Chapter 3

National Mental Health Commission Review

We have every confidence that the adoption of the recommendations in this report will result in transformational reform of the mental health system, promote significant innovation, particularly at a local level, and enable people, their families and communities to thrive.[1]

National Mental Health Commission, Contributing lives, thriving communities – Report of the National Review of Mental Health Programmes and Services

Introduction

3.1        On 4 February 2014 the then Minister for Health, the Hon Peter Dutton MP announced terms of reference for the National Mental Health Commission (the Commission) to review mental health services and programmes.[2] The final report of the Commission was provided to government on 1 December 2014.[3]

3.2        The Commission's review was to 'examine existing mental health services and programmes across the government, private and non-government sectors'. The review was to focus on an assessment of 'efficiency and effectiveness of programmes and services in supporting individuals experiencing mental ill-health and their families and other support people to lead a contributing life and to engage productively in the community'.[4]

3.3        The review's terms of reference were to evaluate:

• the efficacy and cost-effectiveness of programmes, services and treatments;
• duplication in current services and programmes;
• the role of factors relevant to the experience of a contributing life such as employment, accommodation and social connectedness (without evaluating programmes except where they have mental health as their principal focus);
• the appropriateness, effectiveness and efficiency of existing reporting requirements and regulation of programmes and services;
• funding priorities in mental health and gaps in services and programmes, in the context of the current fiscal circumstances facing governments;
• existing and alternative approaches to supporting and funding mental health care;
• mental health research, workforce development and training
• specific challenges for regional, rural and remote Australia;
• specific challenges for Aboriginal and Torres Strait Islander peoples; and
• transparency and accountability for outcomes of investment.[5]

3.4        The review built on the Commission's previous work, including the consultations and research completed for the Commission's two National Report Cards on Mental Health and Suicide Prevention.[6]

3.5        This chapter provides a high-level examination of the Commission's review, and in particular the process it followed, its key findings and recommendations.

Review process

3.6        The Commission described the review as advice to Government on whether:

...Commonwealth programmes and services are being leveraged to maximise impact and achieve the greatest public value in enabling a contributing life for people experiencing mental ill-health.[7]

3.7        The Commission framed its review within what it described as 'the context of the fiscal constraints faced by all Australian governments'.[8] The result was that the review did not propose any reduction or increase in spending on mental health. Instead the review's recommendations are aimed at 'redirecting existing resources rather than new funding, with resources to be used cost-effectively to leverage better outcomes.'[9] The Commission's website notes that the review 'is framed on the basis of making changes within existing resources, as specified by the Terms of Reference provided to the Commission by the Commonwealth Government.'[10]

3.8        The conduct of the Commission's review included:

• calling for submissions from stakeholders;
• conducting face-to-face meetings with stakeholders;
• gathering and analysing information and data from Commonwealth, state and territory governments;
• building on work already completed for the Commission's National Report Cards; and
• commissioning work from consultants.[11]

3.9        On 24 March 2014, the Commission invited all interested individuals and groups to make submissions to inform its review. The Commission also wrote to over 530 stakeholders and encouraged them to make submissions. As a result, the Commission received over 2000 online and paper-based submissions.[12] The Commission noted:

The submissions process wasn’t the only way we gathered views, ideas and evidence – we asked funders and service providers for data and information; we met face to face with consumer and carer, service provider and professional representatives; and we looked at a range of research, evaluations and reviews.[13]

3.10      The Commission carried out detailed research as part of its review, and considered data and information from Commonwealth agencies, states and territories. A particular concern highlighted by the Commission was that gaps in data seemed to be a result of a lack of proper programme evaluation:

Overall the Commission was underwhelmed at the level of programme evaluations available, given the significant investment of Commonwealth funds. Hence in critical areas, and for vulnerable populations, it is not possible to say whether resources are being efficiently and effectively targeted. For many Aboriginal and Torres Strait Islander people, for example, the mental health system requires them to rely on general population services and programmes. However, the degree to which they are accessed by Aboriginal and Torres Strait Islander people or are contributing to better mental health outcomes is largely unknown.[14]

3.11      As part of its review, the Commission commissioned a number of supporting reports from consultancies. These included:

• Improving the integration of mental health services in primary health care at the macro level, Primary Health Care Research & Information Service (PHCRIS)
• Advice on Innovative Technologies in e-Mental Health, Young and Well CRC
• Paving the way for mental health: The economics of optimal pathways to care, KPMG
• Advice and recommendations: Specific challenges for regional, rural and remote Australia, University of Newcastle
• Expert advice on specific challenges for Aboriginal and Torres Strait Islander peoples’ mental health (Final Report), HMA[15]

Review findings

3.12      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.[16]

3.13      However, 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'. The current spending on mental health by Commonwealth, state, and territory governments was, according the review, about $14 billion per annum.[17]

Duplication

3.14      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. [18] The Commission also found that the duplication of services leads to significant gaps in service availability, particularly for Aboriginal and Torres Strait Islander peoples: [19]

For Aboriginal and Torres Strait Islander people, these service and programme gaps can be summarised as:

• a significant gap in community-based social and emotional wellbeing promotion, prevention activity and primary mental health care enabling the prevention, early detection and treatment of mental health problems at an early stage
• culturally competent general population mental health services
• ensuring patient transitions from family and community to primary and specialist mental health care, and then back into the community
• a lack of Aboriginal and Torres Strait Islander specialist care to support transitions and ensure culturally appropriate services that accommodate cultural difference—for example, by supporting access to traditional healers, or working with families.[20]

Resourcing

3.15      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.[21]

Focus on acute care not early intervention

3.16      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.[22]

Financial risk to Commonwealth from current funding structure

3.17      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.[23]

3.18      The Commission pointed out that financial risks also fall in a different way on the state and territory governments. In this instance the financial risk results from increased need for acute care, crisis teams, and admissions to emergency departments.[24]

3.19      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.[25]

Need for overall system change

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

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.[26]

Review recommendations

3.21      The Commission described its recommendations as designed to lead to the creation of 'a system to support the mental health and wellbeing of individuals in a way that enables them to live contributing lives and participate as fully as possible as members of thriving communities'. The Commission explained that:

To achieve the required system reform, the Commission recommends changes to improve the longer-term sustainability of the mental health system based on three key components:

1. Person-centred design principles
2. A new system architecture
3. Shifting funding to more efficient and effective ‘upstream’ services and supports.

These principles underpin the Commission’s 25 recommendations across nine strategic directions. They guide a more detailed implementation framework of activity over the next decade, which provides a comprehensive plan for action in mental health reform.[27]

3.22      The new system architecture proposed in the Commission's review would 'redesign, redirect, rebalance, repackage and ultimately reform the approach to mental health in Australia'.[28] The Commission explained this as:

• redesign the system to focus on the needs of individuals, and their families and other supporters, rather than on what providers do
• redirect Commonwealth dollars as incentives to purchase value‑for‑money, measurable results and outcomes, rather than simply funding a myriad of programmes to produce more and more activity
• rebalance expenditure away from those things which indicate system failure and invest in those things which are known to work— prevention and early intervention, recovery-based community support, stable housing, and participation in employment, education and training
• repackage and bundle funds being spent on that small percentage of people with the most severe and persistent mental health problems and who are the highest users of the mental health dollar. Purchase integrated packages of services which support them to lead contributing lives and keep them out of avoidable high cost care
• reform our approach to supporting people and families to lead fulfilling, productive lives so they not only maximise their individual potential and reduce the burden on the system but also can lead a contributing life and help grow Australia’s wealth.[29]

3.23      In accordance with the instructions from Government, the Commission's recommendations are designed to effect changes to the structure of mental health care and funding within existing resources. For example:

...the Review identifies measures to help the Commonwealth maximise value for taxpayers’ dollars by using its resources as incentives to leverage desirable and measurable results, and funding outcomes rather than activity. It also proposes reallocating funding from downstream to upstream services, including prevention and early intervention.[30]

Person-centred approach to mental health

3.24      The Commission advocated a 'person-centred approach' to mental health. Person‑centred approach means that 'services are organised around the needs of people, rather than people having to organise themselves around the system.'[31] In such an approach:

...as a person’s acuity and functional impairment increase, the care team will expand to include different support providers. As acuity diminishes and functional capacity is improved, the team will contract as the person can take on more self-care. People are not transferred from one team to another but remain connected throughout, to a general practice or community mental health service, and with an ongoing core relationship with their family and other support people.[32]

3.25      Under a person-centred approach, individuals experiencing mental ill-health would be involved in decision-making, embodying the ethos "nothing about us without us".[33] The review described an ideal person-centred mental health system as having 'clearly defined pathways between health and mental health'. Such a system would also recognise and build on the non-health supports 'such as housing, justice, employment and education' and focuses on 'cost-effective, community-based care'.[34]

3.26      Figure 3 below, taken from the Commission's review, illustrates the concept of a person-centred approach. The Commission explained that such an approach includes:

• governance models which engage with people with lived experience, their families and support people and enable them to participate at every level in planning, commissioning and monitoring of services
• funding models (which, if properly designed, can drive the right behaviour)
• the right workforce to provide equitable access and to do the job in the most efficient and effective way
• e-mental health and information technology to link people and services and promote self-care and wellbeing
• research and evaluation to translate evidence into practice
• measurement of results to ensure transparency and accountability and to feed into planning
• regulatory frameworks to protect and promote safety and quality for people but which otherwise should be light touch
• regional planning and organising to be responsive to the diverse local needs of the different communities across Australia.[35]

Figure 3—A person-centred approach with systems and resources as enablers[36]

3.27      Implementing a person-centred approach is only possible in a system which will appropriately support it. Therefore, the Commission advocated for changes to system architecture to ensure support for a more efficient and effective approach to supporting mental ill-health.

Changes to system architecture

3.28      The current system, as described by the Commission, does not necessarily lend itself to a person-centred approach. The Commission therefore argued that to implement the person-centred approaches embodied in review's findings, it will be necessary to make changes to the system architecture.

3.29      To complement the person-centred approach the Commission outlined three main objectives for a reformed mental health system:

• effective: scarce resources used cost-effectively to achieve identified objectives
• efficient: programmes and services maximise net benefits to the community
• evidence-based: decisions based on meaningful data[37]

3.30      The review argued that putting the above objectives into effect would mean:

• matching available resources to identified need;
• a focus on prevention, early intervention, and support for recovery; and
• an emphasis on community support and integration.[38]

3.31      Figure 4 below, taken from the review, demonstrates the way in which system architecture needs to be shaped to support a person-centred approach. In Figure 4, 'the main features of such an approach are to differently target the population as a whole, the segment of the population with low-moderate needs and the segment of the population with high-very high needs'.[39]

Figure 4—Population-based architecture[40]

3.32      The review argued that a 'stepped care framework' should accompany person‑centred care and the complementary changes in system architecture:

The realignment of system architecture as recommended in this report also involves two other important features:

• A stepped care framework that provides a range of help options of varying intensity to match people’s level of need.
• Integrated Care Pathways (ICPs) for mental health, to provide for a seamless journey through the mental health system.

This approach shifts groups of people towards ‘upstream’ services (population health, prevention, early intervention, recovery and participation) and thereby reduces ‘downstream’, costly services (ED presentations, acute admissions, avoidable readmissions and income support payments).[41]

3.33      The review explained that fundamental to a stepped care framework is prioritising the delivery of care through GPs and primary healthcare. The review noted that there is international evidence that:

...national health care systems with strong primary care infrastructures have healthier populations, fewer health-related disparities and lower overall costs for health care than those countries that focus on specialist and acute care. 

Indeed, the World Health Organization (WHO) has endorsed this approach: Integration of mental health into primary health care “not only gives better care; it cuts wastage resulting from unnecessary investigations and inappropriate and non-specific treatments.”[42]

3.34      In an Australian context, the review stated that:

Based on modelling commissioned from KPMG, the outcome of implementing this change [to a stepped care and person-centred approach] would be to slow the rate of increase in Disability Support Pension (DSP) and Carer Payment costs and the costs of acute care and crisis management.[43]

Innovations—refocusing funding

3.35      As a result of the need for restructure of system architecture, the review made the following finding and accompanying recommendations:

Shift funding priorities from hospitals and income support to community and primary health care services

Recommendations:

• Reallocate a minimum of $1 billion in Commonwealth acute hospital funding in the forward estimates over the five years from 2017–18 into more community-based psychosocial, primary and community mental health services.
• Extend the scope of Primary Health Networks (renamed Primary and Mental Health Networks) as the key regional architecture for equitable planning and purchasing of mental health programmes, services and integrated care pathways.
• Bundle-up programmes and boost the role and capacity of NGOs and other service providers to provide more comprehensive, integrated and higher-level mental health services and support for people, their families and supporters.
• Improve service equity for rural and remote communities through place-based models of care.[44]

3.36      The Minister for Health, the Hon Sussan Ley MP, has already stated this recommendation of the Commission would not be accepted by the government:

...the Government does not intend to pursue the proposed $1 billion shift of funding from state acute care to community organisations, as we want to work collaboratively in partnership with other levels of Government.[45]

3.37      An examination of the government's reaction to the Commission's review and recommendations is in Chapter 4.

Sector response to Commission's recommendations

3.38      Since the Commission delivered its review to the government on 1 December 2014, there were calls from mental health groups for the review report to be publicly released. For example, the CEO of Mental Health Australia, Mr Frank Quinlan spoke about the need for the Commission's review to be released as part of a public discussion about mental health sector reform. Speaking on 2 March 2015 about the release of three major reports by non-profit groups, Mr Quinlan said:

“In the face of these reports, we renew our call on government to release the National Mental Health Commission’s Review of Mental Health Services and Programmes to allow consultation and planning, and to commit to ending funding uncertainty for mental health organisations who are delivering essential services across all these areas.”

“The mental health sector is committed to reform and renewal, it’s time to get started”[46]

3.39      However, the Commission's report was not released by the government until 16 April, after parts of the report were leaded to the Australian Broadcasting Corporation on 14 April. Further discussion on the release of the report and the government reaction is in Chapter 4.

3.40      At the committee's public hearing on 26 August 2015, a number of groups were supportive of the work of the Commission and the review's recommendations. For example, Professor Malcolm Hopwood, the President of the Royal Australian and New Zealand College of Psychiatrists told the committee:

We particularly support the review's and other commentators' focus on bringing things together across the sector. Mental health funding is diverse in its origin, and that is a significant barrier to improving mental health care. By this, I mean not just governmental boundaries but also boundaries across the primary, secondary and tertiary sectors.[47]

3.41      Ms Pamela Rutledge, Chief Executive Officer of RichmondPRA, an organisation which provides Partners in Recovery (PIR) services, also praised the Commission's report:

Coming from a slightly different angle, and from RichmondPRA's perspective—we work in a way that is very strongly led by people with a lived experience of a mental health issue, and we also support the National Mental Health Commission Review and the direction that it proposes...[48]

3.42      Mr Jack Heath, Chief Executive Officer of SANE Australia voiced the views of many organisations in both supporting the Commission's review and arguing for a government response to the review recommendations:

In relation to the National Mental Health Commission's review, the sector desperately needs a response this year. We do not want to be in the position where we have funding rolled over for another 12 months. It is just a really terrible way to try and operate services for people with severe needs. When we have seen political leadership in Australia in the past decades—and I would go back to Prime Minister Howard with the work that he did around youth suicide—we have seen significant changes occur. We are not going to see substantial reform in mental health unless we have concerted political leadership around that. I think that at a political level, mental health seems to have dropped off the agenda in the past couple of years. There is an opportunity now for that to be picked up in terms of response to the review. But we need to make sure that those responses are considered and are not done in a simplistic way. At the same time that we have many problems that were identified in the review of the mental health system in Australia, it has been SANE's view for a number of years that we actually believe we have the potential in this country to deliver the best world's best mental health services and programs for a number of reasons but I will not go into that right now.[49]

Committee view

3.43      At the outset the committee wishes to acknowledge the exceptional work of the National Mental Health Commission in undertaking its review. The committee congratulates the Commission on its production of a comprehensive report on the state of delivery of mental health services and programmes in Australia.

3.44      Like the Commission, the committee is underwhelmed by the gaps in data and the lack of detailed evaluation of Commonwealth, state, and territory government services and programmes. Without standardised data collection and thorough programme evaluation, the task of assessing the efficiency and effectiveness of programmes and services becomes high challenging. Poor evaluation not only results in funding being wasted, it also has the far more detrimental consequence of depriving individuals of the help they need.

3.45      The committee notes the findings of the Commission in relation to the need for prevention and early intervention in treating mental ill-health. In particular the committee notes with concern the gap in provision of services to vulnerable groups, including Aboriginal and Torres Strait Islander peoples and those in rural and remote areas. The committee urges the government to have regard to the Commission's findings in relation to prevention and early intervention and the urgent need for support for vulnerable groups.

3.46      Overall the committee considers that the Commission has produced a clear and comprehensive set of recommendations for the future reform of the delivery of mental health programmes and services. The committee urges the government to follow the recommendations made by the Commission, as closely as possible.

3.47      However, the committee is concerned that the Commission was tasked by the government with making recommendations within the boundaries of current government expenditure. The committee believes that this was an unnecessary constraint on the Commission's review.

3.48      Similarly, the committee is concerned that the government has changed the Commission's reporting arrangement, as described in Chapter 2. Placing the Commission within the Department of Health, rather than outside of the department and reporting directly to government, is an unwelcome interference in the independence of the Commission.

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