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.
Professor Ian Hickie
Commissioner, National Mental Health Commission
The previous chapter outlined the issues of governance and funding in
mental health service and programme delivery. This chapter draws again on the
evidence from witnesses and submitters, but focuses instead on issues relating
to service delivery, including services and programmes for specific groups.
These issues include:
Primary Health Networks (PHNs) and mental health;
access to early intervention;
linking housing and employment to mental health;
rural and remote communities;
Aboriginal and Torres Strait Islander peoples;
LGBTI (Lesbian, Gay, Bisexual, Transgender, Intersex);
Culturally and Linguistically Diverse (CALD) communities; and
In considering each issue, the committee examines the findings of the
Commission, the evidence received from witnesses, and where it exists,
government reaction to the Commission's findings.
A theme that runs throughout the Commission's review is that the aim of
any action on increasing the effectiveness and efficiency of mental health services
and programmes should be the de-stigmatisation of mental health. In describing
the current state of mental health services and programmes in Australia, the
Commission first statement was 'Stigma persists'. 
A relevant Commission recommendation states:
Promote easy access to self-help options to help people,
their families and communities to support themselves and each other, and
improve ease of navigation for stepping through the mental health system.
Stigma was an issue which the Commission identified as needing to be
addressed by this recommendation:
Stigma is associated with poorer physical and emotional
health, as well as poorer employment outcomes. It can discourage individuals
from disclosing their illness and from seeking help, both of which are
important steps to gaining assistance in managing symptoms and preventing the
development of a more serious experience of mental illness. In this way, stigma
presents barriers to service access, creates additional distress and mental
ill-health and ultimately drives up system costs.
SANE Australia describe the impacts of stigma as:
People with mental illness put up with a lot more than their
illness. Stigma contributes another major stress they can well do without. Many
say that stigma and prejudice is as distressing as the symptoms themselves.
Most often stigma against people with a mental illness
involves inaccurate and hurtful representations of them as violent, comical or
incompetent – dehumanising and making people an object of fear or ridicule.
Organisations like SANE Australia, ReachOut, RUOK? and Beyondblue try to
reduce stigma by raising awareness of mental ill-health and encouraging public
discussion of mental health issues. ReachOut for instance works to encourage
access to information and assistance for mental ill-health. It has previously
run a campaign to normalise the discussion of mental ill-health by making a
comparison between the way physical health issues are publicly discussed and
the way mental ill-health issues are often hidden or dismissed. ReachOut
publishes graphics which ask 'what if we treated all health issues like we
treat mental health?' Some example answers to this hypothetical question
'I'm so sick of you and your constant heart disease.'
'We all feel like we have diabetes sometimes! Snap out of it.'
'I'm getting very tired of this "cancer" of yours.'
'Yeah, you just think you need your Asthma puffa because you
can't deal with reality.'
Ms Christine Morgan, the Chief Executive Officer of the Butterfly
Foundation supported the need to fight the stigma around mental illness and
facilitate better access to services for sufferers. The Butterfly Foundation
has a particular focus on the treatment of eating disorders. Ms Morgan told the
committee that in the case of eating disorders, the suicide rate is the highest
of any psychiatric disorder. Early intervention in eating disorders is vital,
but a major barrier to early intervention is the stigma associated with mental
At the moment, we know that less than 23 per cent of people
with an eating disorder are seeking treatment. They are highly stigmatised. If
you have anorexia nervosa, thankfully it is relatively accepted as a very
serious illness. It also physically manifests itself and you must receive
treatment. If you suffer from bulimia nervosa, a binge eating disorder or
atypical presentations the average nondisclosure time is 10 years. That is 10
years when somebody is too ashamed to go for help. We must reduce stigma. I
used to think that if you raised awareness, if you raised an understanding of
the genetic vulnerability of somebody with an eating disorder, if you raised
the impact of nutritional deprivation triggering something that actually
changed their neural pathways, if you helped people understand that, they would
not be stigmatised. But they are. Too many people still see it as people who do
not know how to eat properly, who eat too much or too little, and they say 'Get
on with it and fix it up.'
Ms Morgan argued that reducing stigma was more complex than awareness
raising campaigns. What is needed is a multi-faceted approach which targets all
parts of the pathway to accessing mental health services and programmes:
We must reduce stigma, and that is much more complex than
just raising awareness. Sitting behind that, we also need workforce capacity
and workforce development. I share the views of my colleague that GPs must not
only be recognised as an incredibly important first portal but they have to be
resourced. And sitting behind them they need pathways to care that are
appropriately funded whether through...better access to Medicare rebates or
through private health insurance—which to this day remains discretionary for
anybody with an eating disorder, other than for the short time they spend in a
private hospital. Anything as [an] outpatient is discretionary cover by private
health fund. So we must make sure that they have access to those things.
Mr Jack Heath, the Chief Executive Officer of SANE Australia observed
that in terms of fighting the stigma around depression, much work had been
done. However, more work was required so that the treatment of mental
ill-health was seen as equal to the treatment of physical ill-health:
In terms of stigma, we have done reasonably well around depression
in the past five to 10 years. We have made no progress in the very severe end
of the spectrum. SANE Australia earlier this year called for a five-year
national stigma reduction campaign. We must have lived experience involved in
all aspects of mental health policy formulation, research, system design,
promotion, implementation and also evaluation. The life expectancy rates for
people with severe mental illness are simply unacceptable, 25 years less than
the general public. We need to do much better in terms of combining the work
that we do around physical health issues alongside mental health issues. In the
past there was an approach which said: let's get your head sorted first and
then we will get to your body, and what happened was people never got to the
From the evidence the committee has heard, it is clear that one of the
major barriers to people with mental ill-health accessing appropriate help is
stigma. Many times the committee heard that stigma prevented those with mental
illnesses from seeking help, or prevented conversations about the impact of
mental ill-health on a person's social, working, and family life.
Thanks to campaigns like those run by RUOK?, Beyondblue, and ReachOut,
mental health literacy is increasing in Australia. But the stigma around mental
ill-health persists. The committee considers that there is an urgent
need for a national conversation about how to counter it.
The committee recommends that the government response to the National
Mental Health Commission's report should include a national stigma reduction
Primary Health Networks and mental health
Established in July 2015, the Primary Health Networks (PHNs) replaced
the Medicare Locals as a means of organising and facilitating primary health
care services at a regional level.
There are 31 PHNs located around Australia. According to the information on the
Department of Health website, the PHNs have the key objectives of:
...increasing the efficiency and effectiveness of medical
services for patients, particularly those at risk of poor health outcomes, and
improving coordination of care to ensure patients receive the right care in the
right place at the right time.
In its review, the Commission recommended that PHNs be used to help
shift mental health funding priorities from hospitals and income support to
community and primary health care services:
Recommendation 8: Extend the scope of Primary Health Networks
(renamed Primary and Mental Health Networks—PMHNs) as the key regional
architecture for equitable planning and purchasing of mental health programmes,
services and integrated care pathways.
Professor Allan Fels, Chair of the National Mental Health Commission
expanded on recommendation 8 in his evidence to the committee. Professor Fels
argued that PHNs could be a way of 'bringing about greater regional parity in
the treatment of mental health' at a primary care level, with PHNs being the
facilitators of primary care in regional areas.
Underpinning much of the Commission's work is the view that a regional
approach to service delivery is an essential in order to be responsive to the
diverse local needs of the different communities across Australia.
The Commission's first recommendation articulated the Commonwealth's role in
mental health 'is through national leadership and regional integration,
including integrated primary and mental health care.'
In its report, the Commission argued that PHNs are an ideal mechanism to
plan and distribute services on a regional basis, putting mental health care
alongside primary care:
The current development of 30 Primary Health Networks across
Australia provides the ideal opportunity to build on that infrastructure and
better target mental health resources to meet population needs on a regional
basis. These new entities will be the meso-level organisations responsible for
planning and purchasing services on a regional basis.
Further, the Commission saw PHNs as being able to work in partnership
with NGOs and others service providers to apply 'targeted, value-for-money
interventions across the whole continuum of mental wellbeing and ill-health to
meet the needs of their communities'.
With their focus on primary health care, Professor Fels observed that
the PHNs are best placed to promote the role of primary care in treating mental
ill-health, and giving mental health a higher priority. Professor Fels
explained why the Commission felt that the PHNs should be renamed Primary and
Mental Health Networks:
There are a couple of reasons for that. It would be a really
important sign from the government and the parliament that mental health is
taken seriously. It remains a rather low priority, I am sorry to say, all over
Australia—at a federal and state level and in the community.
The grouping of meso-level organisations for regionalisation of planning
and purchasing services has been trialled in both Australia and overseas.
Figure 6 shows the various levels within the Australian health care system and
how meso-level groups could integrate the provision of mental health services.
Figure 6—Australian health care system
The background paper published by the Primary Health Care Advisory Group
(PHCAG), How can Australia improve its primary health care system to better
deal with chronic disease?, provided examples of where meso-level
integration of organisations with combined funding pools have been used. The
paper noted that while examples, including the United Kingdom, New Zealand, and
Australia (SA Health Plus), 'demonstrate the promise of meso-level
integration with combined funding pools, national rollout of the approach could
be inefficient if it is not well coordinated.'
Dr Steven Hambleton, Chair of the PHCAG, told the committee that as part
of the PHCAG's public consultation on its discussion paper on chronic
conditions 'many of our submissions support a meso-level organisation to assist
the GP to deliver an outcome.'
Professor Ian Hickie, a Commissioner of the National Mental Health
Commission explained that regionalisation of care, as advocated in the
Commission's report was a significant shift:
That is the challenge that I think governments face in
responding to this particular report. It fundamentally says there is a need to
redesign the system architecture, to develop regionalisation of care. So I
think both the Australian government and state governments face a challenge:
can they actually back local leadership? Can they provide the resources to the
60‑plus regions in Australia to bring together the relevant health and
social services in a way that is relevant to those particular communities to
provide the range of health and social supports that are necessary for people
to live a contributing life? That is a fundamental shift in the way we have
understood Commonwealth-state relationships and in particular the way that we
have organised that set of funding and service priorities.
Just as Dr Hambleton reported, Professor Hickie explained that despite
the challenges associated with regionalisation, there was general consensus
amongst organisations and state governments:
I think it is important to say that it appears that there is
consensus not only among providers but also among a number of the states—and,
notably, from the Premier of New South Wales. In New South Wales, Queensland
and WA in particular, there is a real appetite for implementation of this
regionally focused approach that is backed by the resources of both the federal
government and the state government. What we want to see is the implementation
of locally led programs that are nationally significant, evidence based and
accountable at the local level. That runs across the key areas of health and
social services and suicide prevention and with a shift to a fundamental focus
on resourcing the community, not necessarily the hospitals, the institutions or
the traditional providers.
However, witnesses told the committee that they had some reservations
about the Commission's recommendation on PHNs. Mr Quinlan of Mental Health
Australia told the committee that during a meeting with the Department of
Health regarding the ERG process, PHNs were 'one of the topics of some heated
and considered discussion'.
Mr Quinlan noted that while there was broad agreement at the meeting about the
need for a focus on mental health and a means of delivering that focus at a
regional level, the main concern about the PHNs being the vehicle for that
delivery was that as organisations they are very new.
Further, Mr Quinlan said the meeting had raised questions about the structure
of the PHNs:
The concern I would summarise as this: if Primary Health
Networks are dominated by GP interests and a GP-centric approach in the local
community—and this is not to suggest that they are—then that will achieve
certain goals but it will not achieve the breadth of engagement that many of
our members are keen to see.
Mr Quinlan argued that if PHNs were to be the delivery mechanisms for
regionalisation, the governance of PHNs would be important and it would be
essential to have consumers and those with lived experience of mental illness
If we are going to achieve the breadth of agreement and
planning that we need, then we would have to go somewhere to what the
commission recommends, which is primary and mental health networks. What would
that mean? That would mean that community organisations, consumers and people
with a lived experience of mental illness themselves and others were all
engaged in those governance structures, on the boards of Primary Health
The Royal Australian and New Zealand College of Psychiatrists (RANZP)
argued that PHNs have the 'potential to greatly enhance the responsiveness and
level of holistic care delivered to consumers', provided the PHN design had an
adequate governance structure.
RANZP recommended that the PHNs should have:
...strong mental health representation at all levels of the PHN
governance structure, including Board, Clinical Council and Community Advisory
In particular, the Community Advisory Committees should:
...draw on the insight and experiences of mental health
consumers and carers. The approach to shared decision making, consumer-focused
care and incorporating consumers, carers and family into the treatment team can
look very different in the mental health sector compared with other instances
where physical health is the focus. For example, the process of developing
informed consent, a recovery plan and a meaningful definition of wellbeing may
be very different for a consumer with a severe mental illness, compared with a
physical health issue. It is therefore essential that the insight, priorities
and experiences of mental health consumers and carers is adequately and
consistently incorporated onto the Community Advisory Committees.
Mr Quinlan also raised concerns about the 'localness' of PHNs and
consequently their ability to deliver mental health services to a local and
...Primary Health Networks would also look at their
localisation and many of them, I suspect, would say: 'Actually, we're not that
local. If there's only one Primary Health Network in this vast area, perhaps we
need to have some structures by which we can have sublocalisation, if you
like.' So I think there is a lot of anxiety about us investing too much too
early in structures that are just emerging, notwithstanding, I think, the broad
agreement that we need local structures to steer and govern investment.
Conversely, Mr Meldrum of Mental Illness Fellowship of Australia
reasoned that ultimately the PHNs are 'the only game in town for a regional
structure and...we are going to have to work out a way...' to use the PHNs for
mental health service delivery.
However, Mr Meldrum thought that some time would be needed for the PHNs to find
their 'mission' and become established.
Without this, Mr Meldrum argued, little could be achieved:
I also feel they need a personality transplant in a lot of
cases before they can do it, because they are focused specifically on the role
of the GP, who has an important role but not all the roles. The key issue is
that they do not have a mission... Why suddenly chuck a whole amount of money at
an organisation yet again without specifying what we want it to achieve? And
while we have a national mental health plan that has not been finished, while
any implementation strategy is yet to be dreamt up, while the NDIS arrangement
is so unclear et cetera and while we do not have any of those key outcome
objectives, there is no mission to give them. I would suggest that we are at
least a year away from being able to describe to a Primary Health Network, 'The
mission we need to achieve in mental health with this money is this.' That
would be the very first step before they get given the job [of equitable
planning and purchasing of mental health programmes, services and integrated
care pathways], from my perspective.
The committee supports the Commission's findings in regards to
regionalisation of service and programme delivery, and commends the Commission
for identifying this area as a means of mitigating inequity of access.
The committee thanks the witnesses at its public hearings for their
insightful comments regarding the suitability of PHNs for regionalisation, and
their support of the need for regionalisation of service delivery.
In its First Interim Report, the committee examined the change from
Medicare Locals to PHNs, and in its Second Interim Report the committee looked
at the progress towards the commencement of the PHNs. The committee agrees with
witnesses who argued that the PHNs need time to become established. For some
PHNs, the process has been easier as they have changed from being Medicare
Locals to being PHNs. For others the process requires more time as they are new
organisations, or Medicare Locals with new regions to establish.
The committee considers that while the PHNs will have an important role
in the regionalisation of service and programme delivery, including them in
this process needs to recognise the challenges the PHNs face being relatively
The committee recommends that the government response to the National
Mental Health Commission's report should examine the possible role for Primary Health
Networks in regionalisation of service and programme delivery.
However, the government should
have regard to the evidence given to the committee in relation to the time
needed for the PHNs to adequately establish themselves in their regions.
PHNs also need time to ensure
that they have a governance structure in place which includes mental health at
each level. The committee considers the suggestions provided by the RANZP about
Community Advisory Councils and the inclusion of those with lived experience of
mental illness to be particularly important.
The committee therefore recommends that the government response should
emphasise the need for mental health, particularly the experience of mental
health consumers and carers, to be imbedded in the governance structure of the
Primary Health Networks.
Access to early intervention
Another central tenet of the Commission's findings was that access to
early intervention not only resulted in a significant benefit to the individual
sufferer, but also produced a major economic benefit as it reduced the need for
acute and crisis care.
However, the Commission found that the current system did not promote access to
For example, sometimes people need to inflict serious
physical harm to gain access to support; even then, sometimes that care and
support is not made available.
The idea of late intervention in physical health conditions (such
as cancer, heart disease, COPD [Chronic Obstructive Pulmonary Disease]) is
plainly unacceptable, with obvious costs and unnecessary harm to individuals.
However, in mental illness, late intervention is too often the norm. This is
due to two factors:
low rates of help-seeking and treatment for mental illness,
including delaying or avoiding treatment due to stigma, stress and other
related factors, as well as anosognosia or lack of awareness of illness
low prioritisation of mental illness within the system as
compared to physical illness.
These are symptoms of a crisis-driven system. Critically,
this system is trapped in a vicious cycle of underinvestment in effective
services, leading to higher demands on more expensive and reactive modes of
care and demand-driven safety net programmes.
Witnesses agreed with the Commission's findings. For example Mr Ivan
Frkovic, the Deputy Chief Executive Officer of Aftercare compared the situation
in Australia with that in New Zealand, where a redirection of funding to
community-based interventions meant a significant saving in spending on acute
care, and a major benefit to individuals with a mental illness:
What we do not have right in this country, and the Mental
Health Commission report picked this up, is that we do not have the right
balance of investment.
I might not have the latest data, but New Zealand got to the
stage where they had an investment in the community sector...at such a level that
they started to feel the pressure come off their ED departments and their
inpatient beds. That was with about 35 per cent of the mental health budget
going into the community sector; that was the point where they started to feel
it. That could be different for Australia and other jurisdictions, but you get
to a point where, if you have supports for people in the community, you will
see that translate into [reduced] pressure on inpatient beds and ED
departments. I cannot tell you what that percentage is, but I think it is a bit
like New Zealand: we need to keep investing until we see the benefits.
Mr Quinlan, the CEO of Mental Health Australia argued that what was
needed to embed early intervention into mental health pathways was certainty
about what resources exist and the outcomes that need to be achieved:
What we continue to fail to do is to set any overarching
targets. So we ask those organisations that you listed—we ask Centacare to look
at some family services, we ask Anglicare to do some youth counselling and we
ask the Salvos to help out with financial support. Nobody ever sets a goal for
your area and says, 'Okay, in the area of Inverell, here is what we want to
achieve with our families: greater stability, higher employment rates and so
forth.' We do not go to that local community of Inverell and say, 'Okay, what
are the local assets and resources in terms of the abattoir and the agencies
that are working there? Overall, how do we actually target this problem? We
will put all of the money into one pool.' At the moment, I can guarantee you
that all of those agencies working in your electorate are drawing a pittance of
funding from 20 different funding sources each to try to put together a
comprehensive program. What I think the commission has done is say, 'We don't
want to support a system anymore, we want to look at some outcomes.' They have
listed some very solid outcomes that could be agreed in the mental health
space, which is to say that we want people to be in more secure and stable
housing, we want people to be in employment, we want people to be less engaged
with the criminal justice system...
Ms Morgan of the Butterfly Foundation agreed that access to early
intervention in mental health could make a significant difference to an
individual's recovery. She advised the committee that the Butterfly Foundation
had commissioned research which demonstrated that early intervention could
reduce the impact of mental illness and increase benefits to the individual and
to society as a whole:
One thing that I would emphasise from an eating disorder
perspective...is the importance of early intervention. The Butterfly Foundation
has commissioned two socioeconomic reports from Deloitte Access Economics to
try and put some figures on it and to take that business approach that we have
heard around it. We know that the illness is very prevalent. It has a very high
socioeconomic cost because the delay in the effect of treatment means that the
productivity costs and the burden of disease cost are highly inflated, much
higher than they need to be. The second report the Butterfly Foundation
commissioned, Investing in Need, put a figure around the benefit of
early intervention and fully integrated care for anybody with an eating
disorder as akin to the sort of care you would get if you suffered from cancer
in this country. Although the cost of rolling out that care was $2.8 billion
the net savings or the benefit to cost was 5.38 to one—because if you intervene
early you reduce the impact of the illness, you increase the survival rate and
you increase productivity.
Mr Jonathan Harms, the CEO of Mental Health Carers, ARAFMI NSW, compared
the mental health funding and treatment model with that for physical health,
and observed that in mental health, there was little funding dedicated to early
intervention. Mr Harms told the committee that the result was that mental
health treatment was so often focused on crisis. He argued that this would be
unacceptable in the treatment of physical ill-health:
There was an article in the Medical Journal of Australia, 'Where
to mental health reform in Australia: is anyone listening to our independent
auditors?' where one of the authors who was a former commissioner of mental
health made the point that because we are spending so little on mental health
compared to the need it is almost always focused on crisis and when people have
become as sick as possible. It is something we would not accept in any other
area of medicine. We would not say to someone with a broken leg, 'Come back
when it's gangrenous.' We would actually start treating it straight away. What
passes for early intervention in mental health is what would pass for simply
ordinary treatment in any other area of health care. So we are squandering
almost all of the money we are spending in many respects when you look at the
results we could achieve compared to the results we do achieve because we are
sticking a bandaid on. We are putting the ambulance at the bottom of the cliff.
We are not comprehensively addressing the needs across sectors and across life
span et cetera.
The committee strongly supports the findings of the Commission in
relation to access to early intervention. The evidence the committee received clearly
demonstrates that early intervention and prevention allows for better treatment
of mental ill-health and facilitates the individual being active socially,
economically, and in their community.
The benefit for Australia as a whole is also clear, as a reduction in
individuals requiring acute care will result in a saving in the health system.
Similarly the committee notes that one of the greatest economic costs of mental
ill-health is through lost productivity. If a person can be treated effectively
at an early stage, they can continue to be productive in both their work and
The committee recommends that the government response to the
National Mental Health Commission's report include evidence-based modes of care
that promote early intervention.
Linking housing and employment to mental health
Closely related to the Commission's findings on access to early
intervention is the connection between the treatment of mental ill-health,
access to housing, and workforce participation.
A major part of the economic cost of mental ill-health (as discussed in
Chapter 2) is the loss of productivity. In its report, the Commission
noted that estimates of the cost of mental ill-health to the Australian economy
from lost productivity and job turnover cost some $12 billion per annum.
The OECD figures, quoted in the Commission's report note:
The costs of mental ill-health for the individuals concerned,
employers and society at large are enormous... Most of these costs do not occur
within the health sector. Mental illness is responsible for a very significant
loss of potential labour supply, high rates of unemployment, and a high
incidence of sickness absence and reduced productivity at work. In particular,
mental illness causes too many young people to leave the labour market, or
never really enter it, through early moves onto disability benefit. Today,
between one-third and one-half of all new disability benefit claims are for
reasons of mental ill-health, and among young adults that proportion goes up to
over 70 per cent. 
As part of its findings the Commission argued that treatments for mental
health conditions should centre on the whole person, and that this approach
needed to include the person's community and economic participation. Professor
Fels, the Chair of the National Mental Health Commission explained:
If you can get labour force participation up, that is almost
the best way of improving productivity and I am sure at this reform summit
today [event on 16 August 2015 sponsored by The Australian Financial Review
and The Australian] we will hear a lot about measures, tinkering here
and there, that will get participation up. People with mental health problems
have a 38 per cent non-participation rate versus 22 per cent in the general
population. Our participation rate is low by the standards of good OECD countries.
We are at the bottom of the top good 10, 12, 13 OECD countries. Most people
with mental illness are at the mild to moderate end. The scope for their better
participation in the workforce is very large. The World Economic Forum
estimates the cost of lost output and income at about 1.75 per cent of GDP.
Most people with mental illness want to work but find it difficult to get a job
and then to hold it.
Professor Ian Hickie, a National Mental Health Commissioner told the
committee that Australia already had a vast amount of evidence that the
approach advocated by the Commission could be beneficial:
There is a lot of evidence from specific trials. We love to
trial things here in Australia. We have done trials of all of these things. We
never move from the trials to the systematic implementation. So you not only
have a reduction in cost; if you have somewhere to live, you do not come back
into hospital. In Sydney a hospital bed is $800 to $1,000 a day. You could be
at a very nice hotel for $800 to $1,000 a day. Currently we are using hospital
beds for that. Not only will you offset the cost, you will be well. You will
stay well if you have a home, and you will be less likely to have a relapse in
your clinical problems. If you have a job, you do better. We use this
expression all the time: 'You don't get well to go to work; you go to work to
get well'. We all thrive in environments where we have a home and we have a job
and we have social connections. Those things are not simply cost offsets; they
deliver better outcomes.
Professor Fels advised the committee that the connection between mental
ill‑health, housing and workforce participation was also recognised
If I could just add to that: there is a movement in the US
called Housing First. It really subscribes to the view that, if you fix housing
for people with mental illness as the top priority, a lot of improvements will
flow simply from that. It does not mean that they do not need other help. There
is now a fair bit of data about the effectiveness of Housing First. Also in
Canada the government gave $100 million to Housing First experiments, if you
like—although that is a fairly big experiment—and there is now reporting and
data showing there has been quite a significant improvement in mental health. I
mentioned a project like that I am part of in Melbourne. It was independently
evaluated by Monash University. Using a number of measures it concluded what
everyone who goes there knows, which is that there has been an enormous
improvement in the lives of people who are at the severe end.
The committee supports the Commission's finding in relation to the
linkages between housing, employment, and mental health.
The committee notes Professor Hickie's comments regarding the need for
action in this area.
The committee agrees that numerous past trials have proven beyond doubt the
benefits to a coordinated approach to supporting those with mental illness. And
the committee therefore reiterates its disappointment that the government,
rather than responding quickly to the Commission's findings, chose to review
the Commission's review resulting in a delay of at least ten months.
Further, the committee considers that this linkage demonstrates that
mental health is not solely the preserve of the health portfolio. The effective
treatment of mental health crosses into the portfolios of housing, employment,
and others. The segregation of policy into separate portfolios has produced a
situation in which programmes and services are not connected, or are
duplicated, and people do not receive the help they need. It is clear that a
mechanism which links programmes and services across portfolios is required.
The committee recommends that the government's response to the
National Mental Health Commission's report recognise the linkages between
housing, employment, and mental health. The government's response should
include ways for services and programmes to be appropriately connected so that
individuals can access holistic care.
The Commission wrote in its report that the inefficiencies it had
identified in the delivery of mental health services and programmes were
exacerbated by issues related to the mental health workforce:
These challenges [inefficiency, incorrect distribution of
funding, the system not being cost-effective] are compounded by a mental health
workforce under pressure, with services experiencing shortages, high rates of
turnover and challenges in recruiting appropriately skilled and experienced
staff. Too frequently, the voices of people with lived experience, their
families and support people are ignored, misheard and undervalued.
Further, the Commission noted that the efficiency of service delivery to
rural and remote areas was greatly affected by the poor distribution of
workforce, amongst other issues.
Workforce issues appear in many of the Commission's recommendations, but
particularly in recommendations 21 and 22 which related to the Commission's
finding around the need to build workforce and research capacity to support
systems change. Recommendations 21 and 22 are:
Recommendation 21. Improve supply, productivity and access
for mental health nurses and the mental health peer workforce.
Recommendation 22. Improve education and training of the
mental health and associated workforce to deploy evidence-based treatment.
A particular example of the types of workforce issues the Commission
identified is the Mental Health Nurse Incentive Programme (MHNIP). The
Commission commented that the effectiveness of the MHNIP is limited by
regulatory barriers, and programme requirements are 'often rigid and
inflexible, potentially stymying innovation and integrated multi-disciplinary
support by limiting fundholding arrangements.'
...headspace cannot access the MHNIP to employ mental health
nurses. Similarly, Indigenous Primary Health Care Organisations (including
Aboriginal Community Controlled Health Services) cannot hold Access to Allied
Psychological Services (ATAPS) funding even though one of the target
populations under the programme is Aboriginal and Torres Strait Islander
people. These types of access barriers decrease timely and appropriate support,
including through community-based services.
Witnesses at the committee's public hearings agreed with the
Commission's findings in relation to the MHNIP and the mental health workforce
generally. For instance Mr Sebastian Rosenberg, a Senior Lecturer at the Brain
and Mind Centre of the University of Sydney told the committee:
With respect to mental health community outreach nurses, the
Mental Health Nurse Incentive Program is a proven program that adds so much to
the armaments of GP practices so that they can follow people into the community
and provide care. The cost is only $40 million, which would be less than three
weeks' worth of the Better Access program [government program which aims to
provide better access to mental health practitioners through Medicare]. It is a
tiny program with massive effectiveness. So, again, Australia has a program
which it could scale but has not... and, again, the amount of money that is set
aside for workforce development is tiny. Some of our colleagues in the College
of Mental Health Nurses have been struggling to build that workforce.
Mr Quinlan of Mental Health Australia told the committee that the MHNIP
is one of the programmes which has been subject to short-term funding extensions
and that this issue is further negatively impacting on the effectiveness of the
Mr Quinlan: The Mental Health Nurse Incentive Program
is one of those programs on the list that has been extended on a
12-month-by-12-month basis for quite a number of years. It is not unique to
this area, but it is one of those areas where clearly if you are a nurse in the
community who is thinking, 'Where will I build my career in nursing?' this
notion of 12-month-by-12-month funding does not create...a platform for people to
say, 'That's where I'm going to invest my future', because you never know—
Mr Peters: The uncertainty of mental health funding
is probably causing as much stress as anything else...
Mr Quinlan also explained that the uncertainty of funding was having an
impact on the wider mental health workforce. He gave the committee an example
from one of the members of Mental Health Australia in relation to the Partners
in Recovery programme:
As at today, if one of our agencies loses a staff member in,
say, the Partners in Recovery Program, it can only offer a replacement staff
member an eight-month contract with an uncertain future beyond that. That means
that, as at today, the sorts of programs and services that we are delivering to
people on the ground are starting to deteriorate again, because of the
uncertainty of the arrangements beyond June next year. That is something that I
think we need to be doing much more work on, and we stand ready to assist
government and other interested parties to develop that work. I am happy to
take further questions as we go on.
Mr Frkovic of Aftercare agreed that uncertainty of funding was causing
significant impacts on the mental health workforce. Mr Frkovic also
acknowledged the consequent flow on effect on the provision of support to those
with a mental illness and their families:
...we have staff who are really struggling in terms of what
happens to them. When you think about it, we have 450 staff, and a lot of
people are wondering what happens beyond June next year. That whole system that
is currently working is being unravelled from a whole range of perspectives,
which I think is causing us some major challenges in terms of ongoing support
for people with mental illness, and their families.
Ms Jaelea Skehan, the Director of the Hunter Institute of Mental Health
told the committee that a further impediment on the effectiveness of funding
for mental health was the current government funding being provided on a
year-by-year basis, creating a stressful situation for staff and putting
pressure on organisations:
Single year funding is inefficient for any service, and it is
completely inefficient when you are trying to work in a prevention framework,
where you are really looking at five-year planning. Like many organisations,
for the past two years we have been given notification of funding extensions in
June for funding starting on 1 July. That is stressful for staff; it is very
hard for staff turnover. My organisation, as well as many others at this table
and in our sector, has staff on contracts. You can imagine that is a very
challenging environment to work in. It is also not very good for those sectors
that we are working with, particularly for front-line services that are
providing services to individuals and families, to have that lack of certainty
around continued funding.
The committee strongly supports the Commission's finding that a robust workforce
is a key to the successful delivery of mental health services and programmes.
The committee was disappointed that the government abolished the Health
Workforce Australia agency in the name of efficiency. The committee considers
that the government's action was a false economy, particularly in light of the
Commission's findings that workforce development and distribution are critical
in effective mental health service delivery.
The committee hopes that a government response to the Commission's
findings will recognise the need for an overall health workforce strategy.
The committee recommends that the government's response to the National
Mental Health Commission's report recognise need for a clear and comprehensive
mental health workforce strategy.
The Commission's report identified suicide as a major issue in mental
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 people and people living outside of major cities.
Reflecting the importance of including suicide prevention in any
national mental health approach, the Commission made three recommendations and
one finding relating specifically to suicide prevention:
Recommendation 2. Develop, agree and implement a National
Mental Health and Suicide Prevention Plan with states and territories, in
collaboration with people with lived experience, their families and support
Recommendation 4. Adopt a small number of important,
ambitious and achievable national targets to guide policy decisions and
directions in mental health and suicide prevention.
Finding 7. Reduce suicides and suicide attempts by 50 per
cent over the next decade.
Recommendation 19. Establish 12
regions across Australia as the first wave for nationwide introduction of
sustainable, comprehensive, whole-of-community approaches to suicide
Witnesses supported the Commission's emphasis on suicide prevention with
many telling the committee that there is a clear and urgent need for action in
this area in Australia. For example Associate Professor Judith Proudfoot, the
Head of eHealth at the Black Dog Institute observed that:
Suicide prevention is cost-effective and Australia was one of
the first countries to develop a national suicide prevention strategy, in 1995.
Suicide rates have not declined significantly, in Australia, in the last
decade. In fact, in the last 12 months the numbers have increased, particularly
in young girls and Aboriginal and Torres Strait Islander men. Progress in this
area has been hampered by the lack of integration and poor coordination of
suicide-prevention activities and strategies. There has been activity there and
a lot of good activity but it has not been integrated or coordinated... The
economic cost, apart from the very traumatic personal cost, is $17.5 billion,
annually, to the Australian community. So it is really timely that we do
something about suicide and suicide prevention.
Associate Professor Proudfoot explained that there was substantial
evidence supporting a multi-faceted, cross-government approach to suicide
prevention of the kind advocated by the Commission's report:
Evidence from overseas shows, very clearly, that successful
suicide prevention requires a simultaneous systems based approach that involves
multisectoral involvement by all government, non-government, health, business,
people with lived experience, and education, research and community agencies
and organisations. That is, it needs multiple points of intervention. Within a
localised area, having done an audit of what services are available in the
localised area, it means implementing evidence based strategies, at the same
time, that are effective and demonstrating sustainability and long-term
commitment... The research shows there are nine strategies that are evidence
based and effective. The most promising of those is restricting means to
suicide, GP education and gatekeeper training but, of course, they need to be
fine tuned and tailored to the particular local area.
One point of disagreement with the Commission's finding and
recommendations on suicide prevention related to funding. The Commission had,
in accordance with the government's direction, made its recommendations with
the assumption of no additional funding to what was already being spent by
government. Mr Matthew Tukaki, a Board Member of Suicide Prevention Australia; and
Chairman of the National Coalition for Suicide Prevention argued that
additional funding was essential if the recommendations the Commission had made
were to be achieved:
The stark reality is that many of our front-line service
providers are already facing funding challenges and living from short-term
contract to short-term contract. Imagine as we go deeper into the rabbit hole
that the number of Australians seeking help will increase, thereby overwhelming
services already under pressure. This comes back to the perennial question of
whether or not the quantum of funding required is enough and how it is
distributed is adequate. This means we need to look past just providing short
and medium‑term contract certainty, if indeed the current model of
tendering or contracting out services is to continue, and focus more on the
long-term certainty required by the many front-line service providers.
Mr Tukaki told the committee that to make an impact on the economic
costs of mental ill-health and suicide, additional funding was vital:
Just as we have outlined our desire to see suicide reduced by
half over the decade, we cannot get to that point unless we have an honest
discussion about the investment required to reach that goal and the return on
investment to the taxpayer. Saving lives saves money. But, as I know in
business, to make money, you need to spend it. You need to make the long‑term
investments to make the return, the return obviously being the increased
economic productivity of those who have been taken from us too early who
otherwise would have made a substantive contribution to the national
The committee supports the priority the Commission has given to suicide
prevention in its review, and commends the Commission's findings to the
The committee notes the comments from witnesses, particular Suicide
Prevention Australia, that additional funding is needed if the suicide
prevention targets recommended by the Commission are to be achieved.
The committee recommends that the government's response to the
National Mental Health Commission's report include tangible and measurable actions
to achieve the suicide prevention targets recommended by the Commission.
Rural and remote communities
The Commission gave particular emphasis to the mental health challenges
facing those in rural and remote areas:
On almost any indicator, people living outside of
metropolitan areas experience inequity both in terms of their health and in
getting access to the right services: lower life expectancy, lower access to
Medicare-funded services which diminishes with increasing remoteness, reduced
health workforce distribution, and lower rates of mental health service access,
with access to psychological services significantly less than in major cities.
The impact of these inequities is particularly significant for Aboriginal and
Torres Strait Islander people living in these areas.
Added to the factors facing those in rural and remote areas, the
Commission also identified access to services, particularly the limited
availability of non-medical services, as a significant barrier to those in
rural and remote areas accessing assistance:
In rural and remote areas, issues in mental health are
compounded by reduced access to infrastructure, communications and costs to
access services. The Commission has learned from submissions to the Review that
discrimination due to mental illness is a factor which affects whether a person
seeks services in their town. For some, anonymity is important and they will
travel to the next town or regional centre to get the support they need. This
presents another barrier to them getting timely access to the type of supports
they need. The impacts of drought, bushfires and hard economic times also add
to the distress of families and communities in these areas.
The Commission found in relation to mental health in rural and remote
Mental health services are often transient, impacted by workforce
shortages, and are decreasing despite increased demand;
Programmes are inadequately funded for the increased cost of
delivering services across the distances in rural and remote areas; and
Access to services could be improved by wider use of technology
and by increasing community capacity.
As a result of its findings, the Commission recommended that service
equity for rural and remote communities should be improved through place-based
models of care.
Professor David Perkins, who is a Director and Professor for Rural
Health Research at the Centre for Rural and Remote Mental Health (CRRMH) agreed
with the Commission's findings in relation to rural and remote communities. He
noted that needs and expectations of those in rural and remote communities is
exactly the same as those in metropolitan areas:
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 [NSW] 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—it might even be in that
order. Sometimes we do not see it that way. Obviously, Aboriginal colleagues
and friends refer to this as social and emotional wellbeing. I think the
professions are beginning to talk about recovery.
Professor Perkins told the committee that the term 'rural and remote'
does not accurately reflect the great variety of communities that exist in
regional areas. This variety is, as was identified in the Commission's
findings, a key part of the difficulty in service delivery in regional
The first [issue] is just how variable rural and remote
communities are. A lot of our data says 'metropolitan and rural'. It does not
distinguish adequately between the needs and the character of such communities,
whether it is farming, mining, tourism or gastronomic rural, such as where I
live in Orange. There are also the needs of the local population—Indigenous and
non-Indigenous. There are socioeconomic differences. There is also location and
distance from service centres... I find myself defining 'rural' by saying the
usual challenge is that there is a shortage of experts and specialists in every
area. Those experts and specialists include medical experts and specialists,
but across the board you begin to lose people with that level of expertise
Despite the challenges of ensuring equity of access to services in rural
and remote areas, Professor Perkins argued that community-based services were
the best means of programme delivery. Further, Professor Perkins advocated for
the need for health promotion and preventative health to be part of any community-based
Often, the poor health outcomes in rural and remote areas are
attributed just to poor access. It is a bit like saying at an interview, 'It is
the chemistry.' People have a simple explanation, which often does not seem to
go far enough. We think that a broader, patient- and community-centred approach
is needed that includes the traditional health services—the GPs and the mental
health services—but also employers, community organisations, local government
and other interested parties. We need rural and remote communities with health
systems that will promote mental health and wellbeing, respond to mental
illness and work collaboratively on those suicide rates. We need to develop
mental health promotion, mental illness care and suicide prevention that are
different for different sorts of communities, and they need to be fairly and
equitably funded. But they will need to be designed to meet local needs—perhaps
backed up by e-health and telehealth solutions where appropriate. In terms of
that mental health promotion, one of the things we are trying to do is to set
off 'mentally healthy Orange'. We are using the phrase 'mentally healthy' to be
different to 'mental illness', and to say what are the things that an
individual can do—at the personal, family, practical and non-institutional
level—and then building in employers and others to improve one's mental health.
The committee commends the Commission for including in its review the
difficulties of mental health service delivery in rural and remote communities,
and the particular challenges facing those communities.
The committee agrees with the Commission's recommendations in relation
to mental health service and programme delivery in rural and remote
The committee recommends that the government's response to the
National Mental Health Commission's report address the challenges of mental
health service delivery in rural and remote communities.
Aboriginal and Torres Strait Islander peoples and mental health
The Close the Gap Progress and Priorities Report 2015 (Close the
Gap Report), which was published in February 2015, shows the stark reality of
the number of Indigenous Australians who suffer from mental health issues:
There is an entrenched mental health crisis among Aboriginal
and Torres Strait Islander peoples that must be addressed. Mental health
problems, including self-harm and suicide, have been reported at double the
rate of that of non-Indigenous people for at least a decade. Recent data
suggests the situation is getting worse...
The Aboriginal and Torres Strait Islander mental health gap:
Psychological Distress: In 2012-13, 30 percent of respondents
to the AATSIHS [Australian Aboriginal and Torres Strait Islander Health Survey]
over 18 years of age reported high or very high psychological distress levels
in the four weeks before the survey interview. That is nearly three times the
non-Indigenous rate. In 2004-05, high and very high psychological distress
levels were reported by 27 percent of respondents suggesting an increase in
Aboriginal and Torres Strait Islander psychological distress rates over the
Mental Health Conditions: Over the period July 2008 to
June 2010, Aboriginal and Torres Strait Islander males were hospitalised for
mental health-related conditions at 2.2 times the rate of non-Indigenous males;
and Aboriginal and Torres Strait Islander females at 1.5 times the rate of non‑Indigenous
females. Rates of psychiatric disability (including conditions like schizophrenia)
are double that of non-Indigenous people.
Suicide: The overall Aboriginal and Torres Strait
Islander suicide rate was twice the non-Indigenous rate over 2001-10. Around
100 Aboriginal and Torres Strait Islander deaths by suicide per year took place
over that decade. In 2012, 117 suicides were reported. The OID [Overcoming
Indigenous Disadvantage report] 2014 Report shows that hospitalisations for
intentional self-harm increased by 48 percent since 2004-2005.
The Closing the Gap Campaign Steering Committee therefore recommended
The National Strategic Framework for Aboriginal and Torres
Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing
provides the basis for a dedicated Aboriginal and Torres Strait Islander mental
health and social and emotional wellbeing plan. This is developed and
implemented with the Health Plan, the National Aboriginal and Torres Strait
Islander Suicide Prevention Strategy 2013 and the National Aboriginal
and Torres Strait Islander Peoples’ Drug Strategy implementation processes
in order to avoid duplication, be more efficient, and maximise opportunities in
this critical field.
The Commission's findings agreed with the findings of the Close the Gap
Of critical concern is the dire status of the mental health
and wellbeing of Aboriginal and Torres Strait Islander people. Indigenous
people have significantly higher rates of mental distress, trauma, suicide and
intentional self-harm, as well as exposure to risk factors such as stressful
life events, family breakdown, discrimination, imprisonment, crime
victimisation and alcohol and substance misuse. Service and system responses to
these poor outcomes are inadequate, and have generally not been designed with
the particular needs of Aboriginal and Torres Strait Islander people in mind.
Similarly to the Close the Gap Report, the Commission found that rates
of mental illness amongst Indigenous Australians are significantly higher than
the non‑Indigenous population:
The mental health needs of Aboriginal and Torres Strait
Islander people are significantly higher than those of other Australians. In
2011-12 nearly one‑third (30 per cent) of Aboriginal and Torres Strait
Islander adults (aged 18 years and older) had high or very high levels
of psychological distress, almost three times (2.7) the rate for other
Australians. Nationally, there were 22.4
suicides per 100,000 Aboriginal and Torres Strait Islander people during 2012,
more than double the rate of 11.0 for other Australians. Aboriginal and Torres Strait Islander people aged 15 years and
older report stressful events at 1.4 times the rate of non-Indigenous people.
Further, the Commission noted that the concept of 'mental health' for
Aboriginal and Torres Strait Islander peoples is 'tied inextricably to the
concept of social and emotional wellbeing', thus placing wellbeing within the
context of a person's experience of family, community, culture, and history:
The concept of mental health comes more from an illness or
clinical perspective and its focus is more on the individual and their level of
functioning in their environment. The social and emotional wellbeing concept is
broader than this and recognises the importance of connection to land, culture,
spirituality, ancestry, family and community, and how these affect the
individual. Social and emotional wellbeing problems cover a broad range of
problems that can result from unresolved grief and loss, trauma and abuse,
domestic violence, removal from family, substance misuse, family breakdown,
cultural dislocation, racism and discrimination and social disadvantage.
The Commission's finding in relation to Aboriginal and Torres Strait
Islander mental health was that there is an urgent need to 'expand dedicated
mental health and social and emotional wellbeing teams for Aboriginal and
Torres Strait Islander people'.
As a result, the Commission recommended:
Establish mental health and social and emotional wellbeing
teams in Indigenous Primary Health Care Organisations (including Aboriginal
Community Controlled Health Services), linked to Aboriginal and Torres Strait
Islander specialist mental health services.
Witnesses at the committee's public hearings echoed the findings of the
Commission and the Closing the Gap Report. Mr Quinlan of Mental Health
Australia told the committee that a key part of delivering services in
Indigenous communities was community ownership. He used the example of the Aboriginal
Community Controlled Health Organisations to illustrate his point:
I think supporting the sort of community controlled
organisations that are genuinely taking control of their own destiny and
delivering programs is important. As part of my trip north I visited the Miwatj
health service, where there is a genuine ownership of the local strategies and services
that are being delivered in that community. I think those sorts of programs
provide an excellent model for what we could be doing in other places too.
Mr Rosenberg of the Brain and Mind Centre agreed with Mr Quinlan, and
gave the committee an example of the effectiveness of the Partners in Recovery
(PIR) programme when coupled with community ownership and Indigenous workforce:
I used to do some work in the Cairns area with their local
Aboriginal mental health service, and that was one of the first times where I
came across PIR in a very effective way. There was an Aboriginal workforce that
was working within that program, and I was blown away. But one of the things
that they found very difficult was that the rules preclude PIR from working
with kids under 16. It is a classic example of a well-intentioned program that
is applied to mainstream health services with rules and so on, but its
application to the Aboriginal community was so completely wrong and counter to
their whole view about family and about the social and emotional wellbeing of
the whole family. I think it was an example of the fact that we have got some
things in place, but they need to be tailored appropriately to make the most of
The committee strongly supports the findings of the Commission in
relation Indigenous mental health. From the evidence the committee has heard,
it is clear that the Commission's findings are widely accepted, and that they
align closely with those of the Closing the Gap Report.
The committee notes that the Closing the Gap Report identified health as
a major area of need for Indigenous Australians and argued that without first
addressing health, including mental health, little could be done to close the
gap in other policy areas.
The committee agrees with this argument and strongly urges the
government to have regard to the alignment between the Closing the Gap Report
and the Commission's review findings and make Indigenous mental health a
priority in the government response.
In this regard the committee notes that the ERG process was informed by
an Aboriginal and Torres Strait Islander Mental Health and Suicide Prevention
Advisory Group. Ultimately, the government response in this area will be judged
by the level of input, support, and ownership it has from Indigenous
The committee recommends that the Government's response to the
Mental Health Commission's report sets out a future policy direction to address
Indigenous mental health and suicide prevention challenges.
The Commission identified LGBTI individuals as a vulnerable group, at risk
in terms of mental ill-health and its attendant economic and social costs.
The Commission noted that there are gaps in the provision of specialised
supports and programmes for LGBTI individuals, and that their situation is made
more difficult as a result of discrimination and stigmatisation.
Ms Rebecca Reynolds, the Executive Director of the National LGBTI Health
Alliance told the committee that her organisation agreed with the findings of
the Commission regarding the risk of mental ill-health for LGBTI individuals:
The prevalence of mental health problems in LGBTI Australians
is disproportionately high and carries significant human, social and economic
consequences... LGBTI people are part of all population groups, including
Australians living in rural and remote areas, in Indigenous communities and in
culturally and linguistically diverse populations. LGBTI people have
demonstrated considerable resilience in looking after themselves in their
communities despite adversity, and they lead healthy and fulfilling lives,
contributing to their families, local communities, workplaces and society as a
whole in most cases. Nevertheless, the experience of dealing with
marginalisation and stigma often impacts on LGBTI people's mental health. These
social determinants of mental health are reflected in higher rates of suicide,
self harm and depression in LGBTI communities.
Ms Reynolds told the committee that in comparison to the general
population, LGBTI communities risk of suffering mental ill-health was in some
...suicide rates for lesbian, gay and bisexual people are 14
times higher than for the general population. The rates for gender diverse
Australians are alarmingly high at 35 per cent. Suicide Prevention Australia
estimates that 28 per cent of lesbians have self harmed, compared with 8.3 per
cent of heterosexual women. Self harm is also higher among gay men at 20.8 per
cent, compared to 5.4 per cent for heterosexual men. Of young bisexual men and
young bisexual women, 29.4 per cent and 34.9 per cent, respectively, commit
self harm. The rate of depression in LGBTI communities is much higher than for
the general population, sitting at three times higher for LGB Australians and
6.5 times higher for gender diverse Australians. Private Lives 2,
a report on the health and wellbeing of LGBTI Australians, reported that 49 per
cent of men and 45 per cent of women had experienced a major depressive episode
and that 16 per cent of all respondents to that online survey had had suicidal
ideation in the two weeks prior to the survey—this was conducted late last
Recommendation 20 of the Commission's review stated the need to:
Improve research capacity and impact by doubling the share of
existing and future allocations of research funding for mental health over the
next five years, with a priority on supporting strategic research that responds
to policy directions and community needs.
In outlining how this recommendation could be achieved, the Commission
argued that there is a need to:
Develop evidence about what works in areas which have the
potential to realise greatest public value; for example:
child and adolescent health
mental health and aged care
stigma and discrimination
medications use, including metabolic syndrome
mental health for vulnerable groups e.g. people from culturally
and linguistically diverse backgrounds, Lesbian Gay Bisexual Transsexual and
Intersex (LGBTI) people
suicide and suicide prevention.
Further, the Commission emphasised the need to direct research on
successful programmes and services into interventions:
Include consideration of interventions across the domains of:
prevention and early intervention
crisis intervention and suicide prevention
recovery and support
Ms Reynolds explained that the lack of adequate data on LGBTI
populations was one major reason for the services targeted at LGBTI communities
not receiving attention and funding:
Data collection is, however, one of the major issues I wanted
to raise with you today—gaps in identifying key strategies for addressing
negative mental health and suicidal behaviours in LGBTI populations and
communities. Those statistics that we do have largely come from service
attached consumers, not general population surveys. The 2007 national survey
was one of the first national Australian surveys to include a question on
sexual orientation. While this was a major step forward in gathering data on
the lives of the same-sex attracted and bisexual people, the survey did not
include questions on gender identity and intersex status. The continued absence
of these questions on sexuality or sexual orientation, gender identity or
intersex status means that our populations remain invisible in the programming
of strategies and data. In the absence of any questions on gender identity and
intersex status, there is no representative national data on the mental health
of trans and intersex Australians and no way of comparing the rates of mental
ill health and suicidal behaviours of trans and intersex Australians to the
mainstream population and general community.
Ms Reynolds also pointed out that in comparison to other vulnerable
groups, LGBTI communities are often left out of national strategies and plans
on mental health, and thus miss out on much-needed research and resourcing:
The National Mental Health Strategy is made up of three
documents: the National Mental Health Policy, released in 2008; the Fourth
National Mental Health Plan, from 2009 to 2014; and the Mental Health Statement
of Rights and Responsibilities, released in 2012. The first two documents have
no mention of LGBTI people in them at all. The Mental Health Statement of
Rights and Responsibilities states that in many cases people deserve to have
their sexual orientation, gender and gender identity taken into consideration
across multiple areas. However, there is no inclusion of intersex people in
that at all—an invisible group. Finally, there are many other examples, but the
National Aboriginal and Torres Strait Islander Suicide Prevention Strategy has
no inclusion of LGBTI, sistergirl or brotherboy people at all.
Ms Reynolds argued that LGBTI mental health issues and support
programmes and services must be included in any response to the Commission's
review, or other national mental health plan:
Given such a glaring lack of consistency across the national
level, we strongly advocate for the adoption of an LGBTI mental health
promotion and suicide prevention strategy, as is being successfully implemented
in the ageing and aged-care sector by other government departments. A mental
health and suicide prevention strategy must address these social determinants
of reduced mental health amongst LGBTI people, including deeply embedded
heterosexist beliefs and practices. It must also build on the capacity of LGBTI
people and organisations to develop social relationships and networks with
LGBTI populations and between LGBTI populations and the mainstream. Such
individual and collective relationships are a source of resilience and social
capital that act as protective factors against the increased risk of mental ill
health and suicidal behaviours for LGBTI people.
The committee commends the Commission on its coverage of LGBTI issues in
its review. The committee supports the Commissions assessment of the LGBTI
community as an extremely at-risk segment of Australian society.
The committee acknowledges the work of the National LGBTI Health
Alliance and similar groups in advocating for those vulnerable members of the
The committee notes that the issue of data collection on 'what works' in
mental health services and programmes is not restricted only to the LGBTI
community. In fact the Commission identified that research across the entire range
of Australian communities and mental health issues is badly needed. Targeted
research funding must form part of the government's response to the
Commission's review, as noted in Chapter 5.
The committee considers that the government response to the Commission's
review must include specific actions in relation to services and programmes for
the LGBTI community.
The committee recommends that the government's response to the
National Mental Health Commission's report include adequate recognition of the
need for data collection to inform services and programmes for LGBTI communities.
The committee also recommends that the government's response
include specific actions and measurable targets in relation to the delivery of
services and programmes for the LGBTI community.
Culturally and Linguistically Diverse communities
One of the Commission's findings was the need to 'promote the wellbeing
and mental health of the Australian community, beginning with a healthy start
As part of this finding the Commission recommended:
Use evidence, evaluation and incentives to reduce stigma, build
capacity and respond to the diversity of needs of different population groups.
This recommendation specifically included the need for cultural
responsiveness and culturally appropriate programmes for Culturally and
Linguistically Diverse (CALD) communities. In explaining how this recommendation
could be achieved, the Commission listed requirements such as:
3. Improve cultural responsiveness by supporting the
widespread adoption of the Framework for Mental Health in Multicultural
Australia: Towards culturally inclusive service delivery as a tool to help
organisations identify what they can do to enhance their cultural
5. Adopt clear and explicit equity-oriented targets for
people from Culturally and Linguistically Diverse (CALD) backgrounds from
multicultural communities to include in government funding agreements.
Mr Hamza Vayani, the National Project Manager of the Mental Health in
Multicultural Australia (MHiMA) told the committee that in fact the first and
most urgent task in providing targeted services to CALD communities was
research and measurement of mental ill-health in CALD populations:
If you then try to disaggregate [overall Australian
mental-ill health population data] by population groups, it is simply not
possible. If we were then to talk about investing prevention money and getting
people in earlier, absolutely we would support that. But if we have not
actually got an understanding or fix on the cultural and linguistic population
groups, whilst you may be wanting to go down that trajectory, if you have not
got any measurement around how that population group is going, the risk is that
innovation in new practice can occur but you do not have quantified information
vis-a-vis this population group and they are left further and further behind as
the system progresses. That is the first kind of key challenge that I would
really encourage us to think about.
Ms Sharon Orapeleng, a Senior Project Officer at MHiMA told the
committee that often language was a barrier to CALD individuals accessing
mental health care. Ms Orapeleng argued the need for workforce training and
cultural communication skills:
Every single service in this country needs to be thinking,
'If I have somebody coming through my door who does not speak English, has a very
different understanding of what mental health is because of their cultural
background, and has a family who do not even have a word for it—because there
are cultures who do not even have a word for mental health—what am I going to
be doing to provide the support?' Either it is in the early intervention or
prevention space or it is in acute. The whole spectrum of mental health care is
where we really need to start thinking about what we are doing for whoever
comes through that door. I would really like to see this conversation happening
as a mainstream conversation rather than a conversation on the side. Almost 50
per cent of the population is born overseas or has one parent born overseas. It
is our reality.
Ms Orapeleng also noted that language was a barrier in collecting data
about mental ill-health in CALD populations:
If somebody comes to me and says, 'You work with
multicultural communities; what is the prevalence of depression in the
multicultural communities?' I would not be able to say what it is, because we
know that, even in the national mental health and wellbeing survey, people who
did not speak English were excluded. If you were able to speak English then you
were able to answer the questions that were provided, but if you were not able
to speak English then you were excluded... Unfortunately, we can say anecdotally
that these things happen, but the data that is out there is not supporting what
is going on.
Mr Vayani told the committee that MHiMA's Framework for Mental Health
in Multicultural Australia: Towards culturally inclusive service delivery
online tool would be a great benefit for organisations to assess their
...the Framework for Mental Health in Multicultural Australia,
which is I believe world-leading work in that it is online and allows services
to really assess what they are doing in terms of being culturally responsive
and sets for the first time some metrics around services being able to plot
what they are doing and also to measure that impact against national standards
for quality and safety in health care as well as the national standards for
mental health services.
In fact, Mr Vayani advised that the Sydney Local Health District had
been using the framework with good results, because it demonstrated a gap in
service provision and allowed action to be taken:
For instance, we know that in the Sydney Local Health
District, when they started using this framework and mapping what they were
doing, they realised that interpreters were not being called in, potentially
two or three days into somebody's length of stay. That person does not have
language and may not define mental health as we know it. Imagine: they are
really unwell, and three days of very little or no communication or
understanding of what is happening to them is difficult.
The committee supports the Commission's findings and recommendations in
relation to targeting services and programme delivery to CALD communities. In
particular, the committee commends the Commission for its support of the MHiMA Framework
for Mental Health in Multicultural Australia: Towards culturally inclusive
The committee recommends that the government response to the National Mental
Health Commission's report should include support for the use of the Mental
Health in Multicultural Australia Framework for Mental Health in
Multicultural Australia: Towards culturally inclusive service delivery.
The Commission included e-mental health and information technology as
part of its person-centred approach to care, noting that technology can be used
'to link people and services and promote self-care and wellbeing'.
In its 'stepped care' approach to the provision of mental health
services, the Commission saw a place for e-mental health and technology to
assist individuals to manage their own care, as well as being a more flexible
service delivery mode:
A stepped care approach supports Australians to take greater
responsibility for their own mental and physical wellbeing. A new service
paradigm is needed to support that choice and responsibility. Significant
advances occurring in e-mental health provide the opportunity to encourage a
society where self-help is more fully integrated in the system, and that people
know where to go and how to get access to the specific information and support
they need. It does not obviate the need for face-to-face care when necessary,
but it does reduce the need for expensive services for those things which
people can do for themselves, or with their families or other support people.
That creates efficiencies but also enables cost-effective use of the time and
skills of clinical and other professionals—and frees up the valuable personal
time of individuals.
The Commission saw e-mental health as a means of implementing its
recommendation in relation to improving 'service equity for rural and remote
communities through place-based models of care'.
The recommendation reads:
Include services that are mental health-specific, delivered
through health and other non-health portfolios, e-mental health and other phone
and online services, as well as broader services which contribute to the
physical health of those with a mental illness.
The Commission also envisaged a role for e-mental health in its
recommendation regarding the promotion of self-help options to assist people,
their families and communities to support themselves and each other, and
improve ease of navigation for stepping through the mental health system.'
In regards to this recommendation, the Commission suggested that
e-mental health could be one of the ways in which the promotion of resources
and support mechanisms could be achieved:
Drawing on the expertise of the mental health and community
sectors—including e-mental health providers—to develop, disseminate and promote
a suite of resources and supports for self-help and online services, and
evidence of effectiveness of these supports.
This could include a ‘Mental Fitness Ready Reckoner’ for people,
their families and other support people to explain psychological distress and
Distribution should be through various channels including social
media, eHealth and telehealth, as well as through general practices,
pharmacies, community centres, Centrelink offices, schools and workplaces.
Mr Heath of SANE Australia agreed with the Commission's view that e‑mental
health should be part of the community-based, or 'upstream' services:
It is critical that the spending on mental health should
align with the burden of disease. At the moment, it is tracking at about seven
per cent in terms of spending, 14 per cent in terms of burden. We need to have
greater investment upstream, especially in the online and digital services. We
are still not connecting with around half the people that have mental illnesses
and we cannot do that in the ways that we have done in the past. The online
world provides an excellent opportunity to do that. Within that environment,
there is a huge untapped resource of peer-to-peer support that is available.
Associate Professor Proudfoot of the Black Dog Institute told the
committee that her organisation had done research which demonstrated the
effectiveness of e‑mental health in providing support for individuals
suffering mental ill-health:
I would like to say that, apart from it being available 24/7
to enable those in need of support and to assess risk factors in real time,
there is a strong body of evidence worldwide demonstrating the clinical and the
cost effectiveness of e-mental health programs for mild to moderate depression
and anxiety, insomnia, alcohol and drugs, as well as suicide prevention.
Controversially, there have been trials which show for these mild to moderate
conditions that e-mental health programs are as effective as face-to-face
therapy. The other great advantage is that they translate to real world
conditions, and research, both ours and international, has shown that they do
improve work and social functioning. They do not just reduce symptoms; they
improve work and social functioning. This means that fewer people need to be
referred to secondary and tertiary services.
We have done some cost effectiveness analyses as well. We
considered a fully-automated program—that is, without clinician support—but
tailored to individuals, and it was about half the cost of antidepressant
medication and about a sixth of the cost of face-to-face CBT [Cognitive
Behaviour Therapy]. They are available; they are effective, but to date they
have not been integrated into a stepped care model or into primary care. That
was one of the recommendations from the National Mental Health Commission.
Mr Woodward, the Executive Director Lifeline Research Foundation,
Lifeline Australia, also supported the use of e‑mental health, alongside
telephone helpline services and web-based services. Mr Woodward explained
that there needed to be clear priorities in the use and management of e-mental
health and telephone helplines:
In relation to the mental health system,
we have made three points. The first is that there should be more recognition
for teleweb and helpline services as components of the wider mental health
system—not as projects or innovation trials or as short-term funded services,
but as part of the overall system—and that they should be provided with
programmed and continued funding on that basis. The second point is that
improvements are possible in the makeup and operation of helplines and teleweb
services in Australia through improved coordination and the operation of those
services in an overall model of service drawing on public health principles to
delineate the roles and specialities across the existing services and making
the services more responsive, more accessible and less confusing to those who
wish to contact and use the services. The third point is that we have
recommended that there be work done with the helplines and teleweb sector to
identify how that model of service and care should operate and the roles to be
performed—rather than government making ad hoc or isolated decisions about one
service's role or funding without reference to the impacts on others.
The committee supports the Commission's recommendations regarding e‑mental
The committee agrees that e-mental health should be seen as an important
element of the overall solution for improving equity in delivery of mental
health services to rural and remote communities. It must be effectively
integrated with community-based mental health services, support, and deliver
ownership by the local community.
The committee recommends that the government's response to the
National Mental Health Commission's report supports the Commission's findings
and recommendations in relation to e-mental health.
Navigation: Previous Page | Contents | Next Page