Barriers to accessing mental health services
Throughout this inquiry, the committee heard there were numerous
barriers specific to rural and remote communities which restricted or prevented
people from accessing mental health services.
The Australian Mental Health Commissions submitted that there are many
factors unique to rural and remote communities which impact their ability to
access mental health services, as well as increase their likelihood of
experiencing mental illness:
Although social features of rural and remote communities are
protective of mental health, for example resilience and a sense of community,
people living in rural and remote areas can also be exposed to a variety of
risk factors that contribute to mental ill-health. These are often tied to
their location and include environmental adversity, geographic isolation,
poorer socioeconomic circumstances, and restricted access to services. For
Aboriginal and Torres Strait Islander peoples, the above risk factors
associated with living in rural and remote Australia are compounded by the
historic and cultural experiences of intergenerational trauma and socioeconomic
This chapter will outline the rates at which rural and remote
Australians access mental health services and the factors which contribute to
the availability of these services. It will consider the practical effects of
distance and other social determinants of health which are felt by rural and
remote communities. Finally, this chapter will consider the continuing impact
of stigma and concerns regarding privacy and confidentiality, which are
pertinent to small communities.
Access rates of mental health services
While the prevalence of mental illness is similar across Australia,
evidence provided to the committee suggested that people living in rural and
remote areas access mental health services at a much lower rate than people
living in major cities and inner regional areas.
In 2016–17, people living in major cities accessed Medicare Benefits
Schedule (MBS) funded mental health services at a rate of 495 encounters per
1000 people. The rate of encounters decreases the more remote the
location, with 297 encounters per 1000 people for outer regional areas, 145 per
1000 people for remote areas and 81 encounters per 1000 people for very remote
The rate of encounters with MBS funded mental health services decreases
rapidly by remoteness across the range of mental health service providers
available including psychiatrists, psychologists, general practitioners (GPs)
and allied health professions, as demonstrated in Table 3.1 below.
Table 3.1—Medicare-subsidised mental health services, by
provider type and remoteness area, per 1000 population (2016–17)
Allied health professionals
1.6 times lower
1.3 times lower
1.3 times higher
2.8 times lower
2.4 times lower
1.6 times lower
1.3 times lower
4.0 times lower
5.3 times lower
4.3 times lower
2.3 times lower
2.2 times lower
6.0 times lower
9.0 times lower
7.2 times lower
4.4 times lower
6.5 times lower
As a percentage of the population, 10.2 per cent of people in major
cities accessed MBS subsidised mental health services, compared to only 8.1 per
cent in outer regional areas, 4.8 per cent in remote areas and 2.8 per cent in
very remote areas.
The committee heard that the low rate of encounters with MBS funded
mental health services is of concern as lower access to early intervention
services can result in intensification of need, comorbidity, chronic conditions
and greater rates of hospitalisation.
Are services available when and where they are needed?
As noted in Chapter 2, one of the goals of Primary Health Networks
(PHNs) is to ensure patients are receiving the right care, in the right place,
at the right time. However, evidence provided to the committee suggested that people in
rural and remote communities are not accessing mental health services as often
as people in urban locations, in part because the right care is not available
at all, or it is not open when people need it most. The following discussion
outlines these issues.
Availability of mental health
Numerous submitters and witnesses indicated that the low rate of access
to mental health services could be partially attributed to the limited number
of practicing mental health professionals in rural and remote Australia.
In regional areas, the per capita number of psychiatrists, mental health
nurses and psychologists in 2015 were, respectively, 36 per cent, 78 per
cent and 57 per cent of those in major cities, with even poorer comparisons in
remote areas, as demonstrated in Table 3.2 below.
Table 3.2—Number of mental health professionals (clinical
FTE per 100 000 population) by remoteness, 2015
Mental health nurses
Source: Department of Health.
The Royal Flying Doctor Service (RFDS) submitted that in 2015, 201 local
government areas (LGA) did not have any psychologists registered within the
area, representing approximately 36 per cent of all 564 LGAs in Australia, many
of which were in rural and remote areas.
The Victorian Government explained that attracting qualified mental
health professionals to rural and remote areas limits the availability of
mental health services:
In many cases, the availability of appropriately skilled
staff can be the single biggest contributing factor limiting the ability to
provide a broader range of services in rural communities, particularly where
around-the-clock care is required.
The factors which contribute to the low number of mental health
professional in rural and remote communities around Australia will be explored
further in Chapter 5.
Outreach and fly-in-fly out
The committee heard that often fly-in, fly-out (FIFO) services and
outreach services are provided in rural and remote communities in an attempt to
address the lack of mental health services and professionals available in rural
and remote communities.
Mr Brendan Morrison from the Kununurra Waringarri Aboriginal Corporation
told the committee that communities are often not receptive towards FIFO
workers as they only visit for short periods and have not built relationships
within the community.
Mrs Danielle Dyall from the Aboriginal Medical Services Alliance
Northern Territory (AMSANT) also described how FIFO workers do not build
relationships with the community and the impact this has on service delivery:
Sometimes there is no cultural safety awareness. There's also
the flying in and flying out and not having access to actual community members
on the ground. They might not be there for appointments or they might not show
up. What we find is that, when people are within the community and have those
relationships, they're able to drive around and find the people that they're
meant to be meeting with and meeting in a safer environment. The people who fly
in and fly out may not necessarily have that sort of relationship with
community members to be able to have an understanding of where to meet and that
sort of thing.
Similarly in Whyalla, Dr Jennifer Cleary from Centacare Catholic Country
SA informed the committee that FIFO services lack important local knowledge:
Service in remote communities often relies on fly-in fly-out
visits, and FIFO as we know it creates less-individualised approaches around
delivery. In the area of supporting those with a mental health challenge, which
obviously can significantly range in severity or impact, those early
intervention opportunities are often lost as people disengage or don't engage
in the first place. Organisations which are not local often don't have the
appropriate connections, knowledge or historical background and so can often
struggle to engage appropriately.
Conversely, the committee also heard in Whyalla that some members of the
community would prefer to see a FIFO mental health worker as this minimises the
risk to their privacy and concerns regarding confidentiality in small
communities. The concerns regarding privacy and confidentiality will be discussed further
later in this chapter.
In Mount Isa, the committee heard that outreach services face similar
criticisms to those of FIFO mental health professionals, as the amount of time
outreach services spend in communities is infrequent or inadequate:
I think one of the issues when you're talking about remote
communities is that most services are outreach to the communities, and it's
what's happening between those visits. We speak with communities all across
Australia where the psychologists might come for a day and a half once a month,
and it's impossible to get time with them because of their availability.
The Royal Australian and New Zealand College of Psychiatrists submitted
that while FIFO and outreach services offer an alternative where specialist
services are otherwise unavailable, they 'should not be seen as permanent
solutions' or replacements for a workforce based on the location.
The committee heard that FIFO workers may be successful in building a
rapport with the community if they come regularly over a long period of time.
Dr Krista Maier, a GP from the Nunyara Aboriginal Health Service told the
committee that it took her three years of coming to the community on a regular
basis to develop the community's trust:
It took me three years of regularly coming up to Nunyara
before I started to feel that I was an accepted and trusted member of the
community, and to establish that trust... Over the years of my service,
particularly at Nunyara, I have seen the beneficial effects, particularly on
people's mental health, of having a constant person to touch base with by not
having to tell their story over and over again but also the relationship that
we develop means that they are much more likely to come in to see me when they
start to struggle with their mental health.
Dr Maier noted that developing this relationship required FIFO staff
committing to long-term relationships with the communities that they seek to
Lack of appropriate 24 hour support
A number of submitters and witnesses told the committee that rural and
remote communities lacked appropriate mental health services outside of
standard business hours. This is particularly problematic for mental health patients as acute episodes
can often occur at night when people cannot sleep or feel socially isolated.
For example in Albany, Ms Jo Brown from the Depression Support Network
Albany explained that mental health services are not available overnight:
If you're suicidal between 8.30 am and 4.30 pm, you can go to
the community mental health service. If you're suicidal after 4.30 pm and
before 10.30 pm you can go to the emergency department, but you have to wait
for the doctor before you can see the mental health nurse. The problem with
this is, if you are having a mental health moment, you just give up and go
away, because it can take up to three hours. If you're suicidal after
10.30 pm, you then have to wait for the mental health people to come back
in, if you are deemed in need. We shouldn't have to be visibly distressed to
convince them that we need help. A small community means people know everyone
and don't want the world to know their business, so they don't go in for help.
The committee heard that it is common for people experiencing mental
health issues to present to their local emergency department. For example in
Mount Isa, the three highest presentations to the emergency department for
mental health issues included: behavioural disturbances; suicide ideation; and
However, submitters and witnesses informed the committee that often
emergency departments in rural and remote communities were not conducive for
mental health patients who present to the emergency department, particularly
after hours when mental health specialists are not on duty.
Dr Niall Small, Chair of the Rural Regional and Remote Committee for the
Australasian College for Emergency Medicine, explained that emergency
departments are not suitable environments for mental health patients:
There are many examples of patients who present with acute
mental health issues in peripheral regional and rural hospitals who are seen
and assessed but who then wait many hours or even days for transfer to a mental
health facility. While these patients wait, they're being cared for in a busy
ED environment with constant activity, noise and lighting. Treatment options
are severely limited in this situation, and these patients require specialist
care in a specialist unit, not to be left in a busy emergency department. Given
this scenario, patients often escalate in their behaviours and require
sedation. This cycle may be repeated more than once until eventually the
patient is transferred to the specialist mental health facility they require.
The committee heard that where specialist mental health staff are not on
duty, hospitals in rural and remote locations may be able to contact mental
health specialists in a regional centre or capital city for consultations on
patients who may present to emergency departments outside of business hours.
For example, the Kimberley Mental Health and Drug Service explained that
emergency departments across remote locations in the Kimberley can contact
staff in Broome:
We have very good relationships with our emergency
departments, and we have 24/7 on-call psychiatrist support after hours as well
to our clinicians that work in hospital. So we can advise and assess any
presentation either by videoconference or in person if necessary. It may well
be that an assessment is made in the emergency department that they can go home
However, the committee heard that on other occasions, patients
experiencing a mental health crisis who present to the emergency department at
their local hospital are not assessed by a mental health specialist nor
admitted to hospital:
There are numerous stories of suicide attempts being treated
in hospital and accident and emergency departments, where the person is held
for the minimum six hours observation only to be released back into the
situation that led them to the attempt on their life without assessment by psych
services whilst in A&E or treatment in the ward or follow-up by psych
services after release.
Dr Small explained to the committee that emergency department clinicians
are skilled in the provision of urgent medical treatment and crisis
interventions, but are not trained in the ongoing care and support of mental
health patients and are dependent upon other components of the mental health
system to provide the ongoing support required by patients.
The Western Australia Association for Mental Health submitted that
emergency response services in rural and remote communities required better
facilities and training to appropriately respond to acute mental health
conditions 24 hours a day.
Witnesses told the committee that this should include greater consideration
of the design of emergency departments and how they are equipped to respond to
patients experiencing psychosis, particularly where it is drug induced. Dr Roland Main of the WA Country Health Service explained:
I think we need a capacity to more safely look after people
who've got that combination of acute behavioural disturbance and psychiatric
symptoms as far as possible in the local setting. This is a problem which
besets the whole of the country. It's more acute in rural areas because our
emergency departments just don't have the capacity to contain those sorts of
The design of emergency departments is relevant as well.
Methamphetamine has changed the game in that respect. Many more people are
coming in with really severe behavioural disturbance due to the effects of
methamphetamines. So the design and staffing have an effect on the morale and
the energy of the staff in emergency departments to look after such patients.
The WA Country Health Service also told the committee that the
employment of psychiatric liaison nurses in regional emergency department had
improved patient care, supported skill development of emergency department
staff and improved connection with the community and patient's families. Similarly, the committee heard that the local hospital in Whyalla has employed
a mental health nurse as well as peer support works with lived experience of
mental illness to better support mental health patients in emergency
Culturally appropriate services
For many Australians, there is the added need for mental health services
to be culturally safe and to recognise the needs of diverse groups of people,
including people from culturally and linguistically diverse (CALD) backgrounds,
people who identify as lesbian, gay, bisexual, transgender and/or intersex
(LGBTI) and Aboriginal and Torres Strait Islander peoples.
The National Mental Health Consumer and Carer Forum submitted that two
key communication barriers exist for people from CALD backgrounds. Information
about services is often not available in accessible formats for these groups,
compounded by poor communication and cultural differences between consumers and
The committee received evidence that for people who identify as LGTBI, a
fear of discrimination from mental health staff can result in a lower take up
rate of mental health services and this is felt more keenly in rural and remote
areas. Submitters also pointed to the higher suicide rates for people who identify as
LGBTI as a reason that culturally appropriate services are critical to ensure
people at risk can access appropriate therapeutic services. The committee heard this need was not met in services, with the National LGBTI
Health Alliance reporting that the LGBTI community has 'incredibly poor or
non-existent' culturally safe access to mental health care.
In rural and remote Australia, the numbers per capita of Aboriginal and
Torres Strait Islander peoples are significantly higher than other groups with
culturally diverse needs. One-fifth of Aboriginal and Torres Strait Islander
persons live in remote or very remote areas (7.7 per cent in remote and 13.7
per cent in very remote), compared to only 1.7 per cent of non-Indigenous
The committee heard that Aboriginal and Torres Strait Islander peoples
in rural and remote areas face a number of barriers to access mental health
services, most notably a lack of culturally appropriate services, leading to
Aboriginal and Torres Strait Islander peoples accessing mental health services
at a far lower rate than non-Indigenous Australians.
In recognition of the far greater numbers of Aboriginal and Torres
Strait Islander peoples in Australia's rural and remote communities and the
unique circumstances they face, Chapter 4 will focus on the need for culturally
competent services for Aboriginal and Torres Strait Islander peoples.
Services under the National
Disability Insurance Scheme
As discussed in Chapter 2, many rural and remote communities are facing
uncertainty, confusion and lack of services due to the rollout of the National
Disability Insurance Scheme (NDIS). In some regions, the introduction of the
NDIS has in turn introduced new barriers to accessing mental health services,
rather than increasing the accessibility of services.
Barriers related to the NDIS
In Albany, where the NDIS had not yet been rolled out at the time of the
committee's hearing, witnesses described how people moving to the Great
Southern region of Western Australia (WA) were struggling to access the mental
health services they require under their NDIS package, as very few
organisations in the region had registered as NDIS providers.
The Western Australian Association for Mental Health noted that even if
there are organisations registered with the NDIS in an area, they may not be
able to provide mental health services:
One of the problems in those situations is that in areas
there are often no psychosocial disability services currently registered under
the NDIS. We heard of one situation where a person was referred to a disability
agency that had no connection with mental health, because that was the only
registered provider in that region, because the NDIS hadn't been rolled out.
A committee member of the Depression Support Network Albany also told the
committee that there were issues in renewing NDIS packages in these areas:
...I do know that there have been some that...have brought their
package down because they've moved. They were allowed to bring their package
with them, but if their package were due to be renewed, it couldn't happen down
here, because it doesn't happen down here. So it's very, very hard and tricky
for a lot of people. They're finding it quite a struggle.
Inappropriate NDIS services
In regions where the NDIS has rolled out, there are concerns that plans
are being designed and written for the services which are available in the
community rather than the services genuinely needed by the individuals on
Service provider selectability provided the committee with a case study
of Palm Island, an island off the coast of Far North Queensland classed as
'very remote' by the NDIS. selectability noted that that the NDIS packages on
the island cost significantly less than those seen on the mainland, because
they are drafted as a reflection of limited service availability in remote
communities, as opposed to being a reflection of the actual needs of people
with disability. selectability further noted that if packages correctly
identified needs, that would mean services could afford to come to remote
communities such as Palm Island:
The average cost of a plan on the mainland is $35,000. On
Palm it's much lower, and that's because the plans have been written for what
services are available rather than what the person actually needs—but that's separate.
If there are 5,000 people living on Palm Island and if 10 per cent of them were
eligible for an NDIS plan, that's 500 people. If they were actually given a
plan that was at least at the average level of $35,000, that's $17 million a
year of economic benefit that should be actually going into Palm Island. What
does that $35,000 plan equate to in a year? If you work out how many hours that
equates to, it works out to providing an additional 200 full-time equivalent
jobs on Palm Island.
We raise that as a case study because if you think about the
people on Palm Island who have a disability, whether it's mental health or
another disability, and if the NDIS was rolled out in full—at 100 per cent—and
rolled out to a time line, and if the plans were written as they should be
written for what the person actually needs, the service providers would come.
That would actually provide ongoing economic benefit for Palm Island, which
means jobs and better lives for the people who actually have a mental illness.
People who are ineligible or who have not yet received a package are
also facing barriers to accessing NDIS-based services. The committee heard at
its Darwin hearing that 'massive gaps' have opened in some areas because
funding moved from service-level or block funding from the Department of Social
Services to the insurance model of NDIS funding before alternative arrangements
for continuity of support were made:
The funding has gone in and people haven't been getting an
NDIS plan. So there have been a lot of gaps. We heard stories of cases of
suicide where they were waiting on a plan but didn't have any other service
because the services had been shut down because all the funding had already
gone over to the NDIS.
In Townsville, a service provider described that people who require
chronic mental health care have gone through the process of applying to the
NDIS 'only to find out they're not eligible...so they get no service whatsoever.' Another service provider in Whyalla described that there are barriers to even
getting to the NDIS assessment processes if doctors don't understand
Initially [the applicant] will receive an access request
form, which they have to take to their GP or any other medical professional,
where the doctor will fill out the form. Then that is any other
information—their diagnosis or when they're not able to show their impairment
impacts on their everyday living. They need evidence of their disability. All
the reports evidence we submit over to the NDIS. Then that which we have had
have come back that they might request more evidence, so therefore the consumer
will have to go back to the doctor or find evidence elsewhere. We're finding
that some of the doctors don't want to know about it, don't have time. One particular
consumer was told by the doctor that she didn't have a disability—she wasn't in
a wheelchair and she could walk—so he wouldn't even look at the paperwork for
her. We've had consumers that have got quite upset. One in particular last week
cried because she was rejected. So it is impacting a lot on the consumers. We
can appeal, but what happens after that we don't really know.
These concerns were similarly raised in Townsville, where a service
provider suggested that people with physical disability, when compared to those
with psychosocial or intellectual disability, are 'probably coming out of [the
assessment process] okay and getting their needs met' as disability services
have been designed around their needs.
The Western Australian Association for Mental Health suggested that a
'lack of assessor, planner and service provider expertise in psychosocial
disability' has resulted in 'significant variations' in assessed eligibility
and approved packages in WA.
Some witnesses also raised concerns that the insurance-based disability
model of the NDIS is at odds with some of the recovery-based mental health
supports previously offered by service providers, and that this is having
detrimental effects on supporting capacity building for individuals. The Queensland
State Manager of service provider Neami National told the committee that:
The NDIS is really a disability model. In people's plans,
what we're finding is that there's only a very small amount, if any, of
capacity building, which is where we would see the work that Neami has done
traditionally—in the capacity building [of] people—to drive self-efficacy for
people. That's very, very small in people's plans. The bulk of people's plans
have been core support, which is the driving to the shops, helping somebody to
learn to cook and that sort of level of support. That is actually diminishing.
What we've seen over the last four years is that the capacity-building element
is diminishing in people's packages as time goes on, as well as support
coordination, which is often a really essential part in addressing, I guess,
the issue around access for people and coordinating their wellbeing support.
The Chief Executive Officer of selectability raised similar concerns and
told the committee that her experience has shown NDIS plans for psychosocial
disability are not being written with these necessary capacity-building
services in mind.
The committee is concerned that rural and remote Australians are
accessing mental health services at a much lower rate than Australians in major
cities and urban areas, and is concerned about the detrimental effect this may
have on their mental health.
The committee believes there is a strong relationship between the
proportionally low number of mental health professionals working in rural and
remote communities and the low access rates of services by rural and remote
The committee is concerned by reports that people in rural and remote
communities experiencing a mental health crisis do not have access to appropriate
24-hour care, particularly within local hospital emergency departments which often
lack appropriate staff or facilities to support these patients.
The committee notes that while FIFO and outreach services provide an
opportunity to offer mental health services in rural and remote communities
where services may not otherwise exist, unless they are reliable and regular,
that is, every couple of weeks with the same trusted practitioner, they should
not be seen as a permanent solution to regular and ongoing mental health
services with local knowledge and relationships with their community.
The committee believes that culturally appropriate services are
essential to meet the mental health needs of a culturally diverse Australia and
that the importance of these services should not be discounted simply because
rural and remote communities are small or because specific skills are required
to deliver culturally competent mental health services.
The committee acknowledges the significant concerns held by witnesses
and submitters to this inquiry that the introduction of the NDIS has
inadvertently created further barriers to accessing mental health services in
many rural and remote areas.
The lack of expertise and understanding of psychosocial disability
within the National Disability Insurance Agency, as well as among health
professionals, is something that has been acknowledged by the Commonwealth
Government in recent months.
The committee is pleased to see the announcement of a dedicated
psychosocial disability stream within the NDIS and hopes that the introduction
of this stream will start to resolve some of the concerns raised during this
inquiry and others.
The committee is concerned about barriers to services for those who are
not eligible for the NDIS.
Transport, telecommunications and the tyranny of distance
One of the biggest barriers to accessing services in rural and remote
Australia is the tyranny of distance. The geography of Australia means that
many rural and remote communities are literally thousands of kilometres from
their nearest capital city and hundreds of kilometres from a regional centre.
This distance impacts not only on the availability of mental health
services on the ground in rural and remote areas, as discussed in the section
above, but on the ability for people to travel to those services. Distance from
major centres is also a factor in access to reliable telecommunications
infrastructure, which is necessary to access telehealth mental health services
where travel is not possible or desirable.
Transport and travel
Transport was raised as a significant barrier to accessing mental health
services in rural and remote Australia by witnesses at every hearing and in
over half of the submissions received by the committee.
Submitters and witnesses noted that transport was only an issue because
often, rural and remote communities lack sufficient local mental health
services. Uniting Care Australia described that for consumers whose only mental
health service option 'is to travel to another location, it may mean a whole
day or two off work rather than a lunch hour appointment, as would be possible
for a city dweller'.
Anglicare Southern Queensland submitted that '[e]ven where services
exist, access may necessitate travelling long distances with implications for
time, costs and managing family responsibilities', while Dr Sabrina Pit, who has conducted research into rural GPs' experiences
and perceptions of depression management and factors influencing effective
service delivery, found that:
Patient's limited ability to travel was perceived as a
significant barrier, identified by nine of the ten GPs. This was due to various
factors, including geographic isolation, reduced mobility, financial
constraints, and lack of public transport in the area.
Surveys conducted by mental health peak bodies and organisations have
shown that many mental health consumers consider transport both as a major
barrier to their accessing mental health services and is itself a cause of
mental health issues. In Tasmania, 50.4 per cent of people described transport
as one of the main challenges for seeking support in rural and remote areas and
47.15 per cent cited access to transport as a contributing factor affecting
their mental health. Similarly in WA, 51.79 per cent of people reported access to transport as
affecting mental health in regional areas.
The Western Australian Association for Mental Health also described how
lack of transport prevents access not only to mental health services and
supports, but to suitable accommodation and housing options, for example more
affordable housing, which is one of the key social determinants of mental
health in regional areas.
The National Rural Health Alliance explained that transport concerns are
particularly compounded for Aboriginal and Torres Strait Islander peoples, as:
...there [are] on average ten
times fewer vehicles per person, a tendency to have older and inappropriate
vehicles, the need to travel long stretches of unsealed roads, and effectively
half of the population not having access to public transport or air transport
Public and private transport
Submitters and witnesses described the transport difficulties faced by
consumers in trying to get from a rural or remote community to a regional or
metropolitan area to receive mental health services.
For many, the lack of public transport in rural and remote areas was
raised as a concern for those without access to, or who cannot use, personal
vehicles. The Executive Officer of CORES Australia, a community-based program for
suicide prevention, told the committee that public transport does not meet the
needs of consumers who need to attend appointments in town:
When we were working on the community action plans for
suicide prevention, they talked about transport. And there are more and more
issues with transport. Even in Tasmania, they found that often the buses left
early in the morning. For people with mental health issues who wanted services
in the city, like Launceston, Devonport or anywhere like that, the services that
were there didn't fit them, because often people with mental health issues
don't want to get out of bed before lunchtime. So people tended to disconnect
One psychiatric nurse submitted that public transport is often not
available in rural and remote areas and, if it is available, it can take a
considerable amount of time and transfers to get to an appointment. COTA Australia also noted that travel over long distances to access services is
a significant issue for older people who may no longer drive and rely on
community or public transport.
Others described how, even where consumers have access to their own
transport, the cost and time required to travel to appointments can impact on
attendance. The Mental Illness Fellowship of Australia made the point that
consumers can face significant additional costs in attending services due to
transport over distances. This point was echoed by Uniting Care Australia, which reported:
One family accessing a UnitingCare service advised that they
had to drive hundreds of kilometres in a year to access mental health support
for their child, spending almost $20,000 on fuel.
A consumer representative in Devonport told the committee that some
people who own their own car may not be able to drive safely to and from
appointments due to the nature of their mental illness or the distress of an
appointment, and therefore may choose not to attend.
Orygen, the National Centre of Excellence in Youth Mental Health,
explained that when there is no public transport, a reliance on someone else to
help a consumer travel to appointments may raise issues of anonymity. This may
be of particular concern in areas where there is a high level of stigma about
mental health issues.
Patient transport programs and
To counteract the lack of readily-available public transport in rural
and remote areas, some service providers are working to offer transport as part
of their service. The committee heard that transport was desperately needed in the Kununurra
region to ensure that people, particularly those with large families and caring
responsibilities, could attend social and emotional wellbeing services. Social
and Emotional Wellbeing representative of the Kununurra Waringarri Aboriginal
Corporation told the committee that:
A lot of the people we work with don't have vehicles, so we
need to go out, pick them up and bring them into town so that they can go to
their appointments or go to our appointments.
In Tasmania, Youth, Family and Community Connections Inc described how providers
have had to transfer some mental health clients from regional areas to Hobart
at the providers' own expense, as the medical transport programs provided by
the state work on a booking system which don't necessarily match with a
Where you're trying to seize an opportunity, if you like, to
get that person the assistance they need at that time, it's often just more
practical to drive the client to Hobart to get treatment.
Rural Alive and Well, another Tasmanian service provider, also submitted
that its workers have 'become involved in transporting clients to attend
appointments given a lack of viable alternatives'.
Primary Health Tasmania explained to the committee is not in a position
to fund transport, but described how it was trying to address the transport and
...within our contracts we do work with our providers to look
at how we can best meet outreach needs so that we're not having a provider
that's based in Devonport and only delivering service in Devonport. So we
articulate in the contracts that we require them to provide outreach into the
smaller communities. The reality is that Tasmania, unlike a lot of other
states, has a very diverse population scattered across a fairly big area. I
don't know if we've got that right at the moment. We're hoping, through the
regional planning process and applying the mental health planning framework
taxonomy, that we'll get a better picture and a better mix of where services
should be, and we can fund to that.
The committee also heard that in some areas transport may be available
for acute or emergency mental illness, but not for day-to-say attendance of
necessary appointments. For example, HelpingMinds submitted that while the WA Country Health Service
provides some support through the Patient Assisted Travel Scheme, 'this is
restricted to appointments with psychiatrists. Access to preventative services
such as psychological or psychosocial services is therefore restricted'.
The National Rural Health Association noted in its submission that
'funding transport in rural and remote areas has been an ongoing challenge –
who funds it, how much, how often and who pays' in terms of return of
investment. Some submitters recommended that greater funding should be invested in outreach
programs to reach people who do not have transport, while others recommended that greater emphasis be placed on patient travel
assistance schemes, transport vouchers or community drivers.
The Goulburn Valley Area Mental Health Service recommended that improvements
to public transport in regional Australia, such as more reliable train and bus
services in rural Victoria, would not only improve consumers' access to mental
health services but would 'enable skilled clinicians to travel more easily to
Services for Australian Rural and Remote Allied Health submitted that
the solution to transport for some clients may also have a therapeutic benefit,
although this would require flexibility in program funding:
Some clients have benefited from obtaining support to
purchase other modes of transport, such as a bicycle. This also serves to
improve their mental and physical health through behavioural activation and
promotes a sense of purpose and empowerment for them. The limitations of this,
however, include extreme heat in summer, where many communities experience
conditions where it is simply too hot to ride a bicycle during the day.
Enabling Mental Health workers to approve the purchase of a
bicycle for a client, or to approve access to travel vouchers for bus or taxi
travel are other possible options for consideration to support client access to
the mental health services they need.
The committee heard that methods of acute and emergency transport for
mental illness in rural and remote areas appear to present other challenges for
consumers and providers, primarily caused when there are no appropriate local
services. The committee further heard that this can cause people to refuse to
access the mental health services they need. The Australian Psychological
Society submitted that some people will not seek treatment for mental illness
due to a fear of being sedated for transport and then being detained a long
distance from home.
The Australasian College for Emergency Medicine submitted that its
members had raised significant concerns about the delays in assessing and
transporting patients presenting with mental illness to emergency rooms in
rural and remote areas:
ACEM members report being actively discouraged from
scheduling mental health patients in rural and remote emergency departments due
to known delays with review by mental health telehealth teams (in the absence
of face-to-face review). For young patients, this means they can be forced to
wait in an isolated room in an emergency department for two to three days until
transport is available to send them to an appropriately declared mental health
facility, depending on the relevant jurisdictional legislation.
Other witnesses and submitters also described the distress felt by patients
because of how they are treated during the transfer process to access services
not available locally. A representative of the National Mental Health Consumer
and Carer Forum told the committee that:
When it does happen and someone gets transported, the RFDS
has a policy of sedating people who are mental health clients. They sedate them
and restrain them. I remember two ladies in particular, both around 25 or 26
years of age. I nearly cried because they spoke about feeling like criminals.
When they came around and they woke up in our Royal Adelaide Hospital, they
thought they must have committed a crime because they were aware of how they
were being treated and they were aware of how they felt. I'm not judging the
staff that managed them at all; I understand the need for doing that. But
that's the reality.
The Australasian College for Emergency Medicine noted in its submission
that mental health patients in rural and remote areas are more likely to be
transported to a hospital emergency department in a police or correctional
vehicle than people with other conditions. The Victorian Council of Social Service submitted that, while police may have
good intentions, they have 'limited ability to provide an appropriate
therapeutic response' for a person experiencing crisis.
The WA Country Health Service told the committee of the situation which
exemplified many of these concerns which had been recently experienced by one
young Aboriginal man in regional WA. In this situation, the young man, who had
a history of substance abuse, presented to a regional emergency department
describing suicidal thinking. He was assessed by an on-call psychiatrist but
absconded from the hospital twice, requiring first responders and police to
retrieve him. In the end, it was determined that:
... to safely perform a full assessment on that person required
his transfer to Perth. To transfer him to Perth required involvement of the
flying doctor. It required a level of sedation to allow his safe transfer on
the plane....He arrived in Perth and he was seen, by sheer coincidence, by a
psychiatrist who actually used to work in the region as well, so he knew of the
family. It was a remarkable kind of circumstance. The Mental Health Act under
which he was referred couldn't be applied to make him an involuntary patient,
and he came home. So he presented to the hospital and was triaged, assessed,
treated, transferred to the city and then sent home, back to the regional
centre again....He didn't want to stay, and there weren't sufficient grounds
under the Mental Health Act to force him to stay as an involuntary patient, and
so he's back in the community.... That's caused some ructions in terms of the
family and their confidence in the mental health service, and so we'll have to
rebuild that trust again. That's not an unusual story.
The Western Australian Government submitted that a post-implementation
review of the state's Mental Health Act 2014 conducted in March 2018 had
highlighted concerns about 'the relationship between limited access to
specialist mental health care in regional areas and the high demand for
transfers of mental health consumers to the metropolitan area' as well as
delays in 'timely access to transportation by police and the Royal Flying
Doctor Service'. The Western Australian Mental Health Commission and Western
Australian Department of Health are now conducting work to 'identify causes and
potential solutions to reduce delays in regional mental health transfers'.
The RFDS submitted that between July 2013 and June 2016, it provided aeromedical
retrievals of 2567 patients experiencing acute mental health episodes requiring
emergency treatment in a tertiary hospital. The RFDS expressed the view that
'many of these emergency retrievals could be avoided if more appropriate and
comprehensive mental health services were available in more remote and rural
Telehealth, as discussed in Chapter 2 of this report, is becoming an
increasingly popular method of service delivery in rural and remote areas to
combat the lack of available local services.
However, a lack of telecommunications infrastructure is limiting
telehealth as a viable option to address the barriers of distance, travel cost,
availability of services for many consumers and health professionals in these
areas. The Western Australian Association for Mental Health submitted that:
...rural and remote areas lack stable, predictable and reliable
infrastructure. Internet and mobile coverage are sporadic and intermittent, so
services delivered through technology are not always reliable or available.
A large number of witnesses and submitters described telecommunications
infrastructure in rural and remote areas, including landline telephones, mobile
telephones and internet access, as poor, intermittent and unreliable. Access to the internet in particular was described as a major issue, as many
mental health services now have online or video-capable offerings such as
telehealth or web-based services and there is an assumption that consumers will
be able to access these if they are unable to use face-to-face services. However evidence suggests that access to the internet for telehealth varies
widely in rural and remote areas across the country.
Census data released in October 2018 shows that 23 per cent of
households in remote and very remote locations in Australia do not have
internet access, compared to only 12 per cent of households in major cities. In some locations and demographics, the proportion of people without access to
the internet is even higher.
The Western Queensland PHN reported that 27.3 per cent of people in
their catchment area have no internet access, while the Victorian Council of Social Service observed that people on low
incomes are even more likely to not have a connection, noting that two thirds
of people who received Salvation Army emergency relief could not afford an
internet connection at home.
Sane Australia submitted that while online mental health support can
bridge some of the gaps in mental health services in rural and remote areas:
...further work is needed to promote digital inclusion for the
approximately 2.5 million Australians who, for health, geographic, education or
socio-economic reasons, are not online.
The adequacy of the internet connection being accessed was also of concern
to submitters, with one cited study finding that 48 per cent of people surveyed
living outside of capital cities described the internet access they had as
inadequate or not meeting their current needs.
OzHelp described in its submission that the quality of internet access
in rural and remote areas is in part based on the technology available and that
good connections may not be affordable or accessible to those who are
disadvantaged; for example, in one 2016 survey, fibre-to-the-premise or
fibre-to-the-node technology was found to be available to 88 per cent of people
in the most socio-economically advantaged outer regional areas compared to only
12 per cent of those in the least advantaged areas. The Local Government Association of Queensland also noted that many rural
property owners and satellite towns will not get access to these technologies
but will remain reliant on satellite internet access.
The Royal Australasian College of Physicians submitted that an 'obvious
technical barrier to the greater use of telehealth' is access to a reliable
broadband internet connection, which was ranked as the number two priority in
the 2016 Australian Medical Association's Rural Health Issues Survey. The joint submission from the Queensland Association of Mental Health and the
Northern Territory Mental Health Coalition expressed the view that:
It's no good providing these [telehealth] services if
internet accessibility is so bad that it doesn't allow a continuous connection,
or if it becomes too expensive for people to get access to adequate internet
The Mental Health Academics Network of the Australian Rural Health
Education Network shared these concerns about the expensive of internet access,
The cost of access to a reliable internet connection is
ongoing an issue, particularly in remote areas where there is no competition or
where only one service provider has reliable coverage.
The committee heard that it is not only consumers who require reliable
internet access to facilitate mental health services and access in rural and
The National Rural Health Association submitted that web-based
continuing professional development, a requirement for ongoing registration, is
important for health professionals working in remote areas and that 'accessing
webinars is dependent on a quality and reliable internet services so they can
participate'. Health professionals also described their frustrations with the quality of
internet access in their work in rural and remote locations. Dr Vladislav
Matic, Board Chair of the Northern Queensland PHN, told the committee:
The other thing is that my experience, at least having done
some locums in some really remote places, is it only takes a couple of people
in the community to be watching Netflix and the bandwidth has gone. And all of
a sudden the surgery computers slow down and there's no access to My Health
Record or anything else.
While some submitters and witnesses discussed the need for internet
connections of a quality that supports the use of videoconferencing for
telehealth, others noted that, where this is not possible, low-bandwidth options such as
mobile apps, online forums and webchat can still play an important role in
early intervention and peer support-based mental health services, as well as
promoting social inclusion.
The committee received evidence that some providers are trying to find
solutions to the internet access barrier: Grow, a provider of mental health and
wellbeing support groups, told the committee that some members of its online
groups are unable to participate due to lack of personal internet access or the
additional cost of using mobile data. To overcome this barrier, Grow has
started to provide these participants with tablets with a data plan for use at
The overwhelming recommendation from submitters to solve the
telecommunications barriers to accessing mental health services was that there
should be investment in infrastructure, such as the National Broadband Network
and mobile phone networks, to ensure reliable phone and internet access in all
rural and remote communities.
Suicide Prevention Australia further recommended:
...greater development of online communication and information
technologies to greatly reduce the barriers of distance that typically
disadvantage communities in rural areas. This must be matched by a commitment
from government to collaborate with telecommunications service providers to
improve parity of access to cost competitive broadband internet networks and
infrastructure across rural and remote areas of Australia.
In the face of limited services 'on the ground' in many rural and remote
communities, transport and telecommunications are vital to accessing services
based in regional and metropolitan areas. However, these obvious solutions to
the barrier of distance can create new barriers in and of themselves.
The committee recognises that public transport is not available in many
rural and remote locations and notes the efforts made by communities and
service providers to transport consumers to the mental health services they
require. The committee considers that service providers in these locations need
flexibility within their funding models to provide transport services and
solutions to overcome lack of transport.
The committee is concerned to hear that the methods of acute and
emergency transport for mental illness in rural and remote communities,
particularly in relation to the sedation of patients, are deterring some people
from seeking help for their mental health. While aeromedical retrievals play a
vital role in emergency medicine across the country, the committee strongly
agrees with the view of the RFDS that such retrievals for mental health could
be avoided if there were more appropriate and comprehensive mental health
services in rural and remote areas.
The committee is aware that the lack of telecommunications
infrastructure, particularly reliable access to the internet, is limiting the
use of telehealth in rural and remote Australia. This must be addressed if
telehealth is to be considered a viable option to address the barriers of
distance, travel, and availability of services.
Other social determinants of health
Submitters and witnesses explained to the committee that some of the
biggest barriers to overcome in accessing mental health services are social
determinants of health, which can be different in rural and remote communities
to those felt in urban locations. These barriers are often difficult to overcome as social determinants of health
can be a result of structural disadvantage.
Social determinants of health include the circumstances in which people
are born, grow up, live, work and age, and the healthcare available to treat
any illness. The World Health Organisation's Commission on Social Determinants of Health
2005–2008 found that:
There is a social gradient in health such that the lower a
person's socioeconomic position, the worse their health, including their mental
health, is likely to be. The Commission broadly identified the cause of
inequity as unequal access to health care, schools and education, conditions of
work and leisure, housing, and their chances of leading a healthy life.
The Australian Psychological Society informed the committee that social
determinants of health have a strong impact on mental health and social and
emotional wellbeing, and that people with a mental health illness are more
likely to have experienced disadvantage and be on a low income, with many
living in poverty.
The committee heard that the impacts of social determinants of health
can be twofold: firstly people may be more likely to experience a mental
illness and secondly, they are less likely to be able to access mental health
support services due to their circumstances.
Many submitters and witnesses informed the committee that socioeconomic
status will impact on the availability and effectiveness of mental health
services in rural and remote areas, as well as the likelihood of a person
experiencing a mental illness or psychological distress.
Research Australia submitted that people living in areas classified as having
the lowest level of socioeconomic status had the highest rate of mental
health-related presentations to hospital emergency departments, representing
26.8 per cent of presentations. Emergency department presentations gradually decrease as socioeconomic status
increases, with the highest socioeconomic status making up 13.8 per cent of
mental health-related presentations.
Furthermore, young people (aged 10–15 years old) from low socioeconomic
backgrounds are two and a half times more likely to be diagnosed with anxiety
and depressed moods than those with high socioeconomic status.
The National Rural Health Alliance informed the committee that the rate
of suicide is also correlated with socioeconomic status. Between 2011 and 2015, the rate of suicide per 100 000 population was 14.5
for the lowest level of socioeconomic status, significantly higher than the
highest level of socioeconomic status at 8.3 per 100 000 population.
The most recent Census of Population and Housing in 2016 found that
people with the highest level of socioeconomic status tend to live in capital
cities, whereas people within the lowest level of socioeconomic status tend to
live in regional and rural areas.
As rural and remote areas generally have a higher proportion of people
with socioeconomic disadvantage, the evidence put to the committee suggests
that socioeconomic status is one factor which contributes to the high rate of
suicide in rural and remote communities in Australia.
However, there are many factors which contribute to a persons'
socioeconomic status such as employment, level of income and housing security,
which subsequently impacts on their ability to access and afford mental health
services. These factors are discussed further below.
Employment and income level
The committee heard that employment and income level can impact a
person's ability to access mental health services as well as their likelihood
of experiencing mental illness during their life, and that this is particularly
relevant in rural and remote communities where there is often a lower
employment rate than in urban locations.
The National Survey of Mental Health Wellbeing found that education,
employment and income are closely related to a person's socioeconomic status. The survey found that people who are unemployed are more vulnerable to mental
illness and they are more likely to experience insecurity, feelings of
hopelessness and risk to their physical health.
Of the survey respondents who were unemployed, 29 per cent experienced a
mental illness within the preceding 12 months, compared to 20 per cent of
people who were employed.
The National Mental Health Consumer and Carer Forum also submitted that
mental health can be impacted by the employment status and the income of
individuals and households. A survey conducted by the Mental Health Council of Tasmania for the purpose of
this inquiry found that 74 per cent of respondents identified unemployment
as an issue affecting their mental health and 67 per cent identified lack of
A number of witnesses also told the committee that unemployment was a
problem in their community which impacted on the rate of mental health illness. For example, Mr John Singer from the Nganampa Health Council, told the
committee that in the Anangu
Pitjantjatjara Yankunytjatjara (APY) Lands, only 30 per cent of people aged
between 16 and 30 years old were employed. As noted below, unemployment can greatly affect a person's mental health if it
impacts on their sense of purpose and self-worth.
The Aboriginal and Torres Strait Islander Healing Foundation (Healing
Foundation) attributed the high unemployment in some remote communities to a
combination of poor educational outcomes and trauma experienced by Aboriginal
and Torres Strait Islander peoples, which continues to undermine their ability
to engage in employment. The impact of trauma on Aboriginal and Torres Strait Islander will be explored
further in Chapter 4.
While social security benefits may be available to some people who are
unemployed, the committee heard that these payments are insufficient to pay for
daily essentials such as food, fuel and housing as the cost of living in rural
and remote areas is significantly higher than in major cities, yet recipients
receive the same amount as their city counterparts.
The National Mental Health Consumer and Carer Forum explained that it is
unlikely that an individual on a low income will be able to afford specialist
support and treatment, particularly in rural and remote Australia where the
costs of these services can be higher. Furthermore, is also common for people who are unemployed to experience
feelings of insecurity and hopelessness which subsequently has a negative
impact on their mental health.
Self-worth and sense of purpose
Some submitters and witnesses attributed the negative impact of
unemployment and low income levels to the sense of purpose and self-worth which
comes from employment. For example, Dr Martin Kelly from the Nganampa Health
Council explained to the committee that providing some community members of the
APY Lands meaningful activity had improved their mental outlook:
I think another broader question is the question of work or
at least structured, meaningful activity. Too many of our younger people don't
have opportunities or hope. 'Where there is no vision, the people perish' is an
old saying. That's what I'm afraid happens to lots of males in particular.
Women in our communities have child raising, and that sort of stuff is an
activity that families rally around and support, and it has meaning, it gives
meaning, it's worthwhile and everybody knows that. I think a lot of men don't
have as much of that going for them. ...But I think, having seen a number of
people in our communities who have meaningful activity, not necessarily paid
employment, and sometimes doing out-of-the-box kind of stuff that gives their
life meaning, it has often turned their lives around.
In Albany, a peer support network has been established to provide
information and support services to people in the region experiencing
depression. The Depression Support Network Albany provides links to support
services, education sessions on mental illness, craft sessions, walking groups
and eat meals together. The peer support network is run by people who have a mental illness as well as
volunteers who do not have full-time employment:
You're enabling them to have purpose. They feel as if they
are contributing. It's very much about using the skills of the people who are
in the groups and saying, 'What have you got to contribute?' So they'll have
art groups and people will have a skill there. It's very much about finding
purpose. People's self-esteem improves, and there is that feeling of not being
alone—that there is someone who you can talk to.
Many submitters and witnesses identified housing security and
overcrowding as a barrier which impacted the mental health of people in rural
and remote communities.
Ms Cheryle Kaesler from the Yura Yungi Medical Service in Halls Creek
told the committee that there is a limited supply of public housing in the
community and there are virtually no private rental properties. Ms Kaesler explained that this often leads to overcrowding in the available
There's often in excess of five families living in a
one-bedroom or two-bedroom home. There have been housing homes here but they
are often only two- or three-bedroom homes and there are a lot more people than
that within the family so, therefore, I feel they are far too small. There's an
extensive waiting list on the housing commission, up to four to eight years.
What we find is that this builds frustration. I honestly think it has sometimes
led to suicide, because people are frustrated, they can't get out of it and
there are arguments and things like that within families.
Mr Jake Hay from the local council in Halls Creek advised that for young
people, feelings of anxiety and depression are often a product of their home
There are no services that exist in the overnight period, and
this is a time where a lot of these traumatic episodes happen for young people,
such as not knowing who's going to be there when they go home—their house might
be overcrowded, there might be family coming in from all sorts of places and
suddenly you've got 20 people in a three-bedroom home. You might also have
issues such as excessive noise and excessive alcohol consumption which scare a
lot of the young people away from their homes at night.
The committee also heard that overcrowded housing can increase the risk
of sexual assault, particularly for young people, which is often an underlying
cause of mental illness.
In some rural and remote communities, housing is unaffordable
(particularly for people receiving social security benefits) and there are
extensive waitlists for public housing.
The National Survey of Mental Health and Wellbeing found that
homelessness was a significant risk factor for mental illness. The survey found that of the respondents who had ever been homeless, 54 per
cent experienced a mental illness in the preceding 12 months, compared to only
19 per cent of people who had never been homeless.
Drug and alcohol addiction
Submitters and witnesses told the committee that drug and alcohol
addiction was often comorbid with mental health issues. The National Mental Health and Wellbeing Survey found that people who drank
nearly every day were more likely to experience mental health issues than those
who drank less than once a month:
People who reported that they drank nearly every day had more
than 10 times the prevalence of 12-month Substance Use disorders compared
with people who reported that they drank less than once a month (10.5% and 1.0%
The statistics do not, however, identify whether the relationship
between alcohol and mental health is causational or correlational. The National
Mental Health and Wellbeing survey finds that people who are diagnosed with
alcohol dependence are more likely to have other mental health problems and
that people with mental health problems were at greater risk of experiencing
problems related to alcohol.
The National Mental Health and Wellbeing survey also found that 63
per cent of respondents who misused drugs nearly every day in the 12
months prior to the survey reported experiencing a mental illness.
The Alcohol and Drug Coordinator for the Ord Valley Aboriginal Health
Service told the committee that the correlation between mental health and
alcohol and drug issues may be related to self-medication:
I believe that, quite often, alcohol and drug use is
self-medication for underlying mental health disorders and psychological
Submitters and witnesses told the committee which drugs they were most
concerned about in their communities. Palmerston Association Inc told the
committee that methamphetamine was emerging as the drug of greatest concern in
the Great Southern region of WA:
Patterns of drug use have shifted significantly in recent
years. Historically, alcohol has been the primary drug of concern for
Palmerston clients. However, in the 2016-17 aggregated data across the
organisation, methamphetamine emerged as the primary drug of concern. In the
Great Southern, we see a very similar picture, however cannabis has long
featured heavily in the Great Southern.
The Ord Valley Aboriginal Health Service in Kununurra and the Nganampa
Health Council in Alice Springs told the committee that they were concerned
about the high level of cannabis use in their communities.
The Central Australian Aboriginal Congress told the committee that alcohol
was a significant contributor to mental ill health and wellbeing:
Alcohol is also a related and major contributor to mental ill
health and poor social and emotional wellbeing, risky behaviour and is a
precursor for suicide. Alcohol abuse is directly associated with at least 8 per
cent of the burden of disease and injury borne by Aboriginal people, including
through homicide, violence, and suicides.
This view was supported by the committee's visit to the Barkly Work Camp
in Tennant Creek where the committee heard that alcohol and violence were often
present in the prisoner's home environments.
The North West Hospital and Health Service explained that significantly
more people presented for alcohol related issues than for other drugs:
In terms of the drug and alcohol side of things, around 79
per cent is alcohol related only. Second to that is cannabis and the third is
amphetamine use, which is three per cent.
Submitters noted it is important to address both mental
health issues and substance abuse issues simultaneously. The Program
Coordinator for Richmond Wellbeing and the Manager of the Great Southern
Alcohol and Drug Service at the Palmerston Association Inc told the committee
that specialist services need to be offered that can deal with alcohol and drug
issues and mental health.
The Central Australian Aboriginal Congress explained that it is
necessary to have a service that treats mental health and substance abuse
issues together to stop the people being moved around the health system without
addressing all of their issues:
Whether it's physical health or mental illness, it's all
beginning in early childhood and we need service systems that can deal with
people in that way. So we're not shuttling people between. 'Oh, you've got a
grog problem; you go there,' and then the alcohol says, 'Oh, hang on; you've
got a bit of psychosis. Even though you've got an alcohol issue, you've also
got this, so go over to mental health.'...We've got to stop all that. We don't
have that [at] congress—we treat the whole person.
The National Mental Health and Wellbeing Survey reported an increased
rate of mental disorder among respondents who had been incarcerated. The survey
reported that 41 per cent of respondents who have ever been incarcerated had a
mental disorder in preceding 12 months compared to only 19 per cent of
people who had never been incarcerated.
The Healing Foundation considered that the circumstances that lead to
the incarceration of Aboriginal and Torres Strait Islander peoples are often
caused by trauma:
The disproportionate levels of incarceration of Aboriginal
and Torres Strait Islander people is both symptomatic of, and a cause of
trauma, with a strong correlation between criminogenic risk factors, the social
determinants of health, and the prevailing symptoms of trauma.
Miss Nawoola Newry told the committee that the trauma that led to
incarceration was a perpetual cycle because parents do not know how to deal
There's definitely a link between incarceration of young
people and the lack of mental health services. Because there's so much trauma
in most of our families up here, the parents don't know how to deal with that,
and the parents are so traumatised themselves that the young people are seeing
really bad behaviour, experiencing bad behaviour, experiencing their own trauma
as well, which is leading them into all the crime, which is ending them up in
The Healing Foundation told the committee that the mental health issues
of Aboriginal and Torres Strait Islander peoples may not be diagnosed until the
person is at a crisis point or is incarcerated.
The committee heard a similar perspective during its visit to the West
Kimberley Regional Prison in Derby. The committee spoke with two prisoners who
explained that their mental illnesses had not been effectively diagnosed or
treated in their respective communities. However, the mental health services
they received at West Kimberley Regional Prison had shown them how their mental
illness had contributed to their offending and equipped them with strategies to
modify their behaviour and improve their mental health.
Danila Dilba Health Service told the committee that when children end up
in the juvenile justice system they are still not provided with adequate
supports even though it is clear what support is required:
When we look at the kids in the juvenile justice system, we
see that every single one of those children is suffering from some form of
trauma. They are affected by trauma. Even the people who run the facility say,
'We know that all of these children are affected by trauma,' and yet the system
is not providing those children with a comprehensive, high-quality mental
health service while they are incarcerated or while they're on parole. There
are very limited mental health interventions available in the youth detention
facility. We have a team that is funded to provide some input, mainly in the
form of social support, but we've snuck a bit of therapeutic support in as
well. We're providing some therapeutic group stuff in the centre, but the
children do not get the level of mental health support that they need.
The Healing Foundation told the committee that the New South Wales
Prison Inmate study found that the rates of mental illness among Aboriginal and
Torres Strait Islander inmates was higher than for non-Indigenous inmates.
The Western Australia Association for Mental Health relayed that the
impact of incarceration away from country can also have an effect on mental
...the resultant impact of incarceration, often away from
Country, on Aboriginal people's connection to family, land and community all of
which impacts negatively on mental health.
Aarnja Ltd reminded the committee that Aboriginal and Torres Strait
Islander peoples continue to be incarcerated at a higher rate than non-Indigenous
Australians and considered that the role of mental illness and the effects of
trauma need to be considered:
The factors that cause mental health are known...Aboriginal
people are not predisposed; it's not in our genetics or DNA to be criminals,
yet we make up the highest rate of people incarcerated...Illness doesn't see
colour. We're all the same; we're human beings. We operate the same way.
The committee notes that there is a strong relationship between social
determinants of health, the likelihood of developing a mental illness and the
accessibility of mental health services, and that the negative impacts of
social determinants of health are more prevalent in rural and remote
The committee acknowledges the relationship between mental health issues
and substance abuse and believes that these issues must be addressed
simultaneously to adequately address both the cause and symptoms of mental
illness and psychological distress.
The committee notes that overcoming these social determinants of health
is challenging as they are often the product of unequal access to health care,
brought about by structural disadvantage and social and economic policy.
However, the committee believes that to address mental health in regional,
rural and remote areas these social determinants must be improved.
Attitudes to mental health
Throughout the inquiry, the committee received evidence about how
attitudes to mental health in rural and remote communities may influence
decision making about whether to seek professional assistance for mental health
issues. This section considers a number of the factors that witnesses and
submitters raised with the committee.
As noted above, while mental health issues are experienced at similar
rates across Australia, mental health services are accessed at lower rates in
rural and remote areas. Royal Australian College of General Practitioners Rural
told the committee that while the principal driver of lower rates of access was
the reduced availability of mental health services in rural and remote areas, a
range of socio-economic and cultural factors, specific to rural and remote
communities, that affect attitudes toward mental health services may also
contribute to lower rates of access. The Royal Australian College of Physicians, Being, the Northern Territory PHN
and others told the committee that stigma was one of the factors that may
explain lower rates of access in rural and remote communities.
Submitters told the committee that people with a lived experience of
mental illness had told them that a number of factors, including their fear of
stigma and a lack of confidentiality or anonymity when accessing services, led
to decisions not access mental health services in their community. The
Australian Mental Health Commissions told the committee that:
Anecdotal evidence from engagement with local communities has
indicated that discrimination due to mental illness is a factor which affects
whether a person seeks services in their town. People living with mental
illness tell us that stigma and discrimination are very common experiences for
them. This acts as a barrier to people receiving the support they need, when
they need it. For some, anonymity is important and they will travel to the next
town or regional centre to get the support they need, if it is available and
they are seeking help or know where to seek help from.
The Queensland Alliance for Mental Health and the Northern Territory
Mental Health Coalition told the committee that they had received similar
feedback regarding stigma from communities they had consulted:
The issue of stigma was one that was constantly raised in our
discussions with members regarding this inquiry. Rural communities have a
culture of self-sufficiency and self-reliance which does not lend itself to
openly seeking treatment when it might be required. The lack of anonymity in
small rural settings often creates barriers to access due to stigma and
The committee received evidence that there was a complex array of
factors that contributed to whether a person sought to access mental health
services. ReachOut described the forces that were faced by younger people deciding
whether to access services as a 'tug of war' for and against seeking help, as
Figure 3.1—Forces for and against seeking help
Submitters who work in youth mental health, such as yourtown, told the
committee that young people it worked with had expressed concerns about being
judged if they accessed a mental health service. yourtown told the committee
that the concerns raised by young people included a fear of being seen as
incapable, being brushed off or being considered or labelled as an attention
A number of submitters told the committee that they considered one of
the factors that may act as a barrier to access was a preference for
self-reliance to manage issues, which was sometimes described to the committee
as 'rural stoicism'. The Queensland Nursing and Midwifery Union told the committee there was some
academic evidence that this preference for self-reliance may lead to lower
rates of access:
In a recent study, Brew et al. (2016) found attitudes to
treatment were the greatest barriers to seeking help for all rural workers. Of
these, 'I prefer to manage myself' was by far the most common and this was
similar for farmers and non-farm workers. Overall...75% preferred to manage
themselves rather than access help for mental health needs (Brew et al., 2016).
These results could indicate a high level of self-sufficiency, however distance
from services and inability to leave rural properties for any length of time
are other relevant factors.
The Queensland Nursing and Midwifery Union noted, however, that in
addition to self-sufficiency, these results may also indicate that an inability
to leave rural properties for any length of time and distance to services may
also serve as barriers to access. The committee received similar evidence from other submitters, such as the
Queensland Alliance for Mental Health and Northern Territory Mental Health
Coalition, who considered that caring obligations and the requirements of
running a property may influence whether a person accesses mental health
Privacy and confidentiality
Some submitters recognised that being part of a small community with a
'community spirit' or close social connections can be a potential protective
factor for people experiencing a mental illness. However, ReachOut, Suicide Prevention Australia and One Door Mental Health also
noted that the same connectedness can also lead to stigma and a perception that
'everyone knows everyone's business'. Submitters told the committee that in a community with a small population some
people may be concerned about being able to protect their privacy while
accessing the service.
Witnesses told the committee that some people had concerns about being
recognised or seeing a service provider with whom they would prefer not to have
a 'dual relationship'. MindsPlus explained that by 'dual relationship', it meant that a person may not
wish to discuss their personal lives with 'someone their sister plays netball
with or someone they may see socially'.
Some submitters advised the committee that people living in rural and
remote communities told them that in some cases they were concerned about
accessing services in case they were recognised while accessing the service. In some cases, submitters told the committee that they were aware of people who
travelled to different towns or took certain steps, such as parking further
from the service, because they were concerned about being recognised. Orygen noted that this could be a particular issue for young people who are
concerned about being stigmatised if they were seen attending a headspace or
another mental health service.
The National Mental Health Consumer and Carer Forum and Neami National
told the committee that concerns about confidentiality could be even more acute
for people from vulnerable groups, such as LGBTI people, CALD populations or
Aboriginal and Torres Strait Islander peoples. The Black Dog Institute noted that some people in these groups may not engage
with professional services for fear of not being understood or facing stigma. The Black Dog Institute noted that similar concerns were also expressed by
veterans groups who considered that veterans were reluctant to engage with
professionals who may not be able to understand their unique experiences.
Some submitters suggested that co-locating health services in one place
could help to address the some of the issues surrounding stigma. The Central
Australian Aboriginal Congress told the committee that by providing wrap-around
services in one location, stigma was reduced by having the same door for
physical and mental health services. OzHelp noted that engaging clients with a focus on physical health and
wellbeing would present an opportunity to discuss topics such as mental health
Some submitters told the committee that there were effective ways to
reduce stigma in a community. The Australian Mental Health Commissions told the
committee that promotional campaigns and training have demonstrated the
capacity to reduce stigma and recommended that such a campaign could be
effective in combatting mental illness in rural and remote communities.
Being, a state-wide peak mental health consumer organisation based in
New South Wales, told the committee that it believed that peer workers, a
trained group of people with lived experience of mental illness, could help to
educate the community:
Peer workers may be able to provide support with regard to a
number of the challenges to mental health help seeking noted above. Peer
workers can be an excellent source of education. Raising health literacy in
schools, universities and workplaces, could very effectively be carried out by
peer workers who themselves embody the message that getting help and learn to
strategies to live with mental health issues can only start with the ability to
recognise when something might be wrong.
ConnectGroups told the committee that peer support groups could play a
significant role in promoting health and wellbeing and reduction of stigma. Others, such as the Depression Support Network Albany, told the committee that
a peer workforce could be effective in breaking down stigma in the community:
I think getting out into the community and doing activities
in the community, whether it be yoga or whether it be tennis, and joining in
with those community groups and saying, 'Hey, we've got mental illness but
we're not different to you,' has been a really good positive way. I talk a lot
with various doctors and people around town, and they've gotten to know me and
realised, 'Yes, she's got a mental illness but she's not that different from
Some submitters advised the committee that they were offering or
developing technological supports that may allow individuals to access mental
health services from the privacy of their computer. For example, Grow developed
an online mutual support group using videoconferencing that catered for people
around Queensland to provide support from people who were not in geographic
proximity to other members of the group. Similarly, OzHelp is developing its digital capacity to try to reduce barriers
to access that might be faced by groups who may otherwise be reluctant to seek
help face-to-face. However, as noted above, technological solutions, while providing benefit to
some people, are not the answer to the overall accessibility of rural and
Concluding committee view
In recent years in Australia there has been an increased national focus
on mental health issues which has improved the diagnosis, treatment and
community acceptance of mental health conditions across Australia. However, the
committee heard compelling evidence that the different causes and service
difficulties felt in rural and remote communities has meant the improvements
driven by the national focus has mostly been felt in urban locations.
The committee recognises that many complex factors influence whether a
person decides to seek help from professional mental health services, including
the availability of those services, whether they believe their confidentiality
can be protected and whether they believe they will be labelled or stigmatised
for accessing those services if they are recognised. The committee considers
that these factors are barriers to accessing mental health services that need
to be addressed to make people more likely and willing to engage with
professional services when they need them.
The committee heard that some communities and service providers are
working to decrease stigma by educating the public about mental health and/or
by co-locating physical and mental health services. The committee commends
groups that are actively working to combat stigma, but considers that more
needs to be done in rural and remote communities around Australia to improve
attitudes toward accessing mental health services.
The committee heard that the impacts of social determinants of health,
which contribute to mental health conditions and impact on the delivery of
mental health services, are felt significantly in rural and remote communities.
The committee believes that addressing the social determinants of health must
be considered in any reform to improve the accessibility of mental health
services in rural and remote communities.
The committee is concerned that mental health services are not available
when and where they are needed in rural and remote communities. The committee
believes that more needs to be done to address the shortfall in mental health
professionals in these areas and overcome the barriers of distance, transport
and lack of reliable telecommunications infrastructure. A catalyst to drive
mental health service improvements in rural and remote locations is clearly
necessary to address the different needs of these communities.
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