Executive Summary

Executive Summary

This interim report is the fourth of a series in which the Senate Select Committee on Health proposes to report its findings and conclusions to date.

This report focuses on the Federal Government's approach to mental health. Unfortunately, mental health policy and funding in Australia is in a state of suspended animation while the government re‑reviews, re‑consults on, and re-considers the findings of the National Mental Health Commission's review of the delivery of mental health services and programmes.

Meanwhile, organisations providing mental health services and programmes are forced to survive on year-to-year funding. The uncertainty caused by the government's constantly delayed decision making has caused workforce instability and increasing uncertainty for mental health consumers and carers. This is an unacceptable situation.

Mental health in Australia – situation: crisis

The National Mental Health Commission (the Commission) begins its report on Mental Health Services and Programme Delivery with a stark set of facts about the prevalence of mental ill-health in Australia:

Each year, it is estimated that more than 3.6 million people (aged 16 to 85 years) experience mental ill-health problems—representing about 20 per cent of adults. In addition, almost 600,000 children and youth between the ages of four and 17 were affected by a clinically significant mental health problem. Over a lifetime, nearly half of the Australian adult population will experience mental illness at some point—equating to nearly 7.3 million Australians aged 16 to 85. Less than half will access treatment.[1]

Mental ill-health can have devastating consequences for individuals and their families. For instance the Commission's report identified suicide as a major issue in mental health:

In 2012 more than 2,500 people died by suicide, while in 2007 an estimated 65,000 Australians attempted to end their own life. Suicide is the leading cause of death among people aged between 15 and 44 years old, and is more likely among men, Aboriginal and Torres Strait Islander peoples and people living outside of major cities.[2]

Disturbingly, a large number of people, particularly young Australians, do not seek or delay seeking help. Dr Michelle Blanchard, the Head of Projects and Partnerships at the Young and Well Cooperative Research Centre told the committee:

In the case of young people, 25 per cent of young people experience a mental health difficulty and 70 per cent of those do not seek help and do not receive care. It is a very high figure for a younger population, and that figure is higher again for young men...

We know from international evidence that the time between the onset of symptoms for someone with a mental illness and the time they receive the right care is up to 10 years.[3]

Previous mental health reviews

The Commission's review is the latest in a long line of reviews and inquiries which have considered the most effective and efficient means of delivering mental health services and programmes. Mr Sebastian Rosenberg, a Senior Lecturer at the University of Sydney's Brain and Mind Centre reflected on the growing list of past inquiries:

Despite four national plans and two national policies, one road map, two report cards and one action plan, genuine mental health reform seems as far away as ever. There is a sense that things have changed and that the asylums have closed in Australia. Well, there are still 1,831 beds in asylums across Australia costing about half a billion dollars per year. Large elements of the old system are still very much in place in our current system... One of the main things that was through all the history of Australian mental health policies and plans has been the desire to establish community-based mental health care, but in fact what we have is an extremely hospital‑focused system of care. Even when the National Mental Health Commission suggested a very small change to those arrangements, Minister Ley unfortunately seemed to indicate that that would not be pursued.

We were interested very much in promotion, prevention and early intervention, but in fact we have a system which really is about postvention and crisis management.

We were very much interested in e-mental health technologies, some of which Australia has led in, but in fact what we have is a continued dependence on face-to-face care and fee-for-service type approaches.[4]

Mr Rosenberg told the committee that there have been 32 reviews into mental health between 2006 and 2012. Chief amongst these was the landmark work of the Senate Select Committee on Mental Health in 2006.

The overall findings of the Select Committee on Mental Health are remarkably similar to our current situation:

...there is much work to do in the area of mental health. There needs to be more money, more effort and more care given to this neglected part of our health care system. There is not enough emphasis on prevention and early intervention. There are too many people ending up in acute care, and not enough is being done to manage their illness in the community. There are particular groups, and people with particular illnesses, who are receiving inadequate care. Many of these findings have been confirmed by other organisations and reports in recent years.[5]

Findings of the National Mental Health Commission

The Commission found that despite various system-related issues, and a lack of proper evaluation of programmes, at a service level there were:

...many examples of wonderful innovation and...effective strategies do exist for keeping people and families on track to participate and contribute to the social and economic life of the community. The key feature of these strategies is that they take a person-centred, whole-of-life approach.[6]

Overall the Commission's findings indicated serious problems in the effectiveness and efficiency of the current 'patchwork of services, programmes and systems for supporting mental health'. The Commission stated that as a result, 'many people do not receive the support they need and governments get poor returns on their substantial investment'. According the review the current spending on mental health by Commonwealth, state, and territory governments was about $14 billion per annum.[7]

The case for reform of the mental health system is irrefutable, with the Commission describing the current situation in its report:

The need for mental health reform has had long-standing bipartisan support. Yet as a country we lack a clear destination in mental health and suicide prevention. Instead of a “mental health system”—which implies a planned, unitary whole—we have a collection of often uncoordinated services that have accumulated spasmodically over time, with no clarity of roles and responsibilities or strategic approach that is reflected in practice.[8]


The Commission also found duplication in the current system. This manifested in a lack of flexibility of service delivery which means that services and individuals may be mis-matched.[9] The Commission also found that the duplication of services leads to significant gaps in service availability, particularly for Aboriginal and Torres Strait Islanders peoples.[10]

Funding priorities

In terms of resourcing, the Commission found that much of the current funding was focussed on acute care, and very little targeted to early intervention and community‑based support:

Nationwide, resources are concentrated in expensive acute care services, and too little is directed towards supports that help to prevent and intervene early in mental illness. Of total Commonwealth spending of $9.6 billion, 87.5 per cent is in demand-driven programmes, including income support, and funding for acute care. This means that the strongest expenditure growth is in programmes that can be indicators of system failure—those that support people when they are ill or impaired—rather than in areas which prevent illness and will reap the biggest returns economically and ‘future proof’ people’s ability to participate and live productive, contributing lives.[11]

Focus on acute care not early intervention

Related to the funding for acute care, the Commission observed the biggest inefficiencies in the system came from:

...doing the wrong things—from providing acute and crisis response services when prevention and early intervention services would have reduced the need for those expensive services, maintained people in the community with their families and enabled more people to participate in employment and education.

In fact, there is evidence that far too many people suffer worse mental and physical ill-health because of the treatment they receive, or are condemned to ongoing cycles of avoidable treatment and medications, including avoidable involuntary seclusion and restraint.[12]

Financial risk to Commonwealth from current funding structure

The Commission identified significant financial risk for the Commonwealth in the current model of funding for mental ill-health:

The Commonwealth’s role in mental health creates significant exposure to financial risk. As a major downstream funder of benefits and income support, any failure or gaps in upstream services means that as people become more unwell, they consume more of the types of income supports and benefits which are funded by the Commonwealth.[13]

The Commission found that a major contributor to government financial risk, and to increased government spending, was a lack of coordination:

Ironically, much risk comes from within governments—portfolios working in isolation of each other, aiming to minimise their exposure and their costs without taking into account the downstream costs to their fellow agencies and the overall costs to their government.

For example, many of the services required to keep people well and participating in their homes and the community lie outside the formal health system. This includes areas such as accommodation, education, employment and family and community services. Yet a breakdown in housing or relationships for an individual can pitch them into crisis, resulting in ED [Emergency Department] presentations and extended periods of hospitalisation and acute care. This means that agencies within governments, as well as agencies across governments, need to work together, collaborate and coordinate to manage overall costs and risks.[14]

Need for overall system change

From these findings, the Commission made 25 recommendations aimed at making substantial system-wide changes to the delivery of mental health services and programmes:

Overall, the findings of this Review present a clear case for reform. The status quo provides a poor return on investment for taxpayers, creates high social and economic costs for the community, and inequitable and unacceptable results for people with lived experience, their families and support people... Managing these costs effectively and sustainably requires a carefully designed programme of practical reforms that rebalance the system to reduce demand for services in the first place and improve the range and appropriateness of support options. This will deliver better mental health outcomes for individuals and promote economically and socially thriving communities.[15]

Government inaction

The Commission provided its report to the Government on 1 December 2014. However, despite the Government's commitment to 'building a world-class mental health system',[16] the government only released the Commission's report after part of the report had been leaked to the media in April 2015.

Since the release of the report, the government has not formally responded to the Commission's recommendations. Instead, the Minister for Health, the Hon Sussan Ley MP, responded to the commission's report with another review by establishing an Expert Reference Group (ERG). The Minister has recently announced that she intends to respond to the Commission's report by the end of the year.[17]

Mental health sector response

Mental health policy has been on hold since the beginning of the Commission's review in February 2014. In October 2015, ten months after the completion of the Commission's thorough review, the government has still not responded to the Commission's recommendations. As a result, the mental health sector struggles with ongoing funding uncertainty and indecision about the future direction of mental health policy in Australia.

The committee heard the concerns of mental health groups, advocates, service providers, consumers and carers in relation to the uncertain future direction of mental health funding and policy. These groups all gave the committee similar evidence: the government needs to respond positively to the Commission's recommendations and it needs to do so before the end of 2015.

For instance Mr Ivan Frkovic, the Deputy Chief Executive Officer of National Operations at service provider Aftercare, told the committee:

...we support the directions that were set in the Mental Health Commission report, particularly, again, from a consumers and carer perspective. Let's have a system that focuses and is incentivised for outcomes, not for maintenance, whether it is the public system, the private system or the NGO system.[18]

Similarly, Professor David Perkins, the Director and Professor of Rural Health Research at the Centre for Rural and Remote Mental Health observed that:

If we start with community members and people who live in rural and remote areas and ask what they want and need, I think we find the answers have been articulated well by the National Mental Health Commission and by my state's mental health commission. People want a contributing life. They want to live well. They want a secure home, reliable income, education or employment, and to be able to take part in their communities, and they want their symptoms addressed...[19]

Professor Ian Hickie, a Commissioner of the National Mental Health Commission spoke of the consensus which has been built around the Commission's findings:

I think what has happened here is very unusual. The whole Australian mental health community, through both its lived experience and its technical experts, has combined to say to our respective governments that there is a fundamental need to move away from a programmatic funding approach in response to each crisis and towards locally led and organised services that work in regional Australia.[20]

Committee recommendations

The Senate Select Committee on Health's examination of the issues around mental health services and programmes is relatively brief in comparison with the work done by the Senate Select Committee on Mental Health in 2006. However, the committee notes that the same issues have been raised in both its inquiry, and in the Commission's review of the delivery of mental health services and programmes.

By examining the work of the Commission, the issues raised by witnesses, and the lack of government response to the Commission's review, the committee has demonstrated that once again mental health policy is at a crossroads. Both the issues and the necessary reforms are well documented throughout many inquiries. The committee believes that action now is essential if Australia is to reform its mental health system.

The committee heard from those with lived experience of mental illness, those who care for mental illness suffers, mental health organisations, service providers, and researchers. The evidence from all witnesses was unanimous support for:

The committee's 13 recommendations reflect what the committee has been told by the mental health sector and those with lived experience of mental illness. The committee considers that the government's lack of response to the Commission's findings has caused significant harm. The committee therefore calls on the government to announce its response as a matter of urgency.

As Professor Hickie said when interviewed on 5 October by ABC Radio's The World Today program:

The Abbott government gave a commitment at the 2013 election to conduct a review and implement reforms during this period of government. So it's good to see the [Health] Minister's finally working her way through these issues, but really, really, it's time for action – not more talk.

So we don't need more reviews, we don't need more consultation, we don't need more discussion about discussion – we actually need the Prime Minister, the new Prime Minister, working in combination with the states, so that people get the services that they need no matter where they live.[21]

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