queensland

1.57      Approximately 33 per cent of Queensland's 5 million residents live in rural and remote areas, with 95 per cent of Queensland's land mass classified as rural or remote.[55]

1.58      The committee held two public hearings in Queensland: Mount Isa on 29 August 2018 and Townsville on 30 August 2018.

1.59      The Queensland Department of Health (Queensland Health) is responsible for the overall management of public health in the state. Public health services, including mental health services, are provided through service agreements with 16 independent Hospital and Health Services, each governed by its own board and chief executive.[56] Queensland Health also commissions non-government organisations to provide mental health services.

1.60      The Queensland Mental Health Commission was established in 2013 to provide ongoing reform towards an integrated, evidence-based, recovery-oriented mental health and substance misuse system.[57] The commission is responsible for preparing, monitoring, reporting and reviewing the Queensland Mental Health, Drug and Alcohol Strategic Plan 2014–2019.[58] In 2016, the Queensland Government and the Queensland Mental Health Commission released the Queensland Rural and Remote Mental Health and Wellbeing Action Plan 2016–18.

New South Wales

1.61      New South Wales (NSW) Health is the provider of public hospital and health services in NSW, including specialist mental health services. NSW Health operates seven rural and regional local health districts, each of which has 'the flexibility to tailor services where most needed and using methods most appropriate to their communities'.[59] Two specialty networks, Justice Health and Forensic Mental Health Network and Sydney Children's Hospitals Network, also provide specialist mental health services to rural and remote areas.[60]

1.62      The NSW Ministry of Health Mental Health Branch funds non-government organisations to deliver treatment, psychosocial rehabilitation and recovery/disability support programs. It also invests in the Centre for Rural and Remote Mental Health to support the mental health of rural and regional residents through research and evidence-based service design, delivery and education.[61]

1.63      The Mental Health Commission of NSW is an independent statutory agency responsible for monitoring, reviewing and improving mental health and wellbeing for people in NSW.[62] The Mental Health Commission developed Living Well: A Strategic Plan for Mental Health in NSW 2014–2024, which was adopted by the NSW Government and informed the development of a new strategic framework for mental health in the state.[63]

1.64      The NSW Strategic Framework and Workforce Plan for Mental Health 2018–2022 was released in September 2018.[64] Other relevant key plans and strategies for mental health and rural health more broadly include the NSW Rural Health Plan Towards 2021 and the NSW Aboriginal Health Plan 2013–2023.[65]

Victoria

1.65      The Victorian Government Department of Health and Human services is responsible for mental health care in the state of Victoria. The Victorian Government funds a range of primary, community-based and hospital mental health services.[66]

1.66      The Mental Health Complaints Commission is an independent, specialist body established to resolve complaints about Victorian public mental health services, safeguard patient's rights and recommend improvements to services.[67]

1.67      In November 2015, the Victorian Government launched Victoria's 10-year mental health plan, outlining the government's long term strategy to improve mental health outcomes for Victorians with a mental illness, their families and carers.[68]

1.68      Major strategies developed under the plan include the Victorian suicide prevention framework 2016–25, the Mental Health Workforce Strategy, and the Aboriginal Social and Emotional Wellbeing Framework.

Tasmania

1.69      The Mental Health, Alcohol and Drug Directorate, within the Tasmanian Department of Health and Human Services, is responsible for the provision of mental health services throughout the state.[69]

1.70      Statewide Mental Health Services is the provider of care for people with a severe mental illness in inpatient facilities and in the community. In addition, Mental Health Services works with the community sector to provide support to people with a moderate to severe mental illness.[70]

1.71      In October 2015, the then Minister for Health launched the Rethink Mental Health Better Mental Health and Wellbeing – A Long-Term Plan for Mental Health in Tasmania 2015–25 which identified a reform agenda to improve the mental health of Tasmanians and priority action areas.[71]

1.72      Approximately 40 per cent of Tasmanian's live outside of Hobart and Launceston in areas classified as outer regional, remote and very remote.[72]

1.73      The committee held two public hearings in Tasmania: one in the north-west town of Devonport on 5 September 2018 and one on the east coast in St Helens on 6 September 2018.

Australian Capital Territory

1.74      ACT Health provides mental health services in hospital and community settings for residents of the Canberra region.[73] However, the committee did not receive any evidence relating to the accessibility of mental health services in the Canberra region.

1.75      The committee held three public hearings in Canberra on 19 July 2018, 18 September 2018 and 16 October 2018 to hear from peak representative bodies of the mental health sector, non-government organisations, academics, and relevant Commonwealth government departments.

Structure of the report

1.76      This report is presented in six chapters:

Conduct of the inquiry

1.77      On 19 March 2018, the Senate referred the inquiry into the accessibility and quality of mental health services in rural and remote Australia to the committee for inquiry and report by 17 October 2018.[74] The Senate subsequently granted the committee extensions of time to report until 4 December 2018.[75]

1.78      The committee advertised the inquiry on its website and wrote to relevant individuals and organisations inviting submissions by 11 May 2018. The committee continued to accept submissions after that date.

1.79      The committee received 138 submissions. A list of submissions received by the committee is available at Appendix 1 and copies of public submissions can be accessed via the committee's website.

1.80      During the inquiry, the committee travelled across Australia to hear from state government bodies, mental health service providers, academics, peak representative organisations, local PHNs and community members about the quality and accessibility of mental health services in rural and remote areas.

1.81      In total, the committee held sixteen public hearings. A list of the witnesses who appeared at each hearing is available at Appendix 2.

1.82      The committee also conducted two site visits in the course of its inquiry. The committee visited the West Kimberley Regional Prison in Derby on 6 July 2018 and the Barkly Work Camp in Tennant Creek on 10 July 2018. Reports on the committee's sites visits are at Appendix 3.

Acknowledgements

1.83      The committee thanks all of the individuals and organisations who submitted to the inquiry and appeared as witnesses.

1.84      The committee also thanks the WA Department of Justice and the NT Department of the Attorney-General and Justice for facilitating the committee's site visits. The committee extends its gratitude to the staff and prisoners of the facilities who were generous with their time and willingness to discuss their experience with mental health.

Notes on references

1.85      References in this report to Committee Hansard are to proof transcripts. Page numbers may vary between the proof and official transcripts.

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