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.
National Mental Health
Commission, Contributing lives, thriving communities – Report of the
National Review of Mental Health Programmes and Services
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.
The final report of the Commission was provided to government on 1 December
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'.
The review's terms of reference were to evaluate:
the efficacy and cost-effectiveness of programmes, services and
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
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
transparency and accountability for outcomes of investment.
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.
This chapter provides a high-level examination of the Commission's
review, and in particular the process it followed, its key findings and
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.
The Commission framed its review within what it described as 'the
context of the fiscal constraints faced by all Australian governments'.
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.'
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.'
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.
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.
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
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
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
Advice on Innovative Technologies in e-Mental Health, Young and
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
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.
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.
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. 
The Commission also found that the duplication of services leads to significant
gaps in service availability, particularly for Aboriginal and Torres Strait
Islander peoples: 
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.
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.
Focus on acute care not early
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.
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.
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
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.
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. 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
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:
- Person-centred design principles
- A new system architecture
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.
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'.
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.
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.
Person-centred approach to mental
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.'
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.
Under a person-centred approach, individuals experiencing mental ill-health
would be involved in decision-making, embodying the ethos "nothing about
us without us".
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
Figure 3 below, taken from the Commission's review, illustrates the
concept of a person-centred approach. The Commission explained that such an
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
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.
Figure 3—A person-centred approach with systems and
resources as enablers
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
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.
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
efficient: programmes and services maximise net benefits to the
evidence-based: decisions based on meaningful data
The review argued that putting the above objectives into effect would
matching available resources to identified need;
a focus on prevention, early intervention, and support for recovery;
an emphasis on community support and integration.
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'.
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:
stepped care framework that provides a range of help options of varying
intensity to match people’s level of need.
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).
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.”
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.
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
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
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
Improve service equity for rural and remote communities through
place-based models of care.
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.
An examination of the government's reaction to the Commission's review
and recommendations is in Chapter 4.
Sector response to Commission's recommendations
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
“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”
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.
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.
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...
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
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
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.
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.
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.
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.
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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